Transpulmonary pressures and EIT-derived alveolar collapse and overdistension in ARDS: association and comparison of two PEEP titration strategies
Abstract
Background Determining the optimal positive end-expiratory pressure (PEEP) to maximize alveolar recruitment while minimizing overdistension remains a clinical challenge. This study investigated the relationship between transpulmonary pressures and alveolar collapse/overdistension, as assessed by electrical impedance tomography (EIT), in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Methods We conducted a physiological study involving 38 mechanically ventilated ARDS patients. Each patient underwent a decremental PEEP trial (20 to 4 cmH₂O), with continuous EIT monitoring and esophageal pressure measurements to calculate end-expiratory (P L,e ) and end-inspiratory (P L,i ) transpulmonary pressures. Percentages of alveolar collapse and overdistension were derived from EIT data. The predictive value of P L,e and P L,i for critical alveolar collapse or overdistension (> 10%) was assessed. We also compared PEEP levels determined by EIT-guided (best compromise between overdistension and collapse) versus esophageal pressure-guided (lowest PEEP yielding a positive P L,e ) strategies. Results P L,e and P L,i strongly correlated with alveolar collapse (r = − 0.68) and overdistension (r = 0.60), respectively (both p < 0.001). Receiver operating characteristic analysis showed good predictive performance of P L,e (AUC = 0.84) and P L,i (AUC = 0.80) for identifying critical collapse and overdistension. A P L,e <2.0 cmH₂O predicted collapse > 10%, while P L,i >18.4 cmH₂O predicted overdistension > 10%, both with ≥ 80% specificity. PEEP levels determined using EIT were significantly higher than those based on esophageal pressure (12.0 [8.0–14.0] vs . 8.0 [4.8–11.3) cmH 2 O; p < 0.001), resulting in reduced alveolar collapse, indicating more effective alveolar recruitment, and improved ventilation in dependent lung region. However, EIT-guided strategy also led to a slight increase in overdistension and reduced compliance in the non-dependent lung. Conclusions P L,e and P L,i accurately identified clinically relevant thresholds of collapse and overdistension, supporting their role as physiologic surrogates of regional lung stress in ARDS. However, EIT- and esophageal-guided strategies result in different PEEP settings, respiratory mechanics, and patterns of alveolar collapse and overdistension.
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BibTeX
@article{brault2026transpulmonary,
title = {{Transpulmonary pressures and EIT-derived alveolar collapse and overdistension in ARDS: association and comparison of two PEEP titration strategies}},
author = {Clément Brault and Yoann Zerbib and Romain Vallee and Rosalie Schoux and Alexis Lambour and Benjamin Swinyard and Valentin Dambrine and Julien Demaiter and Loay Kontar and Julien Maizel and Michel Slama},
journal = {Critical Care},
year = {2026},
month = sep,
doi = {10.1186/s13054-026-06356-4},
url = {https://u-picardie.hal.science/hal-05766980v1},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Transpulmonary pressures and EIT-derived alveolar collapse and overdistension in ARDS: association and comparison of two PEEP titration strategies
AU - Clément Brault
AU - Yoann Zerbib
AU - Romain Vallee
AU - Rosalie Schoux
AU - Alexis Lambour
AU - Benjamin Swinyard
AU - Valentin Dambrine
AU - Julien Demaiter
AU - Loay Kontar
AU - Julien Maizel
AU - Michel Slama
PY - 2026
DA - 2026/09/25
JO - Critical Care
DO - 10.1186/s13054-026-06356-4
UR - https://u-picardie.hal.science/hal-05766980v1
AB - Background Determining the optimal positive end-expiratory pressure (PEEP) to maximize alveolar recruitment while minimizing overdistension remains a clinical challenge. This study investigated the relationship between transpulmonary pressures and alveolar collapse/overdistension, as assessed by electrical impedance tomography (EIT), in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Methods We conducted a physiological study involving 38 mechanically ventilated ARDS patients. Each patient underwent a decremental PEEP trial (20 to 4 cmH₂O), with continuous EIT monitoring and esophageal pressure measurements to calculate end-expiratory (P L,e ) and end-inspiratory (P L,i ) transpulmonary pressures. Percentages of alveolar collapse and overdistension were derived from EIT data. The predictive value of P L,e and P L,i for critical alveolar collapse or overdistension (> 10%) was assessed. We also compared PEEP levels determined by EIT-guided (best compromise between overdistension and collapse) versus esophageal pressure-guided (lowest PEEP yielding a positive P L,e ) strategies. Results P L,e and P L,i strongly correlated with alveolar collapse (r = − 0.68) and overdistension (r = 0.60), respectively (both p < 0.001). Receiver operating characteristic analysis showed good predictive performance of P L,e (AUC = 0.84) and P L,i (AUC = 0.80) for identifying critical collapse and overdistension. A P L,e <2.0 cmH₂O predicted collapse > 10%, while P L,i >18.4 cmH₂O predicted overdistension > 10%, both with ≥ 80% specificity. PEEP levels determined using EIT were significantly higher than those based on esophageal pressure (12.0 [8.0–14.0] vs . 8.0 [4.8–11.3) cmH 2 O; p < 0.001), resulting in reduced alveolar collapse, indicating more effective alveolar recruitment, and improved ventilation in dependent lung region. However, EIT-guided strategy also led to a slight increase in overdistension and reduced compliance in the non-dependent lung. Conclusions P L,e and P L,i accurately identified clinically relevant thresholds of collapse and overdistension, supporting their role as physiologic surrogates of regional lung stress in ARDS. However, EIT- and esophageal-guided strategies result in different PEEP settings, respiratory mechanics, and patterns of alveolar collapse and overdistension.
SN - 1364-8535
SN - 1466-609X
ER -