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225 Positive End-Expiratory

Pressure Ali A. Hamdan
Peter J. Papadakos

Positive end-expiratory pressure (PEEP) refers to pres-
sure in the airway at the end of passive expiration
that exceeds atmospheric pressure. The term is appli-
cable to patients receiving mechanical ventilation. For
spontaneously breathing subjects, the term continuous
positive airway pressure (CPAP) is used when inspira-
tory and expiratory portions of the circuit are pressur-
ized above atmospheric pressure. Positive end-expira-
tory pressure is used mainly to recruit or stabilize lung
units and improve oxygenation in patients with hy-
poxemic respiratory failure.
Key Indications
● Acute lung injury and acute respiratory distress
syndrome
● Cardiogenic pulmonary edema
● Diffuse pneumonia requiring mechanical
ventilation
● Atelectasis associated with severe hypoxemia
● Other forms of severe hypoxemic respiratory
failure
Key Contraindications
●
Pneumothorax without pleural catheter
● Intracranial hypertension
● Hypovolemia (unless concomitantly treated)
2. Stabilizes and recruits lung units
3. Increases functional residual capacity
4. Improves lung compliance
5. Shifts tidal deflections to the right along the
inspiratory pressure-volume curve (Fig. 225 – 1),
minimizing potential for ventilator-induced lung
injury by preventing repetitive collapse of lung
units at end-expiration followed by re-opening
during inspiration
6. May decrease the inspiratory work of breathing
due to auto-PEEP in patients with obstructive
airway disease
C. Hemodynamic effects of PEEP-induced increases in
intrathoracic pressure
1. Increases intraluminal central venous pressure
2. Decreases venous return
3. Decreases left and right ventricular preload
(end-diastolic volume)
4. Increases right ventricular afterload
5. Decreases cardiac output, as a result of the
above effects
a. Hypotension and organ hypoperfusion can
occur.
b. Reduction of both cardiac output and blood
pressure is particularly likely in the presence
of hypovolemia.
6. Decreases left ventricular afterload
7. Decreases ventricular compliance
8. Increases intracranial pressure, by increasing
central venous pressure

