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Intrinsic PEEP(PEEPi), Gas Trapping and the expiratory hold manoeuvre

The EXPIRATORY BREATH HOLD manoeuvre to measure intrinsic PEEP

Intrinsic PEEP

Pressure Machine PEEP

The Physics of Intrinsic PEEP:

Airway opening pressure

Flow
Alveolar pressure

When you exhale,

airflow is driven by the difference between these two pressures.

Volume The difference is created by the elastic recoil of the lungs and
the chest wall.
The Expiratory breath Hold The flow of air out of the lungs is also resisted by the
If there is gas trapped in the alveoli, and expiration is not sufficient EXPIRATORY AIRWAY RESISTANCE
in clearing that gas out, a certain amount of positive pressure will
still be found in the lungs following expiration.
Typically, it takes 1.5 seconds to exhale a tidal breath.
This positive pressure is termed “intrinsic PEEP”
Things which increase intinsic PEEP are things which
An expiratory breath hold stops all flow in the airways; so you can - Impair elastic recoil
eliminate the expiratory airway resistance (the flow dependent o Emphysema
component of intrinsic PEEP). - Increase expiratory resistance
o Bronchospasm
Thus you are able to measure the “static PEEP”, the PEEP due to the o Airway collapse at the equal-pressure point
elastic recoil of the lungs putting pressure on the gas trapped inside them. (where intrathoracic pressure equals
GAS TRAPPING intrabronchial pressure)
VOLUME CONTROLLED ACV o
This is called “gas trapping”,
or Dynamic Hyperinflation.

The key issue is that

THERE IS NOT ENOUGH
Pressure
TIME FOR EXPIRATION.
The flow fails to reach zero; another breath has been
taken before the lungs have had a chance to empty. The solution to this problem is
Observe: it takes a while for the flow to reach
to increase the I:E ratio.
zero. This is a sign of airway obstruction, eg The patient needs more time
bronchospasm.
to exhale the volume.
o
Flow

Volume control target

Volume

With “Basic Assessment and Support in Intensive Care” by Gomersall et all as a foundation, I built using the humongous and canonical “Principles and Practice of Mechanical Ventilation” by Tobins et al – the 1442 page 2 nd edition