Lung ultrasound-guided PEEP titration in COVID–19 patients treated with CPAP

Abstract Objectives An increasing number of COVID–19 patients were treated with continuous positive airways pressure (CPAP). To evaluate the clinical effects of personalized positive end-expiratory pressure (PEEP) compared to standard fixed PEEP in COVID-19 patients requiring CPAP. Methods This is a single center, prospective, randomized clinical study. Sixty-three COVID-19 patients with hypoxemic respiratory failure and bilateral pneumonia were randomized in two Groups: Group A received CPAP with fixed PEEP of 10 cm H 2 O, Group B performed the “PEEP trial”, that consists in the evaluation of best PEEP defined as the PEEP value that precedes the echographic appearance of “lung pulse” determining a PaO 2 /FiO 2 increase. Primary outcome was composite in-hospital mortality + intubation, secondary outcome was the percentage increase of PaO 2 /FiO 2 . As safety indicator, the incidence of pneumothorax was collected. Results Thirty-two patients were enrolled in Group A and 31 in Group B . The two groups were comparable for clinical characteristics and laboratory parameters. The primary outcome occurred in 36 (57.1 %) patients: 23 (71.8 %) in Group A and 13 (41.9 %) in Group B (p<0.01). Mortality was higher in Group A (53.1 vs. 19.3 %, p<0.01), while intubation rate was comparable between groups. Group B showed a higher PaO 2 /FiO 2 increase than Group A (34.9 vs. 13.1 %, p<0.01). Five cases of pneumothorax were reported in Group A , none in Group B . Conclusions Lung ultrasound-guided PEEP trial is associated with lower mortality in COVID-19 patients treated with CPAP. Identifying the best PEEP is useful to increase oxygenation and reduce the incidence of complications.