Personalized mechanical ventilation guided by lung ultrasound in patients with ARDS: a pilot phase of a randomized clinical trial.

Summary

In the PEGASUS trial’s pilot phase (n=80; 68 assessable), lung ultrasound-based classification of ARDS into focal vs non-focal showed substantial agreement with experts (κ=0.72; 88% accuracy), supporting feasibility of LUS-guided personalized ventilation. Protocol adherence was high, though tidal volumes in non-focal patients randomized to personalized MV slightly exceeded targets, and misclassification clustered in anterior LUS regions.

Key Findings

• Substantial interobserver agreement for LUS-based focal vs non-focal ARDS (Cohen’s κ=0.72; accuracy 88%).
• Misclassification in 11.8% (8/68) of assessable exams, 75% due to anterior region LUS scoring disagreements.
• Protocol adherence was generally good; in non-focal ARDS randomized to personalized MV, median VT was 6.2 ml/kg PBW (above 4–6 ml/kg PBW target), and safety limit violations were infrequent.

Clinical Implications

Clinicians can consider integrating LUS morphology to tailor PEEP, tidal volume, recruitment, and proning strategies; minimize misclassification by careful anterior region scoring and ensure tidal volume targets in non-focal ARDS.

Limitations

• Pilot phase not powered for clinical outcomes
• Image quality insufficient in 12/80 cases; misclassification concentrated in anterior LUS regions
• Slight tidal volume overshoot in non-focal personalized arm

Future Directions

Proceed to the full RCT phase, refine anterior LUS scoring to reduce misclassification, and reinforce VT targeting in non-focal ARDS to test outcome benefits.