como evitar a vili uti respiratória hc-fmusp uti hospital sírio libanês eduardo lv costa valerie...
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Como evitar a VILI
UTI Respiratória HC-FMUSP
UTI Hospital Sírio Libanês
Eduardo LV Costa
Valerie VILI
Alt 1,93m
Peso 120 Kg
Mecanismos de lesão
• Recrutamento cíclico• Colapso focal / Estresse• Hiperdistensão• Hiperdistensão cíclica• Strain (deformação)
Tidal recruitment
Cortesia Dr. G Janot
Expiração
Tidal recruitment
Cortesia Dr. G Janot
Inspiração
+ 15
Pressão de distensão local
Transpulmonary
+ 15
+ 70
Local d istend pressure
ing
Ple u ra l S p a c e
Collapsed zone
Colapso focal(stress raisers)
+30 +30
+70 +70
Mead – JAP 1970
Pplat > 26 - 27 cm H2O
Am J Respir Crit Care Med 2007
Protti CCM 2013
Protti CCM 2013
Aeração
CCM 2014
Inflamação
Borges - CCM 2014
Imagem de Fusão
Borges - CCM 2014
10 compartimentos de aeração
Borges - CCM 2014
One size fits all?
Bellani CCM 2009
Evolução da ventilação protetora
• Volume corrente alto• Volume corrente baixo
Amato NEJM 1998
Volume corrente normal
Vt < 30% da CRF Strain < 1,3
Volumes Homem Mulher
CPT 6,0L 4,2L
CRF 2,2L 1,8L
Vt (6-8ml/kg) 600mL 420mL
Evolução da ventilação protetora
• Volume corrente alto• Volume corrente baixo• Vt/peso ideal
ARMA NEJM 2000
Evolução da ventilação protetora
• Volume corrente (Vt) alto
• Vt baixo
• Vt/peso ideal
• Vt/tamanho do pulmão funcionante?
(sizing the lung)
Amato NEJM 1998
ARDS Network NEJM 2000
Mattingley & Hubmayr CCF 2011
Como evitar a VILI
• Ventilando adequadamente o baby lung
• Mudando a história pulmonar
Sipmann CCM 2007
Gernoth CCF 2009
Retamal CCF 2013
Vt adequado ao baby lung(‘medindo’ o tamanho do baby lung)
Colapso:
55.6 %
Pneumocystisjiroveci
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 5 cmH2O
6-8 ml/kg x (1 – 0,556) =2,7-3,6 ml/kg
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 25 cmH2O
( após recrutamento)
Colapso:
0.9 %
6-8 ml/kg x (1 – 0,01) =6-8 ml/kg
Collapse
PEEP 23
PEEP 07
PEEP = 25
decr
em
en
tal
PEEP = 7
Hyperdistensão Colapso
EIT EIT
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
6-8 ml/kg x (1 – 0,05) =5,7-7,6 ml/kg
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
Overdistension Collapse
PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
6-8 ml/kg x (1 – 0,355) =3,9-5,2 ml/kg
Medindo o tamanho do pulmão
Hipoxemia
50%6-8 ml/kg x (1 – 0,355) =
3,9-5,2 ml/kg
Reske CCM 2013
Medindo o tamanho do pulmão
Hipoxemia
Complacência
Complacência = Cs * CRF
Vt e VM protetora
• Complacência ~ CRF– p.e. Pneumonectomia -> ½ comp
Normalização “em vigor”
Vt / Peso ideal
Proposta
Vt / Complacência
Complacência = Vt / ΔP
Vt / Complacência = Vt / (Vt / ΔP)= ΔP
Driving pressure (ΔP) normal
Vt = 6-8 ml/kg ~ 500 ml
Complacência = 80-100 ml/cmH2O
ΔP = Vt / Complacência ~ 7 cmH2O
PEEP
DrivingPressure
(ΔP)
PPlatôVT
VILI
CRS
Stressraisers
Amato NEJM 1998
Amato…………….…….53
Brochard…………..….116
Stewart…………....…..120
Brower……………….…52
ARDSnet….…………..861
ALVEOLI…….………..549
LOVS………………….983
Express………………..768
3502
Quintile of PPLAT
0 1 2 3 4 5
Ad
juste
d R
ela
tive
Ris
k
0.5
0.7
1
1.4
2
P < 0.0001
0 1 2 3 4 5
0
10
20
30
40
Quintiles of ∆Pmatched for PEEP
