Is positive end-expiratory pressure (PEEP) recommended for a patient with potential respiratory failure and possible chronic obstructive pulmonary disease (COPD) after cardiopulmonary resuscitation (CPR)?

PEEP Use After CPR in Post-Cardiac Arrest Patients

Yes, PEEP should be used on the ventilator after CPR, following standard mechanical ventilation principles for patients at risk of acute lung injury, with careful attention to avoiding excessive intrathoracic pressure that could compromise hemodynamics in the immediate post-arrest period. 1

Standard Ventilation Strategy Post-Cardiac Arrest

The 2010 American Heart Association guidelines establish that post-cardiac arrest patients should receive mechanical ventilation using the same evidence-based strategies applied to other critically ill patients at risk for acute lung injury and ARDS 1. Specifically:

• Apply PEEP as part of lung-protective ventilation to prevent atelectasis and maintain adequate oxygenation, particularly since post-cardiac arrest patients are at significant risk for developing acute lung injury 1
• Target tidal volumes of 6-8 mL/kg predicted body weight to reduce ventilator-associated lung injury 1
• Use PEEP and recruitment maneuvers when low tidal volume ventilation is employed, as low VT (6 mL/kg) increases atelectasis risk 1

Critical Hemodynamic Considerations

Avoid excessive PEEP levels that could compromise already fragile post-arrest hemodynamics:

• High PEEP increases intrathoracic pressure, which impedes venous return during chest compressions and compromises forward blood flow 1
• The automatic mode of oxygen-powered resuscitators should be avoided during CPR because it generates high PEEP that impairs venous return (Class III recommendation) 1
• PEEP decreases cardiac preload by increasing pleural pressure and reducing the pressure gradient for venous return to the right ventricle 2

Special Considerations for COPD Patients Post-Arrest

If the patient has underlying COPD with suspected intrinsic PEEP (auto-PEEP), the approach requires modification:

• Apply external PEEP at 60-85% of measured auto-PEEP to counterbalance the inspiratory threshold load without causing further hyperinflation 3, 4, 5, 6
• This strategy improves patient-ventilator synchrony and reduces work of breathing in COPD patients with expiratory flow limitation 5, 6
• External PEEP should not exceed the critical threshold (typically 85% of PEEPi) to avoid additional hyperinflation, hemodynamic compromise, and worsening gas exchange 7, 8

Ventilation Parameters to Optimize

• Maintain normocapnia (PaCO2 40-45 mm Hg) as routine hyperventilation with hypocapnia should be avoided post-ROSC because it worsens global brain ischemia through excessive cerebral vasoconstriction (Class III recommendation) 1
• Avoid hyperventilation and excessive tidal volumes that increase intrathoracic pressure and contribute to hemodynamic instability 1
• For COPD patients, decrease respiratory rate to 10-15 breaths/min to allow adequate expiratory time and prevent auto-PEEP 3

Practical Algorithm for PEEP Titration

1. Initial PEEP setting: Start with moderate PEEP (5-8 cm H2O) as part of standard lung-protective ventilation 1, 2
2. Monitor hemodynamics closely: If hypotension develops, consider whether excessive PEEP is impairing venous return 2
3. For suspected COPD/auto-PEEP: Measure intrinsic PEEP using end-expiratory occlusion technique 3, then apply external PEEP at 60-85% of measured value 4, 7
4. Titrate to oxygenation needs: Adjust PEEP to maintain adequate oxygenation (SaO2 95-98%) while avoiding hemodynamic compromise 1

Common Pitfalls to Avoid

• Do not withhold PEEP entirely based on concerns about hemodynamics—complete absence of PEEP (ZEEP) increases atelectasis risk and decreases compliance 2
• Do not apply PEEP levels exceeding 85% of intrinsic PEEP in COPD patients as this causes further hyperinflation and hemodynamic deterioration 7, 8
• Do not use automatic modes of oxygen-powered devices that generate uncontrolled high PEEP during the resuscitation phase 1