• Roy J Cho, Alex Adams, Sum Ambur, Scott Lunos, Robert Shapiro, and Matthew E Prekker.
• Department of Pulmonary and Critical Care, University of Minnesota, Minneapolis. choxx548@umn.edu.
• Respir Care. 2020 Mar 1; 65 (3): 314-319.

BackgroundWe aimed to investigate the effects of incremental PEEP titration in patients with ARDS on regional diaphragmatic motion with bedside ultrasound.MethodsDorsal diaphragmatic excursion (DDE) and ventral diaphragmatic excursion (VDE) were measured using anatomic M-mode ultrasonography of the right hemidiaphragm as PEEP was randomized to -6, -3, +3, and +6 cm H2O from baseline to achieve a positive transpulmonary pressure. Inter-operator variability of DDE was assessed in 10 separate subjects.ResultsA total of 14 subjects ventilated for ARDS were enrolled. Subjects had a mean age of 54 ± 12 y, mean PaO2 /FIO2 = 137 ± 54 mm Hg, and mean sequential organ failure assessment (SOFA) score = 14 ± 1). Transpulmonary pressure, DDE, and DDE/VDE ratio increased with incremental PEEP titration (-1.15 cm H2O vs 3.63 cm H2O, P < .001; 4.9 mm vs 8.2 mm, P < .001; and 62% vs 93%, P < .001, respectively). When transpulmonary pressure became positive, a visual increase in DDE and DDE/VDE ratio 0.60 to 0.93 was observed (from 0.48 cm to 0.82 cm, R2 = 0.87, P = .02; and R2 = 0.93, P = .006, respectively). There was high agreement in DDE measurements between 2 ultrasonographers (intra-class correlation 0.987, P < .001).ConclusionsDDE was affected by incremental PEEP titration toward a positive transpulmonary pressure. The ultrasound assessment using anatomic M-mode allowed for specific measurement of regional diaphragmatic excursion. This pattern of motion in the dependent regions of the diaphragm during PEEP titration in subjects with ARDS achieving a positive transpulmonary pressure may reflect a potential target for future studies in the bedside assessment for lung recruitment. (Clinical Trials.gov registration NCT02463773.).Copyright © 2020 by Daedalus Enterprises.

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