Quintile of PPLAT
0 1 2 3 4 5
Ad
juste
d R
ela
tive
Ris
k
0.5
0.7
1
1.4
2
P = 0.61
0 1 2 3 4 5
0
10
20
30
40
Quintiles of PEEPmatched for ∆P
Quintile of PPLAT
123456
Ad
juste
d R
ela
tive
Ris
k
0.5
0.7
1
1.4
2
P < 0.0001
123456
0
10
20
30
40
Quintiles of ∆P matched for PPLAT
Quintile of PPLAT
123456
Ad
juste
d R
ela
tive
Ris
k
0.5
0.7
1
1.4
2
P < 0.0001
123456
0
10
20
30
40
Quintiles of ∆P matched for PPLAT
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airway pressure(cmH
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Adjusted Relative-risk
of Death
0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
0 1 2 3 4 5
0
10
20
30
40
0 1 2 3 4 5
0
10
20
30
40
Briel – quintiles PPLAT
Drivingpressure
PEEP 0 1 2 3 4 5
0
10
20
30
40
Briel – quintiles PEEP
Drivingpressure
PEEP
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P = 0.09
P = 0.09 ( negative trend)P = 0.007 ( positive trend)
( 335 ) ( 397 ) ( 251 ) ( 459 ) ( 322 ) ( 270 ) ( 312 ) ( 413 ) ( 320 ) ( 449 )
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P = 0.007
11 2 3 4 5
Quintiles of Plateau - pressure
1 2 3 4 5
P = 0.002( positive trend )
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airway pressure(cmH
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Adjusted Relative-risk
of Death0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
0 1 2 3 4 5
0
10
20
30
40
0 1 2 3 4 5
0
10
20
30
40
Briel – quintiles PPLAT
Drivingpressure
PEEP 0 1 2 3 4 5
0
10
20
30
40
Briel – quintiles PEEP
Drivingpressure
PEEP
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P = 0.09
P = 0.09 ( negative trend)P = 0.007 ( positive trend)
( 335 ) ( 397 ) ( 251 ) ( 459 ) ( 322 ) ( 270 ) ( 312 ) ( 413 ) ( 320 ) ( 449 )
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P = 0.007
11 2 3 4 5
P = 0.24( negative trend )
Quintiles of PEEP
11 2 3 4 5
P = 0.06( negative trend )
Quintiles of PEEP
PEEP
∆P
Quintiles of PEEP
Increasing Plateau and increasing ∆P Increasing Plateau but similar ∆P
High vs. Low PEEP studies (n = 2360)
High vs. Low VTstudies (n = 1197)
High vs. Low PEEP studies (n = 2360)
0 1 2 3 4 5
0
10
20
30
40
0 1 2 3 4 5
0
10
20
30
40
0 1 2 3 4 5
0
10
20
30
40
0 1 2 3 4 5
0
10
20
30
40
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P < 0.0001( positive trend )
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0.5
0.7
1
1.4
2
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0 .5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airw
ay p
re
ssu
re
(cm
H
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Ad
ju
sted
R
ela
tive
-risk
of D
ea
th
0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0.5
0.7
1
1.4
2
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0 .5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airw
ay p
re
ssu
re
(cm
H
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Ad
ju
sted
R
ela
tive
-risk
of D
ea
th
0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0.5
0.7
1
1.4
2
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0 .5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airw
ay p
re
ssu
re
(cm
H
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Ad
ju
sted
R
ela
