What is the recommended level of Positive End-Expiratory Pressure (PEEP) during intubation in cardiac arrest?

PEEP Management During Intubation in Cardiac Arrest

During cardiac arrest resuscitation, PEEP should be minimized or eliminated to prevent hemodynamic compromise and maximize venous return. 1

Physiological Rationale

Positive end-expiratory pressure (PEEP) during cardiac arrest can significantly impair resuscitation efforts through several mechanisms:

1. Decreased venous return: PEEP increases intrathoracic pressure, which reduces venous return to the heart
2. Reduced coronary perfusion: Higher intrathoracic pressures can decrease coronary perfusion pressure
3. Impaired cardiac output: During CPR, cardiac output is already severely compromised, and PEEP can further reduce it

Evidence-Based Recommendations

During Active Resuscitation

• Zero PEEP is preferred during the active resuscitation phase 1, 2
• If ventilator is used, set PEEP to 0-5 cmH2O maximum 2
• A preclinical study demonstrated that PEEP levels of 10 cmH2O or higher resulted in significant declines in cardiac output during CPR 2
• PEEP of 15 cmH2O or higher significantly reduced oxygen delivery during resuscitation 2

Special Considerations

• Brief disconnection from the ventilator circuit is recommended when auto-PEEP is suspected 1
• For patients with obstructive lung disease (asthma/COPD):
  • Consider very low PEEP (≤5 cmH2O) to counterbalance auto-PEEP 1
  • Use smaller tidal volumes (6-8 mL/kg)
  • Maintain slower respiratory rates
  • Allow longer expiratory times 1

Post-ROSC PEEP Management

Once return of spontaneous circulation (ROSC) is achieved, PEEP management changes:

• Apply modest PEEP of 5-10 cmH2O to prevent atelectasis and improve oxygenation 1
• Higher PEEP (>10 cmH2O) may be considered for specific situations such as pulmonary edema 1
• Implement lung-protective ventilation with tidal volumes of 6-8 mL/kg predicted body weight 1, 3
• Monitor for signs of hemodynamic compromise with PEEP application 1

Common Pitfalls to Avoid

• Excessive ventilation rates: Can lead to air trapping and decreased venous return
• Failure to recognize auto-PEEP: Particularly in patients with obstructive lung disease
• Applying high PEEP during active resuscitation: Can significantly impair cardiac output and resuscitation efforts
• Not adjusting ventilation strategy after ROSC: Different PEEP strategies are needed before and after ROSC

Monitoring Parameters

• Observe for signs of adequate chest rise
• Monitor for signs of hemodynamic compromise
• After ROSC, target SaO2 92-97% 1
• Avoid hyperventilation with hypocapnia as it may worsen cerebral ischemia 1

The optimal approach to PEEP during cardiac arrest is to minimize or eliminate it during active resuscitation to maximize hemodynamics, then apply appropriate PEEP after ROSC based on the patient's specific respiratory needs.