REVIEW

CURRENT
OPINION Lung recruitment in acute respiratory distress
syndrome: what is the best strategy?
Joseph C. Keenan a, Paolo Formenti b, and John J. Marini c

Purpose of review
Supporting patients with acute respiratory distress syndrome (ARDS) using a low tidal volume strategy is a
standard practice in the ICU. Recruitment maneuvers can be used to augment other methods, like positive
end-expiratory pressure and positioning, to improve aerated lung volume. Clinical practice varies widely,
and optimal method and patient selection for recruitment maneuvers have not been determined.
Recent findings
Recent developments include experimental and clinical evidence that a stepwise extended recruitment
maneuver may match the improvement in aerated lung volume seen with sustained inflation traditionally
used, with less adverse effects. Positioning and other chest wall modifications may be useful adjuncts to
recruitment maneuvers. In addition, evidence from clinical studies in the operating room suggests that
recruitment maneuvers, as a component of an open lung strategy, may be helpful for mechanically
ventilated patients with normal lungs.
Summary
As a component of ventilation strategy for patients with ARDS, the use of recruitment maneuvers, especially
a stepwise maneuver, in addition to adequate positive end-expiratory pressure and appropriate
positioning, is suggested by currently available data. Until their effect on clinical outcomes is further
defined, the use of recruitment maneuvers in ARDS and other settings will continue to be guided by
individual clinician experience and patient factors.
Keywords
acute respiratory distress syndrome, mechanical ventilation, positive end-expiratory pressure titration,
recruitment maneuver

INTRODUCTION system have been shown to improve for brief periods

Ventilatory management for the injured lung is
continuously evolving, but is still characterized by
pressure/volume-limited lung protection strategies
that lead to a potential risk of derecruitment, especi-
ally if sufficient positive end-expiratory pressure
(PEEP) is not applied. Thus, recruitment maneuvers
have become a component of some ventilatory
strategies. They are generally defined as a dynamic,
intentional, transient process of opening previously
collapsed lung unit by increasing transpulmonary
pressure (Ptp) [1] occurring along the entire inspir-
atory pressure–volume curve [2]. Although
traditionally considered a method using airway
pressure, it may also be accomplished by altering
chest wall elastance, spontaneous breathing
activity, or body position changes.
In the setting of acute respiratory distress syn-
drome (ARDS), oxygenation, functional residual
capacity (FRC), and elastance of the respiratory
with a variety of recruitment maneuvers. Recent
meta-analyses have not found lasting improvement
in clinical outcomes [3,4] possibly due to method-
ology and population heterogeneity.
The aim of this study is to summarize the
physiologic rationale of recruitment maneuvers,
different methodologies, and the recent findings
a
Pulmonary, Allergy, Critical Care and Sleep Medicine Section, Depart-
ment of Medicine, University of Minnesota, Minneapolis, Minnesota, USA,
b
Unità Operativa di Anestesia e Rianimazione, Azienda Ospedaliera San
Paolo – Polo Universitario, Milan, Italy and cPulmonary and Critical Care,
Regions Hospital, Saint Paul, University of Minnesota, Minneapolis,
Minnesota, USA
Correspondence to Joseph C. Keenan, Pulmonary, Allergy, Critical Care
and Sleep Medicine Section, Department of Medicine, University of
Minnesota, Minneapolis, Minnesota, USA. Tel: +1 612 624 0999;
e-mail: keen0061@umn.edu
Curr Opin Crit Care 2014, 20:63–68
DOI:10.1097/MCC.0000000000000054

