What is the treatment for auto positive end-expiratory pressure (auto peep)?

From the Guidelines

The treatment for auto-PEEP (auto positive end-expiratory pressure) should focus on reducing air trapping and improving ventilation by decreasing respiratory rate and tidal volume, as well as using bronchodilators and sedation as needed, as recommended by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. To manage auto-PEEP, the following strategies can be employed:

• Decrease respiratory rate to allow more time for exhalation, typically reducing the rate to 10-14 breaths per minute
• Decrease tidal volume to 6-8 mL/kg of ideal body weight to reduce air trapping
• Use bronchodilators such as albuterol or ipratropium to reduce bronchospasm and airway resistance
• Apply sedation to synchronize the patient with the ventilator and reduce respiratory drive, if necessary
• Consider using systemic corticosteroids like methylprednisolone or prednisone to reduce airway inflammation in patients with severe COPD or asthma exacerbations
• Apply external PEEP at 80-85% of measured auto-PEEP levels to reduce work of breathing, as suggested by the ATS/ERS statement on respiratory muscle testing 1 It is essential to note that the management of mechanical ventilation will vary based on patient-ventilation characteristics, and expert consultation should be obtained, as stated in the 2010 American Heart Association guidelines 1. Additionally, the treatment should prioritize reducing morbidity, mortality, and improving quality of life, and the most recent and highest quality study should be considered, which in this case is the 2010 American Heart Association guidelines 1.

From the Research

Treatment for Auto Positive End-Expiratory Pressure (Auto PEEP)

The treatment for auto PEEP involves several strategies to reduce its effects and improve patient outcomes. Some of these strategies include:

• Reducing minute ventilation 2
• Using small tidal volumes 2
• Prolonging the time available for exhalation 2
• Applying low levels of external PEEP in patients with expiratory flow limitation 2
• Using neurally adjusted ventilatory assist, a novel strategy of ventilatory assist, to improve patient-ventilator interaction 2
• Manipulating mechanical ventilator settings to improve inspiratory/expiratory flow patterns 3
• Reducing causes of increased respiratory rates, such as pain and anxiety 3
• Using pressure support ventilation (PSV) to decrease auto-PEEP and inspiratory muscle effort 4

Ventilator Settings

Ventilator settings should aim to reduce auto-PEEP by:

• Providing external PEEP to 75-80% of auto-PEEP in patients who are spontaneously breathing during mechanical ventilation 5
• Reducing the respiratory rate rather than increasing inspiratory flow 5
• Prolonging expiratory time 5

Monitoring and Detection

Routine monitoring for auto-PEEP in patients receiving controlled ventilation is recommended 5. Auto-PEEP can be detected and quantified by a simple bedside maneuver: expiratory port occlusion at the end of the set exhalation period 5. The presence of auto-PEEP should be suspected when airflow at end-exhalation is not zero 2.