Targeted Lateral Positioning Decreases Lung Collapse and Overdistension in COVID-19-Associated ARDS

Abstract

\n Background\n\nAmong the challenges for personalizing the management of mechanically ventilated patients with coronavirus disease (COVID-19)-associated acute respiratory distress syndrome (ARDS) are the effects of different positive end-expiratory pressure (PEEP) levels and body positions in regional lung mechanics. Right-left lung aeration asymmetry and poorly recruitable lungs with increased recruitability with alternating body position between supine and prone have been reported. However, real-time effects of changing body position and PEEP on regional overdistension and collapse, in individual patients, remain largely unknown and not timely monitored.\nMethods\n\nWe here report a series of consecutive mechanically ventilated patients with COVID-19-associated ARDS. Aiming at to individualize PEEP and body positioning in order to reduce mechanisms of ventilator-induced lung injury, collapse and overdistension, sixteen decremental PEEP titrations were performed in the first days of mechanical ventilation (8 pairs supine vs. targeted lateral position): supine position immediately followed by 30° targeted lateral position. The choice of lateral tilt was based on X-Ray: the less aerated lung was positioned up. Maps and percentages of global and regional collapse and overdistension were measured for each PEEP level by electrical impedance tomography.\nResults\n\nTargeted lateral position resulted in significantly smaller amounts of overdistension and collapse when compared with the supine one: less collapse along the PEEP titration was found within the left lung in targeted lateral; and less overdistension along the PEEP titration was found within the right lung in targeted lateral. Regarding collapse within the right lung and overdistension within the left lung: no differences were found for position.\nConclusions\n\nTargeted lateral positioning with bedside personalized PEEP provided a selective attenuation of overdistension and collapse in mechanically ventilated patients with COVID-19-associated ARDS and right-left lung aeration/ventilation asymmetry.