THE TROUBLE WITH PEEP AND PEEPLE

 PEEP (Positive End Expiratory Pressure) is an important part of the

critical care arsenal
 Like anything we do however (meds, surgery, fluids) if we don’t use it
appropriately we can cause harm
 In the last 2 weeks there have been at least 5 examples of where PEEP
had deleterious effects. 2 of them it was my fault!!
 I have to say no one has ever sat down and taught me this
o I honestly think a lot of ICU people actually don’t think about it
that much
o Marek was the first to point out issues to me
o Sam is really interested in this and doing work on it.

How PEEP works

- PEEP has many advantageous effects that improve oxygenation and WOB
and cardiac function
o Reducing shunt by recruiting alveoli
o Increasing FRC
 Functional residual capacity
o Improving compliance and hence effort or pressure needed to
open alveolus
 If shift the patient’s end expiratory pressure to above the
lower inflection point on the compliance curve, then it is on
the steep part of the curve and will increase its volume
easier for a given in crease in pressure
 Think of blowing up a balloon- the hardest part is the start.
After the initial inflation (above the lower inflection point)
it becomes easy until overdistended
 o Prevent atelectatrauma
 This refers to the shearing stress or trauma the ventilator
creates if it is continually open collapsed alveoli with each
breath
o Reduce Preload
o Reduce afterload
 The effects of these last 2 depend whether you have a sick
or healthy heart Sam will explain it better than me!

Evidence for PEEP

- In ARDS or refractory hypoxaemia, the buzz word is using an Open Lung
strategy
o This basically means you are going to recruit as many alveoli as
possible and keep them open!
- Three trials in the mid 2000s (ALVEOLI, LOV, EXPRESS) advocated this
based on their findings that the improved oxygenation using high versus
low PEEP. There was no survival advantage. A Meta-analysis of 1200
patients showed improved mortality. There are reasons why it did not
show mortality differences
o Firstly I think they weren’t powered sufficiently
 o Secondly it is hard to prove anything in the critical care world
o Thirdly mortality in ARDS is often a consequence of other
complications
 i.e. weakness, PE, pressure injuries, nosocomial infections
o Fourthly ARDS is not a disease itself, but a descriptor and is a
heterogenous condition
 It is a consequence of various multiple predisposing insults,
each of which carry their own morbidity and mortality
 There is no specific treatment for ARDS, the best we can do
is prevent it happening, and prevent it worsening
 MUST VENTILATE LOW TIDAL VOLUME
STRATEGY/ PROTECTIVE LUNG
 IT is an overwhelming inflammatory state, and is often the
extreme stage of a disease
o We are getting older and more unsalvageable patients in ICU
o FINALLY, and a big issue for me, is we are trying to apply a onse
size fits all to patients.
 We are guilty of this in many conditions
 We need to be more specific and tailor our ventilation to
each patients cardiorespiratory state
 Just like prescribing antibiotics for a UTI versus
meningitis vs pneumonia ceftriaxone cures all!
 Takes time and patience

