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positive end-expiratory pressure (PEEP)
Indications:
1) diffuse disease
2) stiff lungs
3) inability to oxygenate on a non-toxic fiO2 (<50%)
4) acute respiratory distress syndrome (ARDS)
Contraindications:
1) no absolute contraindications
2) caution: intracranial abnormalities, lung disease, hypotension
Mechanism of action:
1) opens up atelectic or fluid-filled alveoli
2) decreases ventilation-perfusion mismatch
3) improves oxygenation
Complications:
- PEEP can decrease cardiac output by decreasing preload, thus worsen oxygen delivery to tissues
- auto PEEP
Management:
1) Goals
a) decrease FiO2 to non-toxic level (<50%)
b) maintaining cardiac output
2) start 5 cm H20*
3) > 5 cm of H20 is supraphysiologic
4) increase PEEP to decrease FiO2 [3]
5) indications for PEEP > 10 cm H20 not clear
6) adjust PEEP to maintain end-expiratory pressure < 30-35 cm H20
* PEEP-FiO2 Table for Selecting PEEP for the Ventilation of Patients with ARDS [3,4]
fiO2 PEEP
0.3 5
0.4 5
0.4 8
0.5 8
0.5 10
0.6 10
0.7 10
0.7 12
0.7 14
0.8 14
0.9 14
0.9 16
0.9 18
1.0 18-24
*Also see:
1) permissive hypercapnia
2) auto PEEP
3) mechanical ventilation
Related
lung protective ventilation; low tidal volume ventilation; permissive hypercapnia
mechanical ventilation (assisted ventilation)
Specific
auto-PEEP
General
alveolar pressure
References
- Jon D. Hirasuna, M.D. Clinical Professor of Medicine,
UC Davis, Associate Clinical Professor of Medicine, UCSF, Sept 1997
- UpToDate 14.1
http://www.utdol.com
- Medical Knowledge Self Assessment Program (MKSAP) 17,
American College of Physicians, Philadelphia 2015
- Medical Knowledge Self Assessment Program (MKSAP) 20
American College of Physicians, Philadelphia 2025
- Menk M, Estenssoro E, Sahetya SK, et al.
Current and evolving standards of care for patients with ARDS.
Intensive Care Med. 2020;46:2157-67.
PMID: 33156382