STRATEGIES TO SET PEEP

AND TO ACHIEVE LUNG

RECRUITMENT
JCCA
7 – 8 November 2018
Phase Variables

1. The change from expiration to inspiration

HOW VENTILATOR
2. Inspiration
STARTS

3. The change from inspiration to expiration

HOW VENTILATOR SUSTAINS

HOW VENTILATOR STOPS AN INSPIRATION

4. Expiration

WHAT VENTILATOR DOES BETWEEN INSPIRATION

Phase Variables

1. The change from expiration to inspiration

TRIGGER VARIABLES
HOW VENTILATOR
2. Inspiration
STARTS

3. The change
TARGET VARIABLES
from inspiration to expiration
HOW VENTILATOR SUSTAINS

4. Expiration CYCLE
HOW VENTILATOR VARIABLES
STOPS AN INSPIRATION

BASELINE VARIABLES
WHAT VENTILATOR DOES BETWEEN INSPIRATION

navy lolong
Baseline variables
•Positive End-Expiratory Pressure

PEEP
POSITIVE END-EXPIRATORY PRESSURE (PEEP)

•PEEP as it is commonly used

implies that the patient is receiving
mechanical ventilatory support and
the baseline (i.e.,end-expiratory)
pressure is above zero cm H2O.
Hypoxemia
How to treat hypoxemia….?

•Increase FiO2
•Easiest way
Is it wise to use high FiO2 ?

•NO
•Oxygen toxicity could
start from FiO2 28%
So…is there any other way ?

•Use PEEP
How does PEEP treat hypoxemia ?

•By opening the atelectated alveoli

•BUT, in stable way
•NO cycling opening / closing
= ycling Opening/Closing

Stable alveoli Unstable alveoli

Schiller HJ, Crit Care Med 2001

Steinberg JM, AJRCCM 2004
Indications for PEEP Therapy
• Bilateral infiltrates on chest radiograph
• Cardiogenic edema
• Recurrent atelectasis with low functional
residual capacity (FRC)
• Reduced lung compliance (CL)
• PaO2 <60 mm Hg on FIO2s >0.5
• PaO2/FIO2 ratio <300 for ARDS*
• Refractory hypoxemia: PaO2 increases <10
mmHg with FIO2 increase of 0.2
PEEP & RECRUITMENT
•PEEP 0
PEEP & RECRUITMENT
•PEEP 5
PEEP & RECRUITMENT
•PEEP 8
PEEP & RECRUITMENT
•PEEP 10
PEEP & RECRUITMENT
•PEEP 12
BUT …..
OVERDISTENTION
Is there PEEP in this waveforms ?
Positive End Expiratory Pressure
PEEP range
• Minimum or Low PEEP
• PEEP 3 - 5 cm H2O
• to help preserve a patient’s normal functional residual
capacity (FRC).
• FRC usually decreases when a patient is intubated or
placed in a supine position.
• Therapeutic PEEP
• PEEP is ≥5 cm H2O.
• It is used in the treatment of refractory hypoxemia
• Complications. Physiological response to therapy must be
monitored carefully.
Optimum PEEP
• is the level at which the maximum beneficial effects of PEEP occur
• This level of PEEP is also considered optimal because it is not
associated with profound cardiopulmonary side effects, such as :
• decreased venous return,
• decreased cardiac output,
• ecreased blood pressure (BP),
• increased shunting,
• increased VD/VT,
• barotrauma, and volutrauma,
• and it is accomplished at safe levels of inspired oxygen (FIO2 <0.40).
• the PEEP at which static compliance is highest as PEEP is decreased
following a recruitment maneuver (RM).
INITIATING PEEP THERAPY
•PEEP or CPAP should be initiated early in
the course of therapy to avoid lung
damage from high pressures, volumes,
and FIO2
Optimum PEEP
• PEEP is usually increased in increments of 3 to 5 cm H2O
Simple PEEP TABLE
PEEP should be set
AT LEAST at this level

• Below the lower inflection point (a), increased pressure may

recruit airless alveoli.
• Between the lower and upper inflection points (b), open
alveoli distend with increased pressure.
• Above the upper inflection point (c), alveoli may overdistend
with increased pressure and become injured.
But ..

•As PEEP increased more and more….

•More collapsed alveoli opened and
preserve….
•But more alveoli become over extended
Alveoli distention by CT scan
Barotrauma risk
is increasing …
Example :

3 different lung condition

by CT scan
Monitor
• Patient appearance
• Blood pressure
• Breath sounds
• Static compliance
• PaO2, PaO2/FiO2 ratio
• PaCO2, pH
• Cardiac output
Contraindications for PEEP
•Hypovolemia (relative)
•Pneumothorax
•High Intra Cranial Pressure (relative)
•MAP, CVP, PaCO2
•Emphysema
Staircase Recruitment Manoeuvre
• Using pressure controlled ventilation adjust FiO2 to
target SaO2 90-92%
• Set Pi to 15 cm H2O above the PEEP and maintain
this difference
• Increase PEEP in a stepwise manner to 20, then 30
and then 40 cm H2O with adjustments made every
two minutes (i.e. Pi will reach 55 cmH20)
Staircase Recruitment Manoeuvre (2)

• Reduce PEEP to 25, then 22.5, then 20, then 17.5 or

then an absolute minimum of 15 cm H2O every three
minutes until a decrease in SaO2 ≥ 1% from maximum
SaO2 is observed (the derecruitment point)
• Increase PEEP to 40 cm H2O for one minute then
return to a PEEP level 2.5 cm H2O above the
derecruitment point (the optimal PEEP)
• Adjust to tidal volume ≤ 6 mls/kg IBW and a plateau
pressure ≤ 30 cm H2O, tolerate permissive hypercapnia
if pH >7.15, can increase RR up to 38/min (max)
SRM should be stopped if:

•HR < 60 or > 140/min

•New dysrhythmia
•SBP <80 mmHg
•SaO2 < 85%
Take home message

• Positive end-expiratory pressure (PEEP) increases

functional residual capacity and maintains
recruitment of unstable lung units.
• Alveolar recruitment resulting from PEEP decreases
shunt and improves oxygenation.
• The effect of PEEP on hemodynamic function is
dependent on the level of PEEP, the compliance of
the respiratory system, and cardiovascular status
Thank You