This study evaluates the effect of driving pressure optimization on right ventricular-pulmonary artery (RV-PA) coupling, assessed by TAPSE/PASP ratio, and its association with acute kidney injury (AKI) progression in mechanically ventilated critically ill patients.
Age ≥18 years.
ICU admission.
Invasive mechanical ventilation expected to continue for ≥48 hours.
Adequate transthoracic echocardiographic acoustic window for assessment of TAPSE/PASP.
Pre-existing end-stage renal disease on chronic dialysis.
Severe pulmonic or tricuspid valve disease precluding reliable TAPSE/PASP assessment.
Pre-existing RV dysfunction of a non-pulmonary cause.
Pregnancy.
Parallel
Driving Pressure-Guided Ventilator Optimization
Other interventionA ventilator management strategy in which tidal volume and/or PEEP are titrated to minimize driving pressure (plateau pressure - PEEP) to a pre-specified target, aiming to improve RV-PA coupling and reduce AKI progression.
TAPSE/PASP ratio (RV-PA coupling)
Baseline transthoracic echocardiography will be performed before initiation of the intervention whenever feasible, recording: TAPSE, PASP (estimated from tricuspid regurgitant jet velocity and estimated right atrial pressure), MAPSE (LV longitudinal function parameter), Inferior vena cava (IVC) collapsibility index. Repeat echocardiography will be performed approximately 48-72 hours after initiation of the intervention, using the same measurements.
Acute kidney injury progression
Serum creatinine and urine output will be recorded at baseline and daily for the first 7 days of mechanical ventilation, or until ICU discharge/death if earlier. AKI will be staged according to KDIGO criteria with primary renal endpoint: AKI progression, defined as an increase in KDIGO stage during the 7-day observation period. New AKI and worsening of established AKI may also be described separately.
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