tive
-risk
of D
ea
th
0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0.5
0.7
1
1.4
2
Q u in t i le o f P P L A T
0 1 2 3 4 5
Ad
ju
ste
d R
ela
tiv
e R
is
k
0 .5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airw
ay p
re
ssu
re
(cm
H
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Ad
ju
sted
R
ela
tive
-risk
of D
ea
th
0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
High vs. Low VTstudies (n = 1197)
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
Quintiles of Plateau-pressure
Increasing Plateau and increasing ΔP
( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )
Quintiles of Plateau-pressure
( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )
10
20
30
40
Airway pressure(cmH
2O)
Driving-pressure
PEEP
Driving-pressure
PEEP
Quintiles of PEEP
P = 0.19 (negative trend)P < 0.0001 (positive trend)Adjusted Relative-risk
of Death
0.5
1.0
1.4
2.0
40
30
20
10
0.7
0.5
1.0
1.4
2.0
0.7
Quintiles of PEEP
Increasing Plateau but Similar ΔP
Number of pts:
0
1 2 3 4 5 1 2 3 4 5
0 1 2 3 4 50
10
20
30
40
0 1 2 3 4 50
10
20
30
40
Briel – quintiles PPLAT
Drivingpressure
PEEP 0 1 2 3 4 5
0
10
20
30
40
Briel – quintiles PEEP
Drivingpressure
PEEP
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P = 0.09
P = 0.09 ( negative trend)P = 0.007 ( positive trend)
( 335 ) ( 397 ) ( 251 ) ( 459 ) ( 322 ) ( 270 ) ( 312 ) ( 413 ) ( 320 ) ( 449 )
Quintile of PPLAT
0 1 2 3 4 5
Adjusted Relative Risk
0.5
0.7
1
1.4
2
P = 0.007
Mor
talit
yRi
sk( a
djus
ted
)Ai
rway
pres
sure
( cm
H2O
)
PEEP
∆P
100
95
90
85
80
75
70
0 10 20 30 40 50 60
100
95
90
85
80
75
70
0 10 20 30 40 50 60
100
95
90
85
80
75
70
0 10 20 30 40 50 60
ΔP ≤ 14 cmH2O
Plateau-pressure < 32 cmH2O
and VT < 8 mL / kg / ibw
ΔP > 14 cmH2O
Plateau ≤ 26 cmH2O
Plateau > 26 cmH2O
VT < 7 mL / kg
VT ≥ 7 mL / kg
Only patients under “protective-settings”:
( N = 883 )
P = 0.15
P = 0.10
P = 0.005
Days of mechanical ventilation - after randomization
Adj
uste
d C
umul
ativ
e S
urvi
val (
%)
Adj
uste
d C
umul
ativ
e S
urvi
val (
%)
Adj
uste
d C
umul
ativ
e S
urvi
val (
%)
100
95
90
85
80
75
70
0 10 20 30 40 50 60
100
95
90
85
80
75
70
0 10 20 30 40 50 60
100
95
90
85
80
75
70
0 10 20 30 40 50 60
ΔP ≤ 14 cmH2O
Plateau-pressure < 32 cmH2O
and VT < 8 mL / kg / ibw
ΔP > 14 cmH2O
Plateau ≤ 26 cmH2O
Plateau > 26 cmH2O
VT < 7 mL / kg
VT ≥ 7 mL / kg
Only patients under “protective-settings”:
( N = 883 )
P = 0.15
P = 0.10
P = 0.005
Days of mechanical ventilation - after randomization
Adj
uste
d C
umul
ativ
e S
urvi
val (
%)
Adj
uste
d C
umul
ativ
e S
urvi
val (
%)
Adj
uste
d C
umul
ativ
e S
urvi
val (
%)
∆P ≤ 14 cmH2O
( N = 1457 )
∆P > 14 cmH2O
Plateau > 26 cmH2O
Plateau ≤ 26 cmH2O
VT > 6 mL / kg
VT ≤ 6 mL / kg
P = 0.006
P = 0.55
P = 0.67
High vs. Low VT studies ( n = 883 )
High vs. Low PEEP studies ( n = 1457 )
Patients under stricter “protective” settings ( Plateau-pressure < 32 cmH2O and VT < 8 mL/ kg / ibw )
P = marcador de gravidade?
P = VCrs
Reduction in Driving-Pressure driven by Randomization
0 2 4 6 8 10 12 14 16 18
Adj
uste
d r
elat
ive
ris
k
( in
rel
atio
n to
res
pect
ive
cont
rol a
rm )
0.1
0.5
1.0
2.0
3 “negative” clinical studies:
Driving P.
