Identifying and treating intrinsic PEEP in infants with severe bronchopulmonary dysplasia

Rationale Infants with severe bronchopulmonary dysplasia (sBPD) and airway obstruction may develop dynamic hyperinflation and intrinsic positive end‐expiratory pressure (PEEP i ), which impairs patient/ventilator synchrony. Objectives To determine if PEEP i is present in infants with sBPD during spontaneous breathing and if adjusting ventilator PEEP improves patient/ventilator synchrony and comfort. Methods Interventional study in infants with sBPD. PEEP i measured by esophageal pressure (Pes) and pneumotachometer, during pressure‐supported breaths. PEEP i defined as the difference between Pes at start of the inspiratory effort minus Pes at onset of inspiratory flow. The set PEEP was adjusted to minimize PEEP i . “Best PEEP” was the setting with minimal wasted efforts (WE), an inspiratory effort seen on the Pes waveform without a corresponding ventilator breath. FiO 2 and SpO 2 measured pre‐ and post‐PEEP adjustment. Sedation requirements evaluated 72 hours preprocedure and postprocedure. Results Twelve infants were assessed (gestational age, 24.9 ± 1.4 weeks; study age, 48.8 ± 1.5 weeks, postmenstrual age). Mean baseline ventilator PEEP was 16.4 cm H 2 O (14‐20 cm H 2 O). Eight infants required an increase, one, a reduction, and three, no change in the set PEEP. For the eight infants requiring an increase in set PEEP, there was an 18.9% reduction in WE and a reduction in FiO 2 (0.084   ±   0.058) requirements in the subsequent 24 hours. Conditional sedation was reduced in five infants postprocedure. No adverse events occurred during testing. Conclusion PEEP i is measurable in infants with sBPD with concurrent esophageal manometry and flow‐time tracings without the need for pharmacological paralysis. In those with PEEP i , increasing ventilator PEEP to offset PEEP i improves synchrony.