● Bronchopleural fistula
● Recent pulmonary resection surgery Key Effects of PEEP
Beneficial Adverse
Effects and Mechanisms ● Usually improves ● May worsen gas
oxygenation exchange
A. Gas exchange
● Stabilizes and recruits ● Decreases cardiac
1. Redistributes fluid within the alveoli and re- lung units output
duces intrapulmonary shunting
2. Improves arterial oxygenation (PaO2) ● Improves lung ● Can cause barotrauma
compliance
3. Reduces FIO2 requirements and risk of oxygen ● Interferes with
toxicity ● Minimizes potential for assessment of
B. Lung mechanics ventilator-induced lung hemodynamic short
injury pressures
1. Helps prevent alveolar collapse standard
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816 ● XVII Respiratory Care and Mechanical Ventilation
Alveoli
800
Upper inflection point
600
Volume (mL)
600
400
200
Lower inflection point
0 10 20 30 40
Pressure (cm H2O)
Figure 225– 1. Lung inspiratory pressure– volume curve in a pa-
tient with acute respiratory distress syndrome. The outlines at the
top of the graph indicate the state of alveolar inflation relative to
maximum physiologic distention (dashed circles). The central lin-
ear portion of the curve demonstrates that large volume changes
result when pressure changes occur between the two inflection
points; i.e., when lung compliance, represented by the slope of the
pressure– volume curve, is maximal. At airway pressures above
the upper inflection point, compliance decreases, the limit of lung
distention is approached, and the risk of barotrauma is high.
Airway pressures below the lower inflection point are associated
with low compliance, alveolar collapse, and atelectasis. A pro-
posed strategy for optimizing mechanical ventilation and PEEP
is to select a PEEP level just above the lower inflection point,
and maintain plateau airway pressures below the upper inflexion
point.
Procedure (Initiation and Titration of PEEP)
A. Begin PEEP at 5 cm H2O.
B. Increase or decrease in increments of 2 or 3 cm
H2O.
C. After each adjustment of PEEP, assess effects on
pulmonary function, pressure – volume relation-
ships, oxygenation, and hemodynamics (see Moni-
toring section, below).
D. Goal of titration is to achieve optimal PEEP,
which may be defined as the level of PEEP that
allows the lowest FIO2 (or FIO2 less than 0.50, if
achievable) while maintaining adequate oxygena-
tion (PaO2 greater than 60 torr, SaO2 greater than
0.90) and avoiding uncorrectable adverse effects
induced by PEEP.
E. Alternative proposed definitions of optimal PEEP
1. PEEP set to 2 cm H2O above the lower inflec-
tion point of the inspiratory pressure – volume
curve (see Fig. 225 – 1)
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2. Level of PEEP associated with maximal lung base of text
compliance
3. Level of PEEP associated with maximal sys-
temic oxygen delivery
4. Level of PEEP associated with minimum pul-
monary venous admixture (intrapulmonary
shunt)
Monitoring
A. Observe for development of barotrauma.
1. Manifestations include pneumothorax (includ-
ing tension pneumothorax), subcutaneous
emphysema, pneumomediastinum, interstitial
emphysema, pneumoperitoneum, pneumoperi-
cardium, gas cysts, and systemic gas embolism.
2. Associated with plateau airway pressures
greater than 35 cm H2O, particularly in later
stages of acute respiratory distress syndrome
(ARDS) with lung remodeling
B. Monitor pulmonary function.
1. Monitor gas exchange by pulse oximetry or ar-
terial blood gases.
2. Monitor airway plateau pressure and inspira-
tory:expiratory (I : E) ratio.
3. Assess effects on lung pressure – volume rela-
tionship (see Fig. 225 – 1).
C. Monitor hemodynamic effects of PEEP.
1. Assess for changes in heart rate, blood pressure,
and indicators of organ perfusion (e.g., urine
output, sensorium, and blood lactate concentra-
tion).
2. If available, monitor for changes in cardiac out-
put and SvO2.
3. Consider fluid challenge if hypotension or signs
of hypoperfusion manifest.
4. Positive end-expiratory pressure complicates in-
terpretation of central venous pressure (CVP)
and pulmonary artery occlusion pressure
(PAOP).
a. Positive end-expiratory pressure increases
measured (i.e., intraluminal) values of CVP
and PAOP by increasing intrathoracic pres-
sure. Preload, however, is decreased.
b. Right and left ventricular preload are depen-
dent on transmural end-diastolic ventricular
volumes (or corresponding pressures at a
given level of ventricular compliance), and
PEEP can increase the pressure on both sides
of the cardiac chambers and intrathoracic
veins.
c. Increased intraluminal venous pressure op- short
poses venous return to the right and left standard
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40941 CARLSON BERMEDICA
heart, resulting in decreased ventricular fill-
ing and preload.
d. The degree of transmission of PEEP to intra-
thoracic pressure varies with the degree of
lung injury and its effect on lung compli-
ance.
D. Monitor for auto-PEEP.
1. Auto-PEEP, or intrinsic PEEP, is due to inade-
quate time for lung emptying in the setting of
increased airway resistance and expiratory flow
limitation.
a. Can be caused by expiratory flow limitation
(e.g., bronchospasm), severely decreased
compliance (e.g., ARDS), and very high min-
ute ventilation (e.g., hyperventilation or
trauma)
b. Adverse effects include increased work of
breathing, risk of barotrauma or volu-
B
trauma, and hemodynamic compromise.
2. Auto-PEEP is quantified as the difference be-
tween mean alveolar pressure and external air-
way pressure at end-expiration.
a. Newer generation ventilators can provide
automated assessment of auto-PEEP.
b. May be manually determined by placing pa-
tient on assist-controlled mode, occluding
airway at end-expiration, and observing pas-
sive increase in airway pressure
3. A goal of therapy should be to achieve the
lowest practicable level of auto-PEEP.
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225 Positive End-Expiratory Pressure ● 817 base of RH
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Key Treatment Strategies for Minimizing
Auto-PEEP
● Aggressive bronchodilator therapy
● Pain control and treatment of fever, to decrease
minute volume
● Adequate sedation; consider selective use of
neuromuscular blockade
● Minimize I : E; e.g., increase expiratory time and
inspiratory flow rate, reduce tidal volume, reduce
respiratory rate.
● In some cases, judicious application of (extrinsic)
PEEP will counter intrinsic PEEP and decrease the
work of breathing.
Bibliography
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method for measuring pressure– volume curves during
mechanical ventilation. Am J Respir Crit Care Med
1999;159:275– 282.
Ranieri VM, Dambrosio M, Brienza N. Intrinsic PEEP and
cardiopulmonary interaction in patients with COPD and
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Ranieri VM, Grasso S, Fiore T, Giuliani R. Auto-positive
end-expiratory pressure and dynamic hyperinflation. Clin
Chest Med 1996;:379– 394.
Richard J-C, Maggiore, SM, Jonson B, et al. Influence of
tidal volume on alveolar recruitment. Respective role of
PEEP and a recruitment maneuver. Am J Respir Crit
Care Med. 2001;163:1609– 1613.
Vieira SRR, Puybasset L, Richecoeur J, et al. A lung com-
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Care Med 1998;158:1571– 1577.
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