Selecting the 'Right' Positive End-Expiratory Pressure Level

Curr Opin Crit Care. 2015 Feb;21(1):50-7. doi: 10.1097/MCC.0000000000000166.

Abstract

Purpose of review: To compare the positive end-expiratory pressure selection aiming either to oxygenation or to the full lung opening.

Recent findings: Increasing positive end-expiratory pressure in patients with severe hypoxemia is associated with better outcome if the oxygenation response is greater and positive end-expiratory pressure tests may be performed in a few minutes. The oxygenation response to recruitment maneuvers was associated with better outcome in patients with acute respiratory distress syndrome from influenza A (H1N1). If, after recruitment maneuver, the recruitment is not sustained by sufficient positive end-expiratory pressure, the lung will unavoidably collapse. Several papers investigated the positive end-expiratory pressure selection according to the deflation limb of the pressure-volume curve. It is still questionable whether to consider oxygenation or respiratory mechanics change as the best marker for adequate selection. A growing interest is paid to the estimate of transpulmonary pressure, although no consensus is available on which methodology is preferable. Finally, the positive end-expiratory pressure adequate for full lung opening may be computed combining the computed tomography scan variables and the chest wall elastance.

Summary: When compared, most of the methods give the same positive end-expiratory pressure values in patients with higher and lower recruitability. The positive end-expiratory pressure/inspiratory oxygen fraction tables are the only methods providing lower positive end-expiratory pressure in lower recruiters and higher positive end-expiratory pressure in higher recruiters.

Publication types

  • Comparative Study
  • Review

MeSH terms

  • Animals
  • Humans
  • Influenza A Virus, H1N1 Subtype
  • Influenza, Human / complications
  • Lung Volume Measurements
  • Positive-Pressure Respiration / methods*
  • Positive-Pressure Respiration, Intrinsic
  • Respiratory Distress Syndrome, Adult / etiology
  • Respiratory Distress Syndrome, Adult / physiopathology
  • Respiratory Distress Syndrome, Adult / therapy
  • Respiratory Mechanics*
  • Tidal Volume
  • Tomography, X-Ray Computed