Optimum End-Expiratory Airway Pressure in Patients With Acute Pulmonary Failure

Suter, Peter M.; Fairley, H. Barrie; Isenberg, M. D.; Coppel, D. L.

doi:10.1097/00132586-197512000-00055

Cited by 74 publications

(105 citation statements)

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“…The appropriate level of PEEP should correspond to the lowest dead-space fraction (V D /V T ), as has been reported many years ago by Suter et al 66 and more recently by Fengnei et al 28 Because end-tidal P CO 2 (P ETCO 2 ) is determined, in part, by V D /V T , there has been interest in the use of capnography to assess best PEEP. In an experimental model of ARDS, Murray et al 67 reported that best PEEP was associated with the smallest difference between P aO 2 and P ETCO 2 .…”

Section: Gas Exchangementioning

confidence: 94%

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Recruitment Maneuvers and PEEP Titration

2015

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The injurious effects of alveolar overdistention are well accepted, and there is little debate regarding the importance of pressure and volume limitation during mechanical ventilation. The role of recruitment maneuvers is more controversial. Alveolar recruitment is desirable if it can be achieved, but the potential for recruitment is variable among patients with ARDS. A stepwise recruitment maneuver, similar to an incremental PEEP titration, is favored over sustained inflation recruitment maneuvers. Many approaches to PEEP titration have been proposed, and the best method to choose the most appropriate level for an individual patient is unclear. A PEEP level should be selected that balances alveolar recruitment against overdistention. The easiest approach to select PEEP might be according to the severity of the disease: 5-10 cm H 2 O PEEP in mild ARDS, 10 -15 cm H 2 O PEEP in moderate ARDS, and 15-20 cm H 2 O PEEP in severe ARDS. Recruitment maneuvers and PEEP should be used within the context of lung protection and not just as a means of improving oxygenation.

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Section: Gas Exchangementioning

confidence: 94%

“…Suter et al 66 first described this in 1975. They conducted a physiologic study of 15 subjects in acute respiratory failure; because some subjects were reported to be breathing an F IO 2 of 0.21, presumably some did not have ARDS.…”

Section: Compliancementioning

confidence: 97%

Recruitment Maneuvers and PEEP Titration

2015

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“…The use of PEEP, however, may be associated with undesirable effects including lowering of CO (14,15,17,24,26,28,44,46) and overdistention of alveoli leading to a fall in C (5,6, 12,27,44). In the present studies, the time-course of changes in relevant cardiopulmonary parameters induced by PEEP has been evaluated in normal, spontaneously breathing, anesthetized dogs.…”

Section: Speculationmentioning

confidence: 98%

“…PEEP can be most effective in the treatment of neonatal respiratory distress and other diseases characterized by low pulmonary dynamic compliance (C), low FRC, and intrapulmonary right-toleft shunts (5,17, 18,21,25,28,44,46,47). The use of PEEP, however, may be associated with undesirable effects including lowering of CO (14,15,17,24,26,28,44,46) and overdistention of alveoli leading to a fall in C (5,6, 12,27,44).…”

Section: Speculationmentioning

confidence: 99%

“…Transmission of applied airway pressure will be greatest when the Csp of the lungs is highest; i t may be reduced significantly if either insufficient or excessive levels are used for a given clinical situation. The pleural pressure vs. applied PEEP relationship thus provides a sensitive index of changing status of the lungs, as well as an assessment of therapeutic efficacy.PEEP can be most effective in the treatment of neonatal respiratory distress and other diseases characterized by low pulmonary dynamic compliance (C), low FRC, and intrapulmonary right-toleft shunts (5,17, 18,21,25,28,44,46,47). The use of PEEP, however, may be associated with undesirable effects including lowering of CO (14,15,17,24,26,28,44,46) and overdistention of alveoli leading to a fall in C (5,6, 12,27,44).…”

mentioning

confidence: 99%

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Cardiopulmonary Consequences of Positive End-Expiratory Pressure

