What are the guidelines for administering Positive End-Expiratory Pressure (PEEP) in cardiac arrest?

PEEP Management During Cardiac Arrest Resuscitation

During cardiac arrest resuscitation, PEEP should be minimized or eliminated to prevent hemodynamic compromise, with brief disconnection from the ventilator circuit recommended when auto-PEEP is suspected. 1

Hemodynamic Effects of PEEP During CPR

• High PEEP levels during CPR can significantly impair resuscitation efforts by:

  • Decreasing venous return to the heart
  • Reducing cardiac preload
  • Impairing coronary perfusion pressure
  • Exacerbating hypotension in already compromised circulation 1

• Auto-PEEP (intrinsic PEEP) can develop during CPR, especially with:

  • Excessive ventilation rates
  • Obstructive lung disease
  • Inadequate expiratory time 2, 1

Management of Auto-PEEP During Cardiac Arrest

When auto-PEEP is suspected during cardiac arrest:

1. Disconnect the patient from the ventilator circuit to allow PEEP to dissipate during passive exhalation 2
2. Apply external chest compression after disconnection to assist with exhalation and immediately resolve hypotension 2
3. Reduce respiratory rate and tidal volume to minimize auto-PEEP 2, 1
4. Use shorter inspiratory times (adult inspiratory flow rate 80-100 L/min) 2
5. Allow longer expiratory times (inspiratory to expiratory ratio 1:4 or 1:5) 2

Ventilation Strategy During CPR

• Avoid hyperventilation as it can cause cerebral vasoconstriction and worsen global brain ischemia 1
• Use smaller tidal volumes (6-8 mL/kg) 2, 1
• Maintain slower respiratory rates to prevent air trapping 2
• Consider permissive hypercapnia to reduce the risk of barotrauma 2

Special Considerations for Patients with Obstructive Lung Disease

For patients with asthma or COPD who develop cardiac arrest:

• Use even lower respiratory rates and tidal volumes 2, 1
• Allow longer expiratory times to prevent air trapping 1
• Consider applying minimal PEEP (≤5 cmH2O) to counterbalance auto-PEEP in these specific cases 1

PEEP After Return of Spontaneous Circulation (ROSC)

After ROSC is achieved:

• Apply modest PEEP of 5-10 cmH2O to prevent atelectasis and improve oxygenation 1
• Consider higher PEEP (>10 cmH2O) only for specific situations such as pulmonary edema or ECPR patients 1
• Monitor for signs of hemodynamic compromise when applying PEEP after ROSC 1

Common Pitfalls to Avoid

• Failing to recognize auto-PEEP as a cause of deterioration in intubated cardiac arrest patients 2
• Excessive ventilation rates leading to air trapping and decreased venous return 2, 1
• Applying high PEEP during active resuscitation which can significantly impair hemodynamics 1, 3
• Not considering disconnection from the ventilator when auto-PEEP is suspected 2

While some experimental models suggest potential benefits of PEEP during CPR 4, 5, the most recent clinical guidelines emphasize the hemodynamic risks of PEEP during active resuscitation, particularly in patients without specific pulmonary pathologies requiring PEEP 2, 1.