High Low
ALVEOLI 13 15
LOVS 14 15
Express 13 14
Days after randomization0 10 20 30 40 50 60
Adj
uste
d
Sur
viva
l (%
)
65
70
75
80
85
90
95
100
Control arm ( ∆P-change = + 1.3 )
higher PEEP and ∆P-change = - 3.7
higher PEEP and ∆P-change = + 0.4
higher PEEP and ∆P-change = + 4 .1
P = 0.003
Changes in ∆P caused by randomization ( PEEP trials, only )
(N = 794)
Como mudar o tamanho do pulmão funcionante
PEEP e recrutamento revisitados
Not Protected
Hyperinflated Normally aerated Poorly aerated Not aerated
EI EE
Stepwise Recruitment Strategy
Time0
10
20
30
40
50
60
70
4550
5560
Ba
selin
e
TMAX = 20 min
25 cmH2O
Airw
ay P
ress
ures
(cm
H2O
)
40CPAP
OLA
DP = 15 cmH2O
Borges AJRCCM 2006
Collapse:
55.6 %
Patient # 9Pneumocystiscarinii pneumonia
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 26 cmH2O
( after PPLAT = 55 )
Collapse:
0.9 %
Patient # 9Pneumocystiscarinii pneumonia
PEEP = 5; PPLAT = 25
PEEP = 17; PPLAT = 40
PEEP = 25; PPLAT = 40
PEEP = 25; PPLAT = 60
Vermelho = hiperinsufladoVermelho = hiperinsuflado
PEEP=25 - Inspiração
PEEP=25 - Inspiração – após recrutamento
Vermelho = hiperinsufladoVermelho = hiperinsuflado
Time0
10
20
30
40
50
60
70
PCV DP = 15 cmH2O
25
PEEP STEPS - MAXIMUM-RECRUITMENT STRATEGY
Airw
ay P
ress
ure
(cm
H2O
)Recruitment
phase
25
20
Baseline (PEEP = 10)
10
35
452 min
20
15
5 min
PEEP titrationphase
( : CT scan – end-expiratory pause )
Borges AJRCCM 2006
1 2 3
0.0
0.2
0.4
0.6
0.8
Baseline PEEP (~10)
MaximumPEEP
TitratedPEEP (~24)
No
n-a
era
ted
L
ung
T
issu
e
(
%
of
tota
l lu
ng
mas
s )
0
20
40
60
80
Janot CCF 2012
Bas
elin
e P
EE
P
Max
imum
PE
EP
T
itrat
ed
PE
EP
PaO2/FIO2 = 113
PaO2/FIO2 = 357
Potential for recruitment: 48% Relative response: 98%
Potential for recruitment: 36% Relative response: 45%
Potential for recruitment: 63% Relative response: 82%
PEEP titration study
RM
PCVPins 60PEEP 40cmH2O
2 min
Incremental PEEP steps Decremental PEEP steps
VCV6 ml/kg
8
26
1012
1416
1820
2224
PEEP steps (10 min at each level))
2624
2220
1816
1412
108
VCV6 ml/kg
Changes in Cdyn (OLT)Changes in Oxygenation
Search for Open lung PEEP (Oxyg and Cdyn)
0
5
10
15
20
25
8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8
Pres
sure
(cm
H2O
)D
rivin
g
pre
ssu
re
PEEP PEEP
Rec.
N = 25
0
5
10
15
20
25
8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8
Pres
sure
(cm
H2O
)D
rivin
g
pre
ssu
re
PEEP PEEP
Rec.
“PEEP table trial”
N = 25?
0
5
10
15
20
25
8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8
Pres
sure
(cm
H2O
)D
rivin
g
pre
ssu
re
PEEP PEEP
Rec.
“PEEP table trial”
N = 25
0
5
10
15
20
25
8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8
Pres
sure
(cm
H2O
)D
rivin
g
pre
ssu
re
PEEP PEEP
Rec.
“PEEP table trial”
N = 25
0
5
10
15
20
25
8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8
Pres
sure
(cm
H2O
)D
rivin
g
pre
ssu
re
PEEP PEEP
Rec.
“PEEP table trial”
“decrementalPEEP titration”
N = 25
0
5
10
15
20
25
8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8
Pres
sure
(cm
H2O
)D
rivin
g
pre
ssu
re
PEEP PEEP
Rec.
“ Hysteresis “
“PEEP table trial”
“decrementalPEEP titration”
PaO2/FIO2 = 180 PaO2/FIO2 = 380
N = 25