• Alessandro Protti, Alessandro Santini, Francesca Pennati, Chiara Chiurazzi, Massimo Cressoni, Michele Ferrari, Giacomo E Iapichino, Luca Carenzo, Ezio Lanza, Giorgio Picardo, Pietro Caironi, Andrea Aliverti, and Maurizio Cecconi.
• Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy. Electronic address: alessandro.protti@hunimed.eu.
• Chest. 2022 Apr 1; 161 (4): 979-988.

BackgroundInternational guidelines suggest using a higher (> 10 cm H2O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe ARDS due to COVID-19. However, even if oxygenation generally improves with a higher PEEP, compliance, and Paco2 frequently do not, as if recruitment was small.Research QuestionIs the potential for lung recruitment small in patients with early ARDS due to COVID-19?Study Design And MethodsForty patients with ARDS due to COVID-19 were studied in the supine position within 3 days of endotracheal intubation. They all underwent a PEEP trial, in which oxygenation, compliance, and Paco2 were measured with 5, 10, and 15 cm H2O of PEEP, and all other ventilatory settings unchanged. Twenty underwent a whole-lung static CT scan at 5 and 45 cm H2O, and the other 20 at 5 and 15 cm H2O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above -100 HU) and an increase in the volume of the over-aerated (density below -900 HU) lung compartments, respectively.ResultsFrom 5 to 15 cm H2O, oxygenation improved in 36 (90%) patients but compliance only in 11 (28%) and Paco2 only in 14 (35%). From 5 to 45 cm H2O, recruitment was 351 (161-462) mL and hyperinflation 465 (220-681) mL. From 5 to 15 cm H2O, recruitment was 168 (110-202) mL and hyperinflation 121 (63-270) mL. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them.InterpretationPatients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and Paco2 do not generally improve with a higher PEEP, possibly because of hyperinflation.Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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