Holzman

Scarpelli

1979

Pediatr Res

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SummaryPositive end-expiratory pressure (PEEP), while of major benefit in the therapy of pulmonary diseases characterized by low functional residual capacity (FRC), is frequently associated with depression of cardiac output (CO) and specific dynamic compliance (Csp). The cardiopulmonary consequences of sequential increases of PEEP (3,6,9, 12, 15 cm HzO) in normal dogs were studied utilizing an apparatus that permits measurement of FRC by helium dilution while the animal remains on PEEP. I t was found that increasing levels of PEEP had no effect on tidal volume (VT) or inspiratory time, but appeared to lengthen expiratory time by delaying expiratory flow until the preinspiratory period, and led to facilitated expiration. This response occurred immediately upon changes in the level of PEEP and is felt to be reflex in nature. FRC increased and Csp fell as PEEP was increased. This was reflected in a fall in transmission of applied airway pressure to an esophageal balloon. Pulmonary hypertension did not develop in our animals, but net right atrial (RA) pressure was elevated by PEEP. There was no difference in cardiac index (CI) between the control and study groups. Both the magnitude of applied airway pressure and the extent to which i t is transmitted across the lungs to the pleural space appear to be determinants of possible effects of PEEP on CO and may explain the diversity of results among reported studies of PEEP. Transmission of pressure is related directly to Csp. SpeculationTransmission of PEEP to the pleural space is dependent on the level of PEEP and on the preexisting state of the lungs. Transmission of applied airway pressure will be greatest when the Csp of the lungs is highest; i t may be reduced significantly if either insufficient or excessive levels are used for a given clinical situation. The pleural pressure vs. applied PEEP relationship thus provides a sensitive index of changing status of the lungs, as well as an assessment of therapeutic efficacy.PEEP can be most effective in the treatment of neonatal respiratory distress and other diseases characterized by low pulmonary dynamic compliance (C), low FRC, and intrapulmonary right-toleft shunts (5,17, 18,21,25,28,44,46,47). The use of PEEP, however, may be associated with undesirable effects including lowering of CO (14,15,17,24,26,28,44,46) and overdistention of alveoli leading to a fall in C (5,6, 12,27,44). In the present studies, the time-course of changes in relevant cardiopulmonary parameters induced by PEEP has been evaluated in normal, spontaneously breathing, anesthetized dogs. The objective was to study, comprehensively in each subject, the broad spectrum of changes that may be induced by PEEP and their possible interrelations, and to compare these with control animals that were handled identically except for PEEP. These studies indicate that the extent to which pulmonary C is altered is the important determinant of PEEP transmission to the thorax and of the consequent effects of PEEP on intrathoracic pressures and cardiovascular functi...

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Gas Exchange in the Respiratory Distress Syndromes

Albert

Jobe

2012

Comprehensive Physiology

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This article describes the gas exchange abnormalities occurring in the acute respiratory distress syndrome seen in adults and children and in the respiratory distress syndrome that occurs in neonates. Evidence is presented indicating that the major gas exchange abnormality accounting for the hypoxemia in both conditions is shunt, and that approximately 50% of patients also have lungs regions in which low ventilation-to-perfusion ratios contribute to the venous admixture. The various mechanisms by which hypercarbia may develop and by which positive end-expiratory pressure improves gas exchange are reviewed, as are the effects of vascular tone and airway narrowing. The mechanisms by which surfactant abnormalities occur in the two conditions are described, as are the histological findings that have been associated with shunt and low ventilation-to-perfusion.

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Optimum End-Expiratory Airway Pressure in Patients With Acute Pulmonary Failure

Cited by 74 publications

References 0 publications

Recruitment Maneuvers and PEEP Titration

Recruitment Maneuvers and PEEP Titration

Cardiopulmonary Consequences of Positive End-Expiratory Pressure

Gas Exchange in the Respiratory Distress Syndromes

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