Titrating Optimal PEEP at the Bedside
Determining what is the optimal positive end-expiratory pressure (PEEP) to use in a given patent with acute respiratory distress syndrome (ARDS) has been a controversial topic for several decades now. This controversy, no doubt, exists for two main reasons. One is that there has never been a good ‘gold-standard’ by which to judge success. The other, and more important reason, is that in all likelihood, finding optimal PEEP is an impossible task. All levels of PEEP carry both benefits and detriments. High levels of PEEP have been shown to prevent end-expiratory collapse of lung units and open previously closed units, but come at the expense of potential hemodynamic compromise and overdistention of the lungs. Lower levels of PEEP can avoid these problems but may not be sufficient to recruit or maintain open lung. Added to these difficulties is the fact that the physiology of a patient’s lung with ARDS is constantly changing with fluid shifts, inflammatory responses, body position, and even the effect of the ventilator itself.
KeywordsAcute Respiratory Distress Syndrome Respir Crit Lung Unit Lower Inflexion Point Optimal Peep
Unable to display preview. Download preview PDF.
- 5.Ward NS, Lin D, Houtchens J, et al (2002) Successful determination of lower inflection point and maximal compliance in a population of patients with ARDS. Crit Care Med (in press)Google Scholar
- 8.Hickling KG. Best compliance during a decrementai, but not incremental, positive end-expiratory pressure trial is related to open-lung positive end-expiratory pressure: a mathematical model of acute respiratory distress syndrome lungs. Am J Respir Crit Care Med 163:69–78Google Scholar
- 10.Maggiore SM, Jonson B, Richard JC, Jaber S, Lemaire F, Brochard L (2001) Alveolar derecruitment at decrementai positive end-expiratory pressure levels in acute lung injury. Comparison with the lower inflection point, oxygenation, and compliance. Am J Respir Crit Care Med 164:795–801PubMedCrossRefGoogle Scholar
- 17.Schmitt JM, Vieillard-Baron A, Augarde R, Prin S, Page B, Jardin F (2001) Positive end-ex-spiratory pressure titration in acute respiratory distress syndrome patients: impact on right ventricular outflow impedance evaluated by pulmonary artery Doppler flow velocity measurements. Crit Care Med 29:1154–1158PubMedCrossRefGoogle Scholar