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A software programme (Open Lung Tool™) incorporated into a standard ventilator controlled the recruitment (pressure-controlled ventilation with fixed PEEP at 20 cmH2O and increased driving pressures at 20, 25 and 30 cmH2O for two minutes each) and PEEP titration (PEEP lowered by 2 cmH2O every two minutes, with tidal volume set at 6 ml/kg).
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Because decreasing PEEP lowers the EEPTP (Fig. 3), tidal ventilation would theoretically take place within a lower sector of the lung's pressure/volume curve, encouraging mechanical heterogeneity and potentially increasing the risk of VILI.
In some patients with auto-positive end-expiratory pressure (auto-PEEP), application of PEEP lower than auto-PEEP maintains a constant total PEEP, therefore reducing the inspiratory threshold load without detrimental cardiovascular or respiratory effects.
Results: AN and AA decreased with decreasing PEEP, however in ARDS at PEEP lower than 6 cmH2O they remained stable.
On the contrary, the flow-limited region is not expected to be further hyperinflated by a PEEP lower than its total PEEP, with the result that total PEEP does not change and auto-PEEP decreases.
The clinical implication of this finding is that when PEEP is applied to a tachypneic flow-limited patient, we have in most cases an increase of total PEEP lower than half of the applied PEEP, whereas greater increases of hyperinflation are typical of patients without flow limitation.
To the best of our knowledge, however, there is no clinical evidence confirming that flow limitation by itself is sufficient to prevent the increase in total PEEP when PEEP lower than auto-PEEP is applied.
The concept of predicting fluid responsiveness was initially reported in deeply sedated patients under volume-controlled mechanical ventilation with tidal volume (VT) of at least 8 ml/Kg and positive end-expiratory pressure (PEEP) lower than 10 cm H2O [7].
The respiratory rate was titrated to keep arterial pH above 7.20 and intrinsic PEEP lower than 1 cmH2O.
When FiO2 was lower than 50%%, respiratory rate lower than 30 breaths per minute, expiratory tidal volume higher than 5 mL/kg of predicted body weight with a pressure support lower than 10 cm H2O and PEEP lower than 8 cm H2O, NIV was discontinued and oxygen ventury mask of 50%% initiated.
The total regional compliance of both ROIs decreased at the caudal level during the decremental PEEP trial, whereas it increased initially at the cranial level after PEEP was lowered from 15 to 10 cm H2O.
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