🫁 Are CT, LUS, and EIT the missing link to truly personalized ARDS care?
Abstract:
This narrative review argues that integrating chest CT, lung ultrasound (LUS), and electrical impedance tomography (EIT) with key physiology (compliance, driving pressure, transpulmonary pressure, mechanical power) can sharpen ARDS diagnosis and enable more individualized ventilation. The authors endorse a tiered framework—CT for baseline anatomy/recruitability, then LUS/EIT for bedside, real-time functional tracking. They also stress standardization and note that, to date, imaging/pressure-guided strategies haven’t shown clear mortality benefits, underscoring the need for rigorous multicenter RCTs.
Key Insights:
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What it is: A synthesis linking modern imaging with lung mechanics to move from syndromic ARDS to phenotype-guided care.
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CT—baseline map: Use CT early to classify morphology (focal vs non-focal), estimate recruitability (e.g., low vs high PEEP comparisons), and detect overdistension; pair findings with changes in ΔP, Crs, and oxygenation.
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LUS—bedside workhorse: Portable, repeatable, useful for tracking aeration and pleura; operator-dependent and less sensitive to central lesions. PEGASUS will test LUS-guided personalization; meta-analysis suggests no definitive outcome benefit yet.
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EIT—real-time regional ventilation: Supports PEEP titration and detection of inhomogeneity/recruitment but limited by spatial resolution and standardization needs.
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A practical framework: CT to set the stage → LUS/EIT for daily reassessment and titration (PEEP, proning) with attention to discordant signals (e.g., improved oxygenation with worse Crs may reflect V′/Q′ rather than recruitment).
Why This Matters:
Adopting a morpho-functional approach can reduce time spent in injurious zones and personalize support, but proof of outcome benefit is incomplete—teams should pair imaging with mechanics and implement within protocolized, measurable pathways.
Conclusion:
Use CT for baseline phenotype and recruitability, then leverage LUS/EIT for iterative, physiology-aware titration—promising for personalization, unproven for mortality—with standardization and prospective trials still required.
Take-Home for Clinicians:
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Start with CT (low vs high PEEP) to judge recruitability and avoid mismatched strategies.
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Use LUS/EIT at the bedside to track aeration and distribution, guiding PEEP/proning and flagging deterioration.
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Treat discordance as a signal (e.g., better oxygenation + worse Crs → likely V′/Q′ change, not true recruitment); adjust cautiously.
Discussion Question: What single operational threshold (e.g., EIT-derived collapse/overdistension balance) would you adopt in a trial to trigger PEEP changes?
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