Abstract
CPPV (continuous positive pressure ventilation) is obviously superior to IPPV (intermittent positive pressure ventilation) for the treatment of patients with acute respiratory insufficiency (ARI) and results within a few minutes in a considerable increase in the oxygen transport.
The principle is to add a positive end-expiratory plateau (PEEP) to IPPV, with a subsequent increase in FRC (functional residual capacity) resulting in re-opening in first and foremost,the declive alveolae, which can then once again take part in the gas exchange and possibly re-commence the disrupted surfactant production. In this manner the ventilation/perfusion ratio in the diseased lungs is normalized and the intrapulmonary shunting of venous blood\((\dot Q_s /\dot Q_t )\) will decrease. At the same time the dead space ventilation fraction (VD/VT) normalizes and the compliance of the lungs (CL) increases.
The PEEP value, which results in a maximum oxygen transport, and the lowest dead space fraction, also appears to result in the greatest total static compliance (CT) and the greatest increase in mixed venous oxygen tension\((P\bar vo_2 )\); this value can be termed “optimal PEEP”.
The greater the FRC is, with an airway pressure = atmospheric pressure, the lower the PEEP value required in order to obtain maximum oxygen transport.
If the optimal PEEP value is exceeded the oxygen transport will fall because of a falling\(\dot Q_t \) (cardiac output) due to a reduction in venous return. CT and\(P\bar vO_2 \) will fall and VD/VT will increase. Increasing hyperinflation of the alveolae will result in a rising danger of alveolar rupture.
The critical use of CPPV treatment means that the lungs may be safeguarded against high oxygen percents.
The mortality of newborn infants with RDS (respiratory distress syndrome) has fallen considerably after the general introduction of CPPV and CPAP (continuous positive airway pressures). The same appears to be the case with adults suffering from ARI (acute respiratory insufficiency).
Article PDF
Similar content being viewed by others
Abbreviations
- (A-a)DO2 :
-
Alveolo - arterial - O2 - difference
- ARI:
-
Acute respiratory insufficiency
- CaO2 :
-
Arterial O2-content
- \(\frac{{CaO_2 - C\bar vO_2 }}{{CaO_2 }}\) :
-
O2-extraction ratio
- \((CaO_2 - C\bar vO_2 ) \times \dot Q_t = \dot VO_2 \) :
-
O2-uptake, consumption
- CC:
-
Closing capacity
- CV:
-
Closing volume
- CPAP:
-
Continuous positive airway pressure
- CPPV (IPPV + PEEP):
-
Continuous positive pressure ventilation
- CL :
-
Lung compliance
- CT :
-
“Total static compliance”
- \(C\bar vO_2 \) :
-
Mixed venous O2-content (“O2-reserve”)
- ETP:
-
End Tidal point
- ERV:
-
Expiratory reserve volume
- FRC:
-
Functional residual capacity
- IC:
-
Inspiratory capacity
- IPPV:
-
Intermittent positive pressure ventilation
- IRV:
-
Inspiratory reserve volume
References
Alexander, J. I., Spence, A. A., Parikh, R. K., Stuart, B.: The role of airway closure in post-operative Hypoxaemia. Brit. J. Anaesth. 45, 34 (1973)
Ashbaugh, D. G., Petty, Th. L.: Positive end-expiratory pressure. Physiology, Indications and contraindications. J. thorac. cardiovasc. Surg. 56, 165 (1973)
Barach, A. L., Martin, J., Eckmann, M.: Positive pressure respiration and its application to the treatment of acute pulmonary edema. Ann. Intern. Med. 12, 754 (1938)
Bartlett, R. H., Gazzaniga, A. B., Wilson, A. F., Medley, T., Wetmore, N.: Mortality prediction in adult respiratory insufficiency. Chest 67, 680 (1975)
Benveniste, D. & Pedersen, J.-E. P.: A valve substitute with no moving parts, for artificial ventilation in newborn and small infants. Brit. J. Anaesth. 40, 464 (1968)
Buhain, W. J., Brody, J. S. & Fischer, A. B.: Effect of artificial airway obstruction on elastic properties of the lung. J. appl. Physiol. 33, 589 (1972)
Carden, E., Levin, K., Fisk, G., Vidyasagar, D.: A new method of providing continuous positive pressure breathing in infants. Paediatrics 53, 757 (1974)
