Lung recruitment during mechanical positive pressure ventilation in the PICU: what can be learned from the literature?

Abstract

Summary A literature review was conducted to assess the evidence for recruitment manoeuvres used in conventional mechanical positive pressure ventilation. A total of 61 studies on recruitment manoeuvres were identified: 13 experimental, 31 ICU, 6 PICU and 12 anaesthesia studies. Recruitment appears to be a continuous process during inspiration and expiration and is determined by peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP). Single or repeated recruitment manoeuvres may result in a statistically significant increase in oxygenation; however, this is short lasting and clinically irrelevant, especially in late ARDS and pneumonia. Temporary PIP elevation may be effective but only after PEEP loss (for example disconnection and tracheal suctioning). Continuous PEEP elevation and prone positioning can increase Pao2 significantly. Adverse haemodynamic or barotrauma effects are reported in various studies. No data exist on the effect of recruitment manoeuvres on mortality, morbidity, length of stay or duration of mechanical ventilation. Although recruitment manoeuvres can improve oxygenation, they can potentially increase lung injury, which eventually determines outcome. Based on the presently available literature, prone position and sufficient PEEP as part of a lung protective ventilation strategy seem to be the safest and most effective recruitment manoeuvres. As paediatric physiology is essentially different from adult, paediatric studies are needed to determine the role of recruitment manoeuvres in the PICU.

Use of recruitment maneuvers during mechanical ventilation in pediatric and neonatal intensive care units in the Netherlands

“…The maximal reported RM pressures -significantly higher in PICUs than in NICUs -are similar to those applied in clinical studies [1]. The recruitment pressures needed to open alveoli depend on lung condition, being substantially higher in the diseased lung (up to 45 cmH 2 O in ARDS) [6] than in healthy lungs, in which 25-30 cmH 2 O -and in lowbirth-weight infants probably lessis sufficient [7,8].…”

“…These data show a diversity corresponding with numerous publications on RM with different strategies and inconsistent results which we recently reviewed extensively [1]. A combined PIP and PEEP elevation, as used by most centers, is theoretically the most effective mode, as recruitment and derecruitment are continuous processes throughout the ventilatory cycle, during which PIP recruits alveoli and PEEP maintains alveolar patency [2].…”

“…However, despite the absence of reported adverse effects on lung injury, and possible advantages of RM, a critical review of the literature regarding both short-term effectsoxygenation, hemodynamics -and long-term parameters -morbidity and lung injury -does not support the routine use of RM [1]. In a large clinical RM study (n = 72) a temporary clinically irrelevant increase in TcSaO 2 (1.7%) was found [11].…”

“…Although the beneficial effects of recruitment maneuvers (RM) during conventional mechanical ventilation (CMV) are unclear and the incidence of adverse effects is unknown [1], RM seem to be widely employed. We investigated the use of RM in all Dutch pediatric (n = 8) and neonatal (n = 10) intensive care units.…”

Neonatal Pneumothorax Pressures Surpass Higher Threshold in Lung Recruitment Maneuvers: An In Vivo Interventional Study

“…16,17 Barotrauma is one of the major clinical concerns, especially in neonates and infants, due to their infinite thorax compliance, which makes them particularly sensitive to increases in airway pressure and prone to pneumothorax. 18,19 Most studies regarding recruitment maneuvers have been conducted in adult lungs with ARDS, 1,10,11,20 and information regarding the response to recruitment maneuvers in either healthy or sick pediatric patients is scarce.…”