Assessing the Physiological Response to PEEP in Acute Hypoxemic Respiratory Failure: Proposed Structured Clinical Intervention Using Electrical Impedance Tomography
CCCF ePoster library. Lee M. Oct 31, 2016; 150887; 9
Ms. Misan Lee
Ms. Misan Lee
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Topic: Quality Assurance & Improvement

Assessing the Physiological Response to PEEP in Acute Hypoxemic Respiratory Failure: Proposed Structured Clinical Intervention Using Electrical Impedance Tomography

Misan Lee1, Vagia Campbell2, Howard Chiam3, Matthew Ko2, Niall Ferguson2,4,5, Stephen Lapinsky2,5, Eddy Fan2,4,5, Ewan Goligher2,4,5
1Schulich School of Medicine & Dentistry, London, Ontario, Canada
2Sinai Health System, Toronto, Ontario, Canada
3Institute of Biomaterials and Biomedical Engineering, Toronto, Ontario, Canada
4University Health Network, Toronto, Ontario, Canada
5Interdepartmental Division of Critical Care Medicine, University of Toronto


Positive end-expiratory pressure (PEEP) can reduce mortality by reducing ventilator-induced lung injury (VILI)1,2 but may also cause VILI in some patients because the response to PEEP varies widely1,3. Electrical impedance tomography (EIT) provides a non-invasive but sophisticated means of monitoring regional ventilation4,5 and quantifying lung recruitment during PEEP titration6,7;however, EIT has not been widely  implemented in routine clinical practice.
To develop and implement a structured EIT-based protocol for assessing the response to PEEP in patients with acute hypoxemic respiratory failure.
Based on previously published literature, we identified several potential parameters (including EIT-based parameters) of the physiological response to PEEP focusing on oxygenation, recruitment, and compliance. A structured assessment protocol was developed to standardize EIT-based patient assessment by the registered respiratory therapists (RRTs) in the ICU at Mount Sinai Hospital. Patients with hypoxemic respiratory failure (P/F < 200 mmHg) were considered for evaluation. The protocol has three stages: (1) oxygenation (P/F) response to increased PEEP, (2) a lung recruitment maneuver8, and (3) decremental PEEP titration. EIT signals are recorded continuously throughout the assessment (~25 minutes total).  The de-identified EIT signals are then rapidly analyzed at the bedside using customized signal analysis software (LabVIEW, National Instruments) on a personal computer.
After in-servicing, RRTs were able to independently conduct both the structured assessment and signal analysis. The assessment and signal analysis required approximately 30 minutes of time for experienced therapists. To date, 3 patients have completed the assessment; the procedure was well-tolerated in those cases.
A structured EIT-based protocol for assessing individual responses to PEEP can be implemented as a routine clinical tool. Future research will aim to characterize the range of responses to PEEP and assess the impact of the standardized assessment on clinical decision-making.


1.          Kallet RH. Should PEEP Titration Be Based on Chest Mechanics in Patients With ARDS? Respir Care. 2016;61(6):876-890. doi:10.4187/respcare.04657.
2.          Kassis EB, Loring SH, Talmor D. Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS. Intensive Care Med. 2016;42(8):1206-1213. doi:10.1007/s00134-016-4403-7.
3.          Zafrani L, Lemiale V, Lapidus N, Lorillon G, Schlemmer B, Azoulay E. Acute respiratory failure in critically ill patients with interstitial lung disease. PLoS One. 2014;9(8). doi:10.1371/journal.pone.0104897.
4.          Frerichs I, Becher T, Weiler N. Electrical impedance tomography imaging of the cardiopulmonary system. Curr Opin Crit Care. 2014;20(3):323-332. doi:10.1097/MCC.0000000000000088.
5.          Blankman P, Gommers D. Lung monitoring at the bedside in mechanically ventilated patients. Curr Opin Crit Care. 2012;18(3):261-266. doi:10.1097/MCC.0b013e3283534a4a.
6.          Muders T, Luepschen H, Putensen C. Impedance tomography as a new monitoring technique. Curr Opin Crit Care. 2010;16(3):269-275. doi:10.1097/MCC.0b013e3283390cbf.
7.          Yun L, He H, Möller K, Frerichs I, Liu D, Zhao Z. Assessment of Lung Recruitment by Electrical Impedance Tomography and Oxygenation in ARDS Patients. Medicine (Baltimore). 2016;95(22):e3820. doi:10.1097/MD.0000000000003820.
8.          Respiratory Therapy - ICU - Policy/Procedure. Lung Recruitment Manouevers. 2015.

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