Pick Your PEEP: Panelists debate methods of optimal PEEP selection in ARDS

An optimal level of positive end-expiratory pressure (PEEP) is of paramount importance in ARDS; however, the best way to select optimal PEEP remains elusive and controversial. A frequently used tool is the ARDSNet PEEP table, but its utility has come into question as several alternate methods have evolved. Another method that has increasingly fallen out of favor is esophageal balloon manometry.

A panel of pulmonary specialists debated the pros and cons of both methods during the CHEST 2021 session Pick Your PEEP: Debates on Methods of Optimal PEEP Selection in ARDS.

It’s 2021—Time to Debunk the PEEP Table?

In the first debate, Parijat Sen, MD, MBBS, Assistant Professor of Medicine in the Division of Pulmonary and Critical Care at the University of Kentucky, and Matthew T. Siuba, DO, Assistant Professor of Medicine at the Cleveland Clinic Respiratory Institute, presented arguments for and against continued use of the PEEP table.

“The PEEP table has been extensively used in ARDSNet and other ARDS trials for the last 20 years or so, so it has some validity in that it is commonly used, even though it’s not been shown to be superior compared with any other strategy,” Dr. Siuba said, taking the position that the PEEP table has outlived its usefulness as a “one-size-fits-all” approach to determining PEEP levels.

“The best strategy for PEEP titration is yet to be determined. PEEP tables may be a reasonable starting point, but individual lung characteristics need to be considered,” he said. “Multimodal assessment in ARDS is absolutely key and, as in the rest of critical care, context is everything. We need to focus on fundamentals because, as we all know, we’re still not meaningfully achieving our targets as a community for low tidal volume ventilation and prone positioning.”

Dr. Sen, on the other hand, argued that there is still a role for the PEEP table, as alternative strategies for determining PEEP settings are not perfect either and present challenges of their own.

“If you’re not going to use the PEEP table, what are your alternate strategies? There’s the esophageal balloon, there’s the stress index or P-V curve, and then there are some real-time recruitment strategies, which are pretty complex, such as bedside ultrasound with PEEP application,” Dr. Sen said.

However, he said, each of those strategies require significant levels of expertise, are costly, and not always readily available.

“The advantages of the PEEP table are that it follows a simple algorithm—the more severe the ARDS, the higher the PEEP—and it is not affected by variables such as spontaneous breathing or rapidly changing compliance,” Dr. Sen said. “But most importantly, it is consistently reproducible across settings, providers, and studies. If you believe there is a role for protocolized medicine, there is definitely still a role, in the right context and in the right situation, for the PEEP table.”

Is 2021 the Year Esophageal Balloon Manometry Makes a Comeback?

In the second debate, Richard A. Oeckler, MD, PhD, FCCP, Assistant Professor of Medicine and Physiology and Director of the COVID and Medical Intensive Care Units at the Mayo Clinic, and Ronald A. Reilkoff, MD, Assistant Professor of Medicine at the University of Minnesota and Director of the Medical Intensive Care Unit at Southdale Hospital, debated the utility of esophageal pressure monitoring in the management of ARDS.

“Things seem to be cyclical in critical care, and esophageal manometry seems to come and go,” Dr. Oeckler said.

And while its use in guiding PEEP titration in ARDS may not have widespread applicability, he said esophageal manometry can provide important information in certain patients, particularly those with severe ARDS where specificity beyond what can be gained by following the PEEP table, for example, is needed.

“I’ll admit that most patients don’t need a balloon, but there are those subsets who do,” Dr. Oeckler said. “I’m really arguing pro-information—as much information as we can have at the bedside to help patients—and esophageal manometry can provide valuable guidance when surrogates fail.”

This year will not mark a “comeback” for esophageal manometry, Dr. Reilkoff countered, for the simple reason that it never garnered widespread clinical use to begin with.

“It’s actually kind of curious because esophageal manometry is appealing to intensivists,” he said. “It clicks all the right buttons—it’s physiologically appealing, the information is of clinical importance and value, and it kind of meets the need to individualize and tailor therapies to our individual patients. So, there’s a bit of a paradox—it’s very popular in thought but not in practice.”

Although esophageal manometry has been an available modality for nearly half a century, Dr. Reilkoff said that a number of hurdles continues to impede its popularity.

“There are multiple logistical and clinical issues that would have to be overcome before esophageal manometry will become common in its application again,” he said. “It requires specific equipment, which equates to cost, and it requires specific training to gain confidence and comfort with its use.”

Additionally, he said its measurement can be cumbersome and inconvenient at best, erroneous at worst, and finally, the clinical benefit of its use is still yet to be determined.

“So, when you add all that up, no, 2021 is not the year esophageal balloon manometry makes a comeback,” Dr. Reilkoff said.