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Rationale <p>The significance of the Recruitment to Inflation (R/I) ratio in identifying PEEP recruiters in patients undergoing ultra-protective lung ventilation during venovenous ECMO is not well established.</p> Objectives <p>To compare the concordance of the R/I ratio and Electrical Impedance Tomography (EIT) in determining optimum PEEP settings in severe ARDS patients on ECMO and ventilated with very low tidal volumes.</p> Methods <p>Initially, a low-flow insufflation was performed to detect and measure the airway opening pressure (AOP). Subsequently, the R/I ratio was calculated from PEEP 15–5&#xa0;cmH<sub>2</sub>O, followed by a decremental PEEP trial (20–6&#xa0;cmH<sub>2</sub>O in 2&#xa0;cmH<sub>2</sub>O steps) monitored by EIT. The optimum EIT-based PEEP was defined as the intersection of the collapse and overdistension curves.</p> Main results <p>Among 54 ECMO patients (tidal volume: 4.8 [3.0–6.0] mL/kg), 13 (24%) exhibited an airway opening pressure (AOP) of 11 (8–14) cmH<sub>2</sub>O. The cohort’s median R/I ratio was 0.43 (0.28–0.61). A tertile-based analysis of the R/I ratio (≤ 0.34; 0.34–0.54; &gt; 0.54) revealed median optimum EIT-based PEEP of 8 [8–10], 10 [8–14], and 14 [12–16] cmH<sub>2</sub>O, respectively. The R/I ratio demonstrated weak inverse correlations with lung overdistension (R<sup>2</sup> = 0.19) and positive correlations with lung collapse (R<sup>2</sup> = 0.26) measured by EIT (<i>p</i> &lt; 0.01).</p> Conclusion <p>The R/I ratio is feasible during ultra-protective ventilation and provides valuable indications for guiding PEEP titration. Specifically, an R/I ratio &gt; 0.34 may help identify patients likely to benefit from further individualized PEEP optimization using EIT. In contrast, when the R/I ratio is ≤ 0.34, a moderate PEEP level (8–10&#xa0;cmH₂O) may suffice.</p>

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Optimum electrical impedance tomography-based PEEP and recruitment-to-inflation ratio in patients with severe ARDS on venovenous ECMO

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年5月16日

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  • Alexandre Coppens,
  • Sarah Aissi James,
  • Hadrien Roze,
  • Charles Juvin,
  • Benjamin Repusseau,
  • Guillaume Lebreton,
  • Charles-Edouard Luyt,
  • Guillaume Hékimian,
  • Juliette Chommeloux,
  • Marc Pineton de Chambrun,
  • Alain Combes,
  • Guillaume Franchineau,
  • Matthieu Schmidt

摘要

Rationale

The significance of the Recruitment to Inflation (R/I) ratio in identifying PEEP recruiters in patients undergoing ultra-protective lung ventilation during venovenous ECMO is not well established.

Objectives

To compare the concordance of the R/I ratio and Electrical Impedance Tomography (EIT) in determining optimum PEEP settings in severe ARDS patients on ECMO and ventilated with very low tidal volumes.

Methods

Initially, a low-flow insufflation was performed to detect and measure the airway opening pressure (AOP). Subsequently, the R/I ratio was calculated from PEEP 15–5 cmH2O, followed by a decremental PEEP trial (20–6 cmH2O in 2 cmH2O steps) monitored by EIT. The optimum EIT-based PEEP was defined as the intersection of the collapse and overdistension curves.

Main results

Among 54 ECMO patients (tidal volume: 4.8 [3.0–6.0] mL/kg), 13 (24%) exhibited an airway opening pressure (AOP) of 11 (8–14) cmH2O. The cohort’s median R/I ratio was 0.43 (0.28–0.61). A tertile-based analysis of the R/I ratio (≤ 0.34; 0.34–0.54; > 0.54) revealed median optimum EIT-based PEEP of 8 [8–10], 10 [8–14], and 14 [12–16] cmH2O, respectively. The R/I ratio demonstrated weak inverse correlations with lung overdistension (R2 = 0.19) and positive correlations with lung collapse (R2 = 0.26) measured by EIT (p < 0.01).

Conclusion

The R/I ratio is feasible during ultra-protective ventilation and provides valuable indications for guiding PEEP titration. Specifically, an R/I ratio > 0.34 may help identify patients likely to benefit from further individualized PEEP optimization using EIT. In contrast, when the R/I ratio is ≤ 0.34, a moderate PEEP level (8–10 cmH₂O) may suffice.