In this AVF Podcast: ICU Tips & Tricks episode, Professor Laurent Brochard shares his thoughts on the setting of positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). Professor Brochard is Keenan Chair in Critical Care and Respiratory Medicine at St. Michael’s Hospital and the University of Toronto, Head of the Interdepartmental Division of Critical Care Medicine at the University of Toronto, Deputy Editor of the American Journal Of Respiratory and Critical Care Medicine, former Editor-In-Chief of Intensive Care Medicine, Head of the PLUG Working Group on pleural pressure for the European Society of Intensive Care Medicine, former Head and Member of the REVA (European Research Network on Mechanical Ventilation), and Member of the Canadian Critical Care Trials Group.
 

Issues discussed in this interview:

• Why we set a PEEP for ARDS and problems if the PEEP is too low or too high
• Ranges of PEEP when we say higher versus lower levels of PEEP
• Issues with the PEEP:FIO2 tables
• Issues with older ways of using compliance to define optimal PEEP
• Individualising PEEP using the recruitment-to-inflation ratio
• Other methods of individualising PEEP, including oesophageal pressure measurements and computed tomography (CT) scans
• Titrating PEEP after initial settings
• What to do if plateau pressure exceeds 30 cmH2O on optimal PEEP

Work cited:

1. Fan E, Del Sorbo L, Goligher EC, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2017;195:1253-63.
2. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial Investigators, Cavalcanti AB, Suzumura EA, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA 2017;318:1335-45.
3. Dantzker DR, Lynch JP, Weg JG. Depression of cardiac output is a mechanism of shunt reduction in the therapy of acute respiratory failure. Chest 1980;77:636-42.
4. Mekontso Dessap A, Boissier F, Leon R, et al. Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome. Crit Care Med 2010;38:1786-92.
5. Chen L, Del Sorbo L, Grieco DL, et al. Potential for lung recruitment estimated by the recruitment-to-inflation ratio in acute respiratory distress syndrome. A clinical trial. Am J Respir Crit Care Med 2020;201:178-87.

Useful website to guide assessment of recruitment-to-inflation ratio: https://rtmaven.com/.