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Conclusion Limiting driving pressure of severe ARDS under ECMO is of high clinical interest.
Pplat: plateau pressure; PEEPtot: total PEEP; Vt/PBW, tidal volume per predicted body weight; Pdriv: driving pressure of respiratory system; Ers: elastance of respiratory system; EL/Ers: the ratio of lung elastance to respiratory system elastance; Vder: derecruited volume.
In the paraquat-induced ARDS model in rats, Rzezinski et al. [32] compared a single common SI (40 cm H2O × 40 sec) to a progressive RM in which, starting from PEEP 15 cm H2O the baseline driving pressure of 10 cm H2O was increased by three steps of 5 cm H2O lasting 2 minutes each; the end-inspiratory pressure reached 40 cm H2O within 12 minutes and lasted 2 minutes.
Adequacy of cerebral oxygenation can be assessed by monitoring: cerebral perfusion pressure (CPP), the driving pressure of cerebral perfusion; oxygen saturation of jugular bulb (SjO2), the ratio between global cerebral oxygen availability and consumption: partial pressure of brain tissue oxygen (PbrO2), the driving pressure of oxygen diffusion to mitochondria at tissue level [ 1, 2].
Detailed analysis of the time capnogram revealed a strong association between Raw and ST-III when the respiratory mechanics was altered by increasing PEEP, which was significantly affected by the degree of expiratory driving pressure of the respiratory system.
In these patients, in order not to exceed a plateau pressure of 30 cm H2O, setting up PEEP of 12 to 15 cm H2O left room for a limited inspiratory driving pressure of not more than 15 to 18 cm H2O.
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However, the role of driving pressure on the severe ARDS patients requiring ECMO was uncertain, and a clinical review recommended that driving pressure is important determinant of outcome during ECMO [6].
Protective ventilation involved end-expiratory pressures above the lower inflection point on the static pressure volume curve, a tidal volume of less than 6 mL/kg, driving pressures of less than 20 cm of water above the PEEP value, permissive hypercapnia, and preferential use of pressure-limited ventilatory modes.
The demonstrated linkage of driving pressure to outcome [5] indicates that CRS, the quotient of tidal volume and driving pressure, is a reasonable and clinically accessible variable to be optimized during PEEP titration.
The results are interpreted in terms of the driving pressures for recrystallization in the presence of unstable subgrain structures.
PEEP was then increased in 5-cmH2O steps, each lasting 10 breaths, until reaching an inspiratory opening pressure of 50 cmH2O (that is, 20 cmH2ofof driving pressure and 30 cmH2ofof PEEP).
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