Recruitment Maneuvers and PEEP Titration

Abstract

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.

Effect of individualized PEEP titration guided by intratidal compliance profile analysis on regional ventilation assessed by electrical impedance tomography – a randomized controlled trial

“…With regard to the conflicting clinical data regarding the setting of adequate PEEP during general anesthesia, many techniques have been developed to determine adequate PEEP [5][6][7][8]. One technique, first described in 1979 for patients with severe lung injury [9], is based on setting the PEEP slightly above the lower inflection point of the inspiratory limb of the static pressure-volume curve [5,10,11].…”

Postoperative Pulmonary Complications: An Epidemiological, Risk Factors and Prevention Review

“…Meta-analysis showed that there is a reduction in hospital mortality with the use of high levels of PEEP compared to low levels in patients with PaO 2 :FiO 2 <200 mm Hg [28]. The application of PEEP will be in accordance with the classification of ARDS, according to Berlin Definiton, with higher PEEP levels being applied, when the severity of the syndrome is higher: 5-10 cm H 2 O PEEP in patients with mild ARDS, 10-15 cm H 2 O in patients with moderate and 15-20 cm H 2 O in patients with severe [32,33]. Although Gattinoni et al state that the better the PEEP, the better the oxygenation, they also say that the best PEEP does not exist [32].…”

“…Many approaches have been proposed to select the most appropriate PEEP value and, in general, it was found that hypoxemia rates were lower when higher levels of PEEP were used [28,33]. Currently, the selection of the PEEP can be taken according to the severity of ARDS, as mentioned [32,33].…”

Electrical impedance tomography in clinical use: Unnecessary technology or a unique angle in respiratory monitoring?

“…4 The largest studies have been performed in adult patients with acute respiratory distress syndrome (ARDS) around recruitment maneuvers and positive end-expiratory pressure (PEEP) titration. 6 It has also been proven to be a useful tool to help the clinician to minimize ventilatorinduced lung injury. 7 The setting of an ideal PEEP in patients with ARDS to minimize areas of atelectasis and alveolar strain is a challenge for clinicians.…”