Background
Methods
AOP measurements and definitions
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“Standard method”: Using low-flow insufflation (5 L/min), airway closure was detected as the presence of an abrupt change in slope on the time-pressure curve (Fig. 1) [1, 8]. The value of the airway pressure at which the slope changes provided the value of the AOP. Two investigators (FB and AL) detected airway closure and measured AOP with the standard method, blinded to the results of the new method described below. If a significant difference (> 1 cm H2O) was observed between the assessments of the two investigators, a consensus was reached with the input of a third investigator (J-CR).
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“Pcond method”: Using a usual constant-flow rate (60 L/min) in volume assist control ventilation, the Pcond was identified by visual inspection of the airway pressure waveform. Resistive pressure was also detected as the difference between the peak and plateau pressures measured after at least 0.3 s of end-inspiratory occlusion [18]. Detection of an airway closure was defined as: Pcond − Pres > 1 cm H2O. The AOP value was defined as: AOP = PEEP + (Pcond − Pres) (Fig. 1). Two investigators (A-FH and EM) detected and measured AOP with the Pcond method, blinded to the results of the standard method. If a significant difference (> 1 cm H2O) was observed between the assessments of the two investigators, a consensus was reached with the input of a third investigator (GC).
Study design
Proof-of-concept evaluation: Bench study
Mechanical bench
Physiological bench
Performance of the new method: physiological study
Evaluation of clinical tolerance
Endpoints
Statistics
Results
Proof-of-concept assessment
Mechanical bench
Method | Standard method | Pcond method | ||
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Flow rate | 5 L/min | 60 L/min | ||
AOPsim = 10 cm H2O | PEEP 5 cm H2O | 11 | 10 | |
PEEP 12 cm H2O | No AOP | No AOP | ||
No airway closure | Control 1 | PEEP 5 cm H2O | No AOP | No AOP |
PEEP 12 cm H2O | No AOP | No AOP | ||
Control 2 | PEEP 5 cm H2O | No AOP | No AOP | |
PEEP 12 cm H2O | No AOP | No AOP |
Physiological bench
Performance of Pcond method
Pcond method | |
---|---|
Sensitivity (%) | 93 |
Specificity (%) | 91 |
Positive predicted value (%) | 77 |
Negative predicted value (%) | 97 |
Likelihood ratio of positive test | 9.77 |
Likelihood ratio of negative test | 0.08 |
Diagnostic accuracy (%) | 91 |
Youden index | 0.83 |
Clinical study: tolerance assessment
Baseline | Standard method | Pcond method | p | |
---|---|---|---|---|
PEEP, cm H2O | 12 [10–12] | 5 [5–5] | 5 [5–5] | – |
SpO2, % | 95 [94–96] | – | – | – |
Minimal SpO2, % | – | 92 [90–95] | 94 [93–96] | < 0.0001 |
Variation in SpO2, % | – | − 2 [− 4 to − 1] | 0 [− 1 to 0] | < 0.0001 |
Respiratory rate, cycles/min | 28 [23–30] | 5 [5–5] | 20 [20–20] | < 0.0001 |
Heart rate, beats/min | 73 [60–91] | – | – | |
Minimal heart rate, beats/min | – | 73 [60–91] | 74 [59–91] | 0.36 |
Maximal heart rate, beats/min | – | 73 [62–92] | 76 [63–92] | 0.47 |
Systolic arterial pressure, mmHg | 117 [104–131] | – | – | – |
Maximal systolic arterial pressure, mmHg | – | 125 [106–136] | 122 [108–136] | 0.04 |
Variation in systolic pressure, mmHg | – | 4 [0–17] | 1 [− 1 to 15] | 0.04 |
Mean arterial pressure, mmHg | 75 [70–87] | – | – | – |
Minimal mean arterial pressure, mmHg | – | 75 [70–88] | 77 [71–84] | 0.62 |
Variation in mean arterial pressure, mmHg | – | 0 [− 1 to 4] | 0 [− 3 to 5] | 0.14 |