Individualized Lung-Protective Ventilation Strategy Based on Esophageal Pressure Monitoring in Patients With ARDS Associated With Severe Acute Pancreatitis-A Randomized Controlled Trial.

Abstract

Acute respiratory distress syndrome (ARDS) secondary to severe acute pancreatitis (SAP) presents significant management challenges with high mortality rates. This study aimed to investigate the application value of an individualized lung-protective ventilation strategy guided by esophageal pressure (Pes) monitoring in patients with ARDS associated with SAP. This randomized controlled trial included 124 patients with SAP-related ARDS admitted to our hospital from January 2023 to December 2023, and they were randomized to a conventional lung protective ventilation group (conventional group, n = 62) and an esophageal pressure monitoring-guided group (EPM-guided group, n = 62). The conventional group adopted a conventional lung protective ventilation strategy; whereas, the EPM-guided group received the individualized ventilation strategy based on EPM. The EPM indicators, respiratory mechanics parameters, oxygenation indicators, and clinical outcomes were compared between the two groups. After treatment, the EPM-guided group showed significantly lower transpulmonary pressure (PL) [(16.82 ± 2.46) versus. (22.41 ± 3.23) cmH2O, p = 0.006], transpulmonary driving pressure (ΔPL) [(12.36 ± 1.83) versus. (16.52 ± 2.37) cmH2O, p = 0.007], and driving pressure (ΔP) [(11.43 ± 1.83) versus. (14.52 ± 2.24) cmH2O, p = 0.008] than the conventional group, whereas static compliance (Cst) [(37.82 ± 4.46) versus. (29.41 ± 5.23) mL/cmH2O, p = 0.009] and the PaO2/FiO2 ratio [(268.82 ± 32.46) versus. (195.41 ± 28.23) mmHg, p = 0.008] were significantly higher. The EPM-guided group had shorter mechanical ventilation duration [(12.32 ± 3.24) versus. (16.83 ± 4.52) d, p = 0.013] and intensive care nit (ICU) length of stay [(18.53 ± 4.62) versus. (23.72 ± 5.83) d, p = 0.018] compared to the conventional group, along with a lower VAP incidence (14.52% vs. 25.81% and p = 0.038) and a 28-day mortality rate (19.35% vs. 32.26% and p = 0.042). Multivariate logistic regression analysis showed that ΔPL at 72 h (OR 1.56, 95% CI 1.25-2.01, p < 0.001) was an independent predictor of a 28-day mortality rate. ROC curve analysis showed that ΔPL had a good diagnostic value for predicting a 28-day mortality rate (AUC = 0.832 and 95% CI 0.760-0.904). Correlation analysis showed that ΔPL at 72 h was significantly negatively correlated with the PaO2/FiO2 ratio (r = -0.71 and p < 0.001) and static compliance (r = -0.69 and p < 0.001). Individualized lung protective ventilation strategy guided by EPM can more accurately assess the actual lung inflation pressure, optimize the setting of ventilation parameters, and improve clinical outcomes of patients with SAP-related ARDS.