Positive End-Expiratory Pressure

Aka: Positive End-Expiratory Pressure, PEEP, PEEP Table

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II. Indications

  1. Pulmonary condition with widespread alveolar collapse
  2. Adult Respiratory Distress Syndrome (ARDS)
    1. PEEP increases Lung Compliance
    2. PEEP decreases intrapulmonary shunting
    3. Increases PO2 and allows lower FIO2 below 60%
    4. May increase dead space ventilation
      1. Overdistends normal lung
  3. Pulmonary Edema
    1. PEEP allows decrease in FIO2 below 60%
    2. PEEP may increase extravascular lung water

III. Indications: Disproved uses of PEEP

  1. Localized Lung Disease (e.g. Lobar Pneumonia)
    1. PEEP may worsen Hypoxemia
      1. Overdistends normal lung
      2. Directs Blood Flow to diseased lung
    2. PEEP not recommended
      1. Unless selectively applied to diseased lung
  2. Prophylactic PEEP
    1. PEEP does not reduce ARDS Incidence
  3. Routine PEEP
    1. PEEP does not appear indiscriminately beneficial
  4. Mediastinal Bleeding
    1. PEEP does not protect against mediastinal bleeding

IV. Physiology

  1. PEEP maintains small end-expiratory pressure
    1. Helps to prevent alveolar collapse
    2. Promotes alveolar-capillary gas exchange
  2. Increases lung function parameters
    1. Increases Functional Residual Capacity (FRC)
  3. Increases Cardiac Output with low airway pressures
    1. May result in increased Oxygen Delivery

V. Dosing: PEEP Table (ARDSNet, Low PEEP Version)

  1. Usual PEEP setting: 5 to 10 cm H2O
  2. Maximum PEEP = FIO2 * 20
    1. Where FIO2 ranges from 0.3 (30%) to 1.0 (100%)
    2. Maximum PEEP: 8 for FIO2 0.4
    3. Maximum PEEP: 10 for FIO2 0.5
    4. Maximum PEEP: 12 for FIO2 0.6
  3. ARDS-NET PEEP Adjustment based on FIO2 for mechanically ventilated patients
    1. PEEP Levels >15 cm H2O are rarely required and are associated with complications (Barotrauma)
      1. Strategy listed here correlates to the ARDSNet lower PEEP version
    2. FIO2: 0.3
      1. PEEP: 5 cm H2O
    3. FIO2: 0.4
      1. PEEP: 5 to 8 cm H2O
    4. FIO2: 0.5
      1. PEEP: 8 to 10 cm H2O
    5. FIO2: 0.6
      1. PEEP: 10 cm H2O
    6. FIO2: 0.7
      1. PEEP: 10 to 14 cm H2O
    7. FIO2: 0.8
      1. PEEP: 14 cm H2O
    8. FIO2: 0.9
      1. PEEP: 14 to 18 cm H2O
    9. FIO2: 1.0
      1. PEEP: 18 to 24 cm H2O

VI. Complications

  1. Decreased Cardiac Output
    1. Associated with higher airway pressures
    2. Associated with decreased ventricular filling
  2. Barotrauma
  3. Fluid Retention
  4. Intracranial Hypertension

VII. References

  1. Marino (1991) ICU Book, Lea & Febiger, p. 375-9

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