From the Guidelines
Positive End-Expiratory Pressure (PEEP) is a ventilation technique that maintains a positive pressure in the airways at the end of exhalation, preventing alveolar collapse, and is typically set between 5-15 cmH2O depending on the patient's condition.
Key Points
- PEEP works by keeping the alveoli open throughout the respiratory cycle, which improves oxygenation by increasing functional residual capacity and preventing atelectasis 1.
- The optimal PEEP level should be individualized based on the patient's lung compliance, oxygenation requirements, and hemodynamic stability 2.
- In conditions like acute respiratory distress syndrome (ARDS), higher PEEP levels (12-15 cmH2O or more) may be needed to improve oxygenation and prevent ventilator-induced lung injury (VILI) 3, 4.
- Clinicians must monitor for potential adverse effects including decreased cardiac output due to reduced venous return, barotrauma, and pneumothorax when implementing PEEP 2.
- PEEP can be delivered through mechanical ventilators in intubated patients or via CPAP devices in non-intubated patients 1.
Recommendations
- Use a low tidal volume (4–6 ml/kg) and low plateau pressure (< 30 cmH2O), and appropriate positive end expiratory pressure (PEEP) for invasive mechanical ventilation in patients with ARDS 4.
- Consider using higher PEEP levels and prone ventilation for more than 12 h a day along with deep sedative analgesia in the first 48 h of mechanical ventilation for patients with moderate to severe ARDS 4.
- Individualize PEEP levels based on lung recruitability, end-expiratory transpulmonary pressure, and other factors to optimize lung protection and oxygenation 2.
From the Research
Definition of PEEP
- Positive End-Expiratory Pressure (PEEP) is a technique used in mechanical ventilation to keep the lungs open at the end of exhalation, improving oxygenation and preventing alveolar collapse 5, 6, 7, 8, 9.
Benefits of PEEP
- Improves arterial oxygenation by recruiting collapsed alveoli and preventing alveolar collapse at end expiration 5, 6, 7, 8, 9.
- Reduces tidal lung stress and strain by promoting more homogenous ventilation 9.
- May improve patient outcomes in acute respiratory distress syndrome (ARDS) by reducing ventilator-induced lung injury 5, 7.
PEEP Titration Strategies
- Various strategies have been proposed to optimize PEEP titration, including PEEP/FiO2 tables, mechanical parameters, and techniques to assess lung recruitment 9.
- No single method of PEEP titration has been shown to improve clinical outcomes compared to other approaches 9.
Clinical Applications of PEEP
- PEEP is commonly used in the management of ARDS, acute lung injury, and other respiratory conditions requiring mechanical ventilation 5, 6, 7, 8, 9.
- Higher levels of PEEP may be necessary to maintain the lungs open and assure homogenous ventilation in ARDS patients 5, 7.
- PEEP-induced lung recruitment maneuvers can improve oxygenation and prognosis in patients with moderate to severe ARDS 6.