Study Control Group Experimental group Major findings

ALVEOLI Volume assist-control. VT = 6 Volume assist-control. VT Higher PaO2/FIO2 ratio in high PEEP
Younger pts in mL/kg IBW; Pplat ≤ 30 cm = 6 mL/kg IBW; Pplat ≤ group (220 ± 89 vs 168 ± 66) on day 1.
experimental group H2O. Combinations of PEEP 30 cm H2O. Combinations Higher compliance in the higher-PEEP
More hypoxic at and FIO2 to maintain PaO2 of PEEP and FIO2 to group (39 ± 34 vs 31 ± 15 mL/cm H2O) on
baseline in (55-80 mm Hg) or SpO2 maintain PaO2 (55-80 day 1.
Expiremental group (88%-95%). PEEP on days mm Hg) or SpO2 (88%- Mortality before hospital discharge (low
Expiremental gp did 1-4 was 8.3 ± 3.2 cm H2O. n = 95%). PEEP on days 1-4 PEEP, 24.9%; high PEEP, 27.5%; P = .48).
not exactly have high 273 was 13.2 ± 3.5 cm H2O. In Ventilator-free days (low PEEP, 14.5 ±
PEEP or Mean airway the first 80 patients, 10.4 d; high PEEP, 13.8 ± 10.6 d; P = .50). I
pressures recruitment maneuvers ncidence of barotrauma (low PEEP, 10%;
PEEP in experiment of 35-40 cm H2O for 30 s. high PEEP, 11%; P = .51).
was low relative to n = 276
the scale used in
ARDS net (how
hypoxic/sick were
they
Study stopped after
549 for futility
Tried recruitment in
1st 80- no effect so
stopped
LOV canadaian and Volume assist-control. VT = 6 Pressure control. VT = 6 Higher PaO2/FIO2 ratio in higher-PEEP
australian mL/kg IBW; Pplat ≤ 30 cm mL/kg IBW; Pplat ≤ 40 group (187 ± 69 vs 149 ± 61) on day 1
H2O. Combinations of PEEP cm H2O. Combinations of . Higher Pplat in the high-PEEP group
and FIO2 to maintain PaO2 PEEP and FIO2 to (30.2 ± 6.3 vs 24.9 ± 5.1). T
(55-80 mm Hg) or SpO2 maintain PaO2 (55-80 he higher-PEEP group had lower rates of
(88%-93%). PEEP on days mm Hg) or SpO2 (88%- refractory hypoxemia (4.6% vs 10.2%; P =
1-3 was 9.8 ± 2.7 cm H2O. n = 93%). PEEP on days 1-4 .01), death with refractory hypoxemia
508 was 14.6 ± 3.4 cm H2O. (4.2% vs 8.9%; P = .03), and previously
Recruitment maneuvers defined eligible use of rescue therapies
after each disconnect (5.1% vs 9.3%; P = .045).
from the ventilator of 40 28 day mortality (high PEEP, 28.4%; low
cm H2O for 40 s. n = 475 PEEP, 32.3%; P = .2). Incidence of
barotrauma (high PEEP, 11.2%; low PEEP,
9.1%; P = .33).
EXPRESS Volume assist-control. VT = 6 Volume assist-control. VT Higher PaO2/FIO2 ratio in higher-PEEP
mL/kg IBW. Moderate PEEP = 6 mL/kg IBW. PEEP set group (218 ± 97 vs 150 ± 69) on day 1.
(5-9 cm H2O). n = 382 to reach Pplat of 28-30 Higher compliance in the high-PEEP
cm H2O (14.6 ± 3.2 cm group (37.2 ± 22.7 mL/cm H2O vs 33.7 ±
H2O) on day 1. n = 385 14.3 mL/cm H2O) on day 1. The increased
PEEP group had higher median number of
ventilator-free days (7 d vs 3 d; P = .04),
organ failure-free days (6 d vs 2 d; P =
.04), and use of adjunctive therapies.
Incidence of barotraumas (high PEEP,
6.8%; low PEEP, 5.8%; P = .57).

Detrimental effects of PEEP

- Overdistension of alveolus
o Risk of barotrauma
o May actually worsen compliance and work of breathing
- Worsening dead space
o If shunt is improved, then dead space must be increased
o This mean the alveolus may be distended, and actually impede
flow through the capillaries adjacent to these alveoli, and hence
worsen gas exchange
 This will potentially create a difference between end tidal
and arterial CO2
 Note not always seen!
 o May be especially in the hypovolaemic patient
- Increasing intrathoracic pressure
o Reduceing RV preload, output and afterload
o Worsening strain on the RV with risk of cor pulmonakle
 See article by Antoinne Viellard Baron ( Will send it out
when I can find it myself!)
- Risk of gas trapping

Setting PEEP

- Not as easy as it seems

- 9/10 you will be fine with any PEEP. Its knowing the 1/10 and
recognizing when you are stuffing it up (we can all do that easily)
- There are not many times that PEEP >10cmH20 is necessary, and rarely
>12cmH20
- I am scared of the ARDSnet ( a group that studied ventilation in ARDS and
came up with the 6ml/kg IBW for setting tidal volume) protocol for
setting PEEP. It is excessive and is guilty of the one size fits all.
o Do not assume that hypoxia necessitates increasing PEEP- you may
actually need to reduce it!!!

