Category: Critical Care
Keywords: Mechanical Ventilation, PEEP (PubMed Search)
How to set the correct PEEP remains one of the most controversial topics in critical care. In fact, just on UMEM Pearls there are 55 hits when one searches for PEEP, including this relatively recent pearl on PEEP Titration.
A recent Systematic Review and Network Meta-Analysis looked at existing trials on this issue. They found that:
1) Higher PEEP strategies were associated with a mortality benefit compared to lower PEEP strategies
2) Lung Recruitment Maneuvers were associated with worse mortality in a dose (length of time of the maneuver) dependent fashion.
This fits with recent literature and trends in critical care and bolsters the feeling many intensivists are increasingly having that we may be under-utilizing PEEP in the average patient.
Bottom Line: As an extremely broad generalization, we would probably benefit the average patient by favoring higher PEEP strategies, and avoiding lung recruitment maneuvers. Do keep in mind that it is probably best to continue lower PEEP strategies in patient populations at high risk of negative effects of PEEP (e.g. COPD/asthma, right heart failure, volume depleted with hemodynamic instability, bronchopleural fistula) until these groups are specifically studied.
Dianti J, Tisminetzky M, Ferreyro BL, Englesakis M, Del Sorbo L, Sud S, Talmor D, Ball L, Meade M, Hodgson C, Beitler JR, Sahetya S, Nichol A, Fan E, Rochwerg B, Brochard L, Slutsky AS, Ferguson ND, Serpa Neto A, Adhikari NK, Angriman F, Goligher EC. Association of PEEP and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-Analysis. Am J Respir Crit Care Med. 2022 Feb 18. doi: 10.1164/rccm.202108-1972OC. Epub ahead of print. PMID: 35180042. https://pubmed.ncbi.nlm.nih.gov/35180042/