Cheney, F. W.: The effects of tidal-volume change with positive end-expiratory pressure in pulmonary edema, Anaesthesiology 37, 600 (1972)
Christiansen, P. M., Kamper, J., Peitersen, B., Baekgaard, P., Frits-Hansen, B.: Teknik og methoe ved behandling of “respiratory distress” — syndrom med overtryk i luftvejene (continuous positive airway pressure) Ugeskr. laeg. 135, 2212 (1973)
Colgan, F. J., Nichols, F. A., De Weese, J. A.: Positive end-expiratory pressure, oxygen Transport and the low-output state. Anaesth. Analg. Curr. Res. 53, 538 (1974)
Craig, D. B., McCarthy, D. C.: Airway closure and lung volumes during breathing with maintained airway positive pressures. Anaesthesiology 36, 540 (1972)
Dobbinson, T. L., Nisbet, H. I. A., Pelton, D. A. & Levison, H.: FRC and compliance in anaesthetized paralysed children. Part II. Canad. Anaesth. Soc. J. 20, 322 (1973)
Don, H. F., Craig, D. B., Wahba, W. M. & Canture, J. G.: The measure of gas trapped in the lungs at FRC and the effects of posture. Anaesthesiology 35, 582 (1971)
Don, H. F., Wahba, W. M. & Craig, D. B.: Airway closure, gas trapping and the functional residual capacity during anaesthesis. Anaesthesiology 36, 533 (1972)
Falke, K. J., Pontoppidan, H., Kumar, A., Leith, A. E., Geffin, B., Laver, M. B.: Ventilation with end-expiratory pressure in acute lung disease. J. clin. Invest. 51, 2315 (1972)
Frits-Hansen, B.: Behandling med assisteret ventilation ved respirationsinsufficeins hos nyfødte. Tidskr. Norsk. Laegef. 94, 686 (1974)
Giordano, J. M., Joseph, W. L., Klingenmaier, C. H. & Adkuis, P. C.: The management of interstitial pulmonary edema. Significance of hypoproteinaemia. J. thorac. cardiovasc. Surg. 64, 739 (1972)
Gregory, G. A., Kittermann, J. A., Phibbs, R., Today, W. H., Hamilton, W. K.: Treatment of the idiopathic respiratory distress syndrome with continuous positive airway pressure. New Engl. J. Med. 284, 1333 (1971)
Guyton, A. C.: Regulation of cardial output. Anesthesiology, 29, 314 (1968)
Hall, S. V., Johnson, E. E., Hedley-Whyte, J.: Renal hemodynamics and function with continuous positive-pressure ventilation in dogs. Anesthesiology 41, 452 (1974)
Harris, Th. R., Stevens, R. C., Nugent, M.: On the use of nasal continuous airway pressure. Paediatrics 53, 768 (1974)
Hellberg, M., Källskog, H., Wolgast, M.: Effect of hemorrhage on single glomerular blood flow of related to control hemodynamics and acid-base balance. Acta anaesth scand. 17, 27 (1973)
Henriksen, H.: Lesson on acute respiratory insufficiency in Odense 13. 01. 1975
Herman, S., Reynolds, E. O. R.: Methods for improving oxygenation in infants mechanically ventilated for severy hyaline membrane disease. Arch. Dis. Childh. 48, 612 (1973)
Heslet Andersen, L., Bø, G., Sundstrøm, G., Wranne, B.: Closing volume, influence of extrabronchial factors. Scand. J. clin. Lab. Invest 34, 00 (1974)
Heslet Andersen, L., Johansen, J. K., Hyldebrandt, N.: The regional pattern of pulmonary blood flow as a function of central hemodynamic data in patients with mitral valve disease, studied by xenon radiospirometry. In press
Johnson, E. E. & Hedley-Whyte, J.: Continuous positive-pressure ventilation and portal flow in dogs with pulmonary edema. J. appl. Physiol. 33, 385 (1972)
Jørgensen, S., Straede Nielsen, J. & Ultang, F.: Circulation and gas tensions during continuous positive pressure ventilation. Proceedings of the Vth Europ. Congress of Cardiology (Athens, Sept. 1968)
Kaneko, K., Milic-Emilie, J., Dolovich, M. B., Dawson, A., Bates, D. V.: Regional distribution of ventilation and perfusion as a function of body position. J. appl. Physiol. 21, 767 (1966)
Kamper, J., Baekgaard, P., Peitersen, B., Christiansen, P. M., Tygstrup, J., Friis-Hansen, B.: Behandling of respiratory “distress” syndrom med overtryk i luftvejene (continuous positive airway pressure). Ugeskr. Laeg. 35, 2207 (1973)
Kelman, G. R., Nunn, J. F., Prys-Roberts, C., Greenbaum, R.: The influence of cardiac output on arterial oxygenation, a theoretical study. Brit. J. Anaesth. 39, 450 (1967)