Finding the optimal PEEP

- Watch the saturations
o Before adjusting PEEP, it helps to reduce the FiO2 so that saO2 is
at 91%. This is the point on the HbO2 curve where any further fall
in PaO2 will show up quickly on the saO2 and likewise an increase
in PaO2 will still be noticed.
o The argument against using saO2 solely, is that PEEP affects
cardiac output
  If CO is reduced due to PEEP it actually may increase the
time that it takes for a RBC takes to go past an alveolus and
increase its saturation
 Theoretical argument, but I do think it is very simplistic just
to set PEEP based on saturations
- Monitor the RV
o We are trying to figure out what would be the earliest marker of
risk of RV dysfunction in ventilation speak to Sam
o But perform regular echoes (advanced echo, not just RACE)
- Monitor the BP and inotropic support

- Watch the compliance

o Can be graphed and the static compliance can also be found on the
additional displays in the Draeger

- Watch what happens to the Plateau and Peak pressure

o This is something I have been doing subconsciously but a recent
article came out on that confirmed my thoughts.
 If you increase PEEP and the peak or plateau pressure
increases more than that increase, then you have worsened
compliance- BAD
 If you increase PEEP and the peak and plateau pressures
fall, then this is great- you have recruited alveoli an
improved compliance
 If Plateau and Peak pressure increase the same then this is
ok, as long as other parameters
 The new buzzword for this is driving pressure and how it
changes with the change in PEEP
 = Pplat – PEEP (remember this is the part of the
pressure delivered by the ventilator that affects the
alveolus)
  If the driving pressure remains the same with a
change in PEEP, fine, if it increases with an increase
in PEEP- Bad!

PPlat PEEP ΔP Mortality

rising same Rising rising

rising rising Same same

same rising Falling falling

- Watch Volumetric Capnography- this is the marker of dead space. It is not

available on Draeger.
o Note you will not always see the gradient between arterial and end
tidal CO2 unless in extreme circumstance, but keep an eye out for
it!
o Volumetric capnography watches the volume of CO2 exhaled with
each breath and over a minute rather than the partial pressure of
CO2
o CO2 clearance or ventilation = RR x (Tidal volume- dead space
volume)
 If there is an increase in dead space there will be a drop in
CO2 clearance (as explained above)
o If when reducing PEEP you see and improvement in CO2 clearnace,
then you have lessened the dead space. If it worsens, you may have
derecruited alveoli and worsened the shunt.
 - What would be really cool would be is we could get an oesophageal
balloon which can measure pressure in the oesophagus. This gives a
surrogate measure of transpulmonary pressure. This is the difference
between alveolar and pleural pressure, and is the true distending
pressure of lungs.

- There is an argument whether you should gradually increase PEEP and

watch this or do a recruitment manouevre, and then gradually reduce the
PEEP until you have found a sweet spot- Don’t forget there may not be a
sweet spot- one parameter may always be a bit worse with your PEEP
setting
o I used to prefer the former method
o The latter is better though as it allows you the chance to make sure
you have opened all recruitable alveoli first. If you go slow, it takes
time to open the alveoli and potentially improve compliance. If you
are impatient you may actually miss seeing an improvement in
compliance with an increase in PEEP.
o This is not to say that I do recruitment manouevres regularly. I
think they are quite often dangerous.

IF you think that a high PEEP may be causing detriment to the cardiorespiratory
circuit, then don’t just drop it yourself- have a chat to the boss/ SR first!