Global and regional parameters to visualize the 'best' PEEP during a PEEP trial in a porcine model with and without acute lung injury

Background. Setting the optimal level of positive end-expiratory pressure (PEEP) in critically ill patients remains a matter of debate. "Best" PEEP is regarded as minimal lung collapse and overdistention to prevent lung injury. In this study, global and regional variables were evaluated in a porcine model to identify which variables should be used to visualize "best" PEEP. Methods. Eight pigs (28-31 kg) were studied during an incremental and decremental PEEP trial before and after the induction of acute lung injury (ALI) with oleic acid. Arterial oxygenation, compliance, lung volume, dead space, esophageal pressure and electrical impedance tomography (EIT) were recorded at the end of each PEEP step. Results. After ALI, "best" PEEP was comparable at 15 cmH2O between regional compliance of the dorsal lung region by EIT and the global indicators: dynamic compliance, arterial oxygenation, alveolar dead space and venous admixture. After ALI, the intratidal gas distribution was able to detect regional overdistention at 15 cmH 2O PEEP. "Best" PEEP based on transpulmonary pressure was lower and no optimal level could be found based on lung volume measurements alone. In addition, the recruitment phase significantly improved end-expiratory lung volume, PaO2, venous admixture and regional and global compliance, both in ALI and the "healthy" lung. Conclusion. Most of the evaluated parameters indicate comparable 'best' PEEP levels. However, a combination of these parameters, and especially EIT-derived intratidal gas distribution, might provide additional information. The application of lung recruitment was beneficial in both ALI and the "healthy" lung.

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