Kirby, R. R., Downs, J. B., Civetta, J. M., Modell, J. H., Danemiller, F. J., Klein, E. F., Hodges, M.: High level positive end expiratory pressure (PEEP) in acute respiratory insufficiency. Chest 67, 156 (1975)
Kumar, A., Falke, K. I., Geffin, B., Aldredge, C. F., Laver, M. B., Loewenstein, E., Pontoppidan, H.: Continuous positive-pressure ventilation in acute respiratory failure. Effects on hemodynamics and lung function. New Engl. J. Med. 238, 1430 (1970)
Lamy, M., Deghislage, J., Lamalle, D., Hanguet, M.: Hemodynamic effects of intermittent or continuous positive-pressure breathing in man. Acta anaesth. belg. 3, 270 (1973)
Lutch, J. S., Murray, J. D.: Continuous positive pressure ventilation. Effects on systemic oxygen transport and tissue oxygenation. Ann. Intern. Med. 76, 193 (1972)
Lysons, D. F., Cheney, F. W.: End-expiratory pressure in dogs with pulmonary edema breathing spontaneously. Anaesthesiology 37, 518 (1972)
McIntyre, R. W., Laws, A. K., Ramachandran, P. R.: Positive expiratory pressure plateau: Improved gas exchange during mechanical ventilation. Canad. Anaesth. Soc. J. 16, 477 (1969)
Molnar, I., Refsum, H. E.: Influence of simultaneous and equal increase in external dead space and tidal volume on arterial blood gases in artificially ventilated patients. Acta anaesth. scand. 18, 161 (1974)
Pedersen, O. F., Kampmann, H. & Nielsen, T. M.: Lukningsvolumen, “Closing Volume”. En ny lungefunktionsparameter. Ugeskr. Laeg. 49, 2671 (1973)
Petty, Th. C. & Ashbaugh, D. G.: The adult respiratory distress syndrome. Clinical features, factors influencing prognosis and principles of management. Chest 60, 233 (1971)
Pontoppidan, H., Geffin, B. C., Loewenstein, E.: Acute respiratory failure in the adult. New Engl. J. Med. 287, 690 (1972)
Pratt, P. P.: Pathology of pulmonary oxygen toxicity. Amer. Rev. resp. Dis. 110, 51 (1974)
Qvist, J., Pontoppidan, H., Wilson, R. S., Loewenstein, E., Laver, M. B.: Hemodynamic responses to mechanical ventilation with PEEP: The effect of hypervolaemia. Anesthesiology 42, 45 (1975)
Rein, H., Schneider, M.: Physiologic des Menschen. Berlin, Göttingen, Heidelberg: Springer 1960
Rehder, K., Wenthe, F., Sessler, A. D.: Function of each lung during mechanically ventilation with ZEEP and with PEEP in man anaestetized with thiopental-meperidine. Anesthesiology 89, 597 (1973)
Shubrooks, S. J., jr.: Positive pressure breathing as a protective technique during + Gz acceleration. J. appl. Physiol. 35, 294 (1973)
Sugerman, H. J., Rogers, R. M., Miller, L. D.: Positive End-expiratory Pressure: Indication and physiologic considerations. Chest 62, 86 (1972)
Suter, P. M., Fairley, B. H., Isenberg, M. D.: Optimum end-expiratory airway pressure in patients with acute pulmonary failure. New Engl. J. Med. 284 (1975)
Trichet, B., Falke, K., Togert, A., Laver, M. B.: The effect of pre-existing pulmonary vascular disease on the response to mechanical ventilation with PEEP following open-heart surgery. Anesthesiology, 42, 56 (1975)
Vidyasager, D., Pildes, R. S., Salem, M. R.: Use of Amsterdam infant ventilator for continuous positive pressure breathing. Critical Care Med. 2, 89 (1974)
Webb, H. H., Tierney, D. F.: Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures: Protection by positive end-expiratory pressure. Amer. rev. Resp. Dis. 41, 3 (1974)
Weenig, C. S., Pietak, S., Hickey, R. F., Fairley, H. B.: Relationship of preoperative closing volume to FRC and alveolararterial oxygen difference during anaesthesia with controlled ventilation. Anesthesiology 41, 3 (1974)
Westbrook, P. R., Stubbs, S. E., Sessler, A. D., Rehder, K., Hyatt, E.: Effects of anaesthesia and muscle paralysis on respiratory mechanics in normal man. J. appl. Physiol. 33, 81 (1973)
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Stokke, D.B. Review: Artifical ventilation with positive end-expiratory pressure (PEEP). Europ. J. Intensive Care Med 2, 77–85 (1976). https://doi.org/10.1007/BF01886120
Issue Date:
DOI: https://doi.org/10.1007/BF01886120