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 Respiratory system
KEY POINTS
 Recruitment maneuvers are helpful in increasing
aerated lung volume, which decreases strain and tidal
recruitment/derecruitment.
 Patients with early, severe ARDS with diffuse changes
on chest radiograph and low lung compliance are
good candidates for recruitment maneuver.
 A stepwise recruitment maneuver with increasing PEEP
and a stable driving pressure (Fig. 1) that gradually
approaches maximum tidal pressures will achieve the
majority of attainable recruitment while minimizing
hemodynamic compromise and production of humoral
markers of lung damage.
 Postrecruitment application of adequate PEEP,
appropriate positioning, and vigilant management of
fluid balance are all critical to maintain recruitment
maneuver-generated gains in aeration.
in clinical and experimental studies that suggest
possible risks and benefits of this procedure and
its role in ventilator strategies.
PHYSIOLOGY OF RECRUITMENT
Ptp, the difference between airway pressure (Paw)
and pleural pressure (Ppl), is the lung’s distending
pressure. A successful recruitment maneuver needs
to overcome chest wall elastance and impart a Ptp of
a magnitude that opens collapsed alveoli. At a given
Ptp, the lung volume is usually higher on the expir-
atory limb than the inspiratory limb of the pressure–
volume curve, suggesting that a lower pressure is
Airway 50
pressure
(cmH2O)
40
Decremental PEEP titration
30
20
10
Stable driving pressure, increasing PEEP
FIGURE 1. Schematic of a stepwise recruitment maneuver followed by decremental PEEP titration. PEEP, positive end-
expiratory pressure.
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required to avoid re-collapse and maintain aeration
once opened. The magnitude of Ptp is an important
factor in determining both the likelihood of success
and adverse effects [5].
The length of time that a given distending pres-
sure is applied has less importance in determining
recruiting success [6]. In an effort to quantify the
relationship between magnitude of Ptp and the
duration of inflation, and to allow comparison
between different methods, the term ‘pressure–time
product’ is used. However, these are not equivalent
variables; at commonly applied pressures, most
recruitment occurs in the first few seconds of a
sustained inflation [7]. Time does play an important
role in hemodynamic alterations, which generally
occur with a longer duration of inflation.
Although most studies have evaluated recruit-
ment maneuvers in the context of ARDS, this inter-
vention may be of value in patients with atelectasis
related to general anesthesia, during postoperative
ventilation, following suctioning, after endotra-
cheal intubation, or in other conditions producing
hypoxemia, including heart failure [8,9].
Both compressive and absorptive atelectasis can
occur in ARDS and all the above-mentioned con-
ditions. Often, the airway pressure required to re-
open and recruit distal lung units collapsed due to
compressive atelectasis is relatively moderate and
may be accomplished by positioning. Most lung
units re-open at airway pressures below 35 cmH2O,
but considerably higher pressures may be required
for absorptive atelectasis, especially if the chest wall
is stiff [10,11].
Reversal of atelectasis may decrease potentially
damaging tidal opening/closing cycles, as well as
10–15 minutes
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reduce the shear forces associated with ventilating
heterogeneous lungs. In addition, increasing lung
volume at a given tidal volume decreases the venti-
lator-induced lung injury (VILI) associated strain
ratio of tidal volume to FRC [12]. Thus, identifying
patients who will respond to a recruitment maneu-
ver is important, and several studies have identified
characteristics that may predict this positive
response such as measured oxygenation, lung ela-
stance, and amount of dead space – all factors that
indicate higher severity of lung injury [13].
TYPES OF RECRUITMENT MANEUVERS
Recruitment maneuvers, broadly defined, can be
separated into categories based on the method
of intervention.
Airway pressure-based maneuvers
Airway pressure-based recruitment maneuvers are
the most frequently used technique in clinical set-
tings, and sustained inflation to high Paw is the
most commonly used method. A continuous
positive airway pressure mode with Paw of 35–
45 cmH2O applied for 30–40 s has become the most
commonly reported method [4]. An early method
used in conjunction with monotonous tidal
volumes was to interpose large breaths at regular
intervals to mimic ‘sighs’ observed during normal
breathing in healthy individuals. It can be set as a
number of independent or consecutive sighs to
reach high inspiratory pressure in either the pressure
or volume-control mode or a periodic increase in
PEEP for a few breaths [14]. Diverse methods that
continue ventilation using stepwise increases in
peak pressure and/or PEEP have been employed,
with a goal of mitigating the prolonged high Ptp
used in sustained inflation. Examples include incre-
mental increase in PEEP with a stable peak end-
inspiratory pressure [15], or in others a stepped,
prolonged recruitment maneuver [11] using a fixed
driving pressure or tidal volume and a stepwise
increase in PEEP (Fig. 1).
Ventilation mode
Certain nontraditional modes of ventilation, such
as airway pressure release ventilation and high-
frequency oscillatory ventilation, maintain inher-
ently higher mean airway pressures during tidal
breathing, thereby promoting recruitment [16].
Both strategies have been shown to improve
oxygenation, but there is no evidence that these
methods reduce mortality or improve clinical out-
comes [17].
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Best strategy for lung recruitment in ARDS Keenan et al.
Chest wall modification
Alteration of the pleural compartment that
surrounds the lung may increase and sustain the
Ptp. Because Ppl, and therefore Ptp, vary site to site
within the thorax, regional recruitment or com-
pression may occur even when the overall FRC does
not change.
The least invasive method is to allow spon-
taneous breathing activity. Active expansion of
the chest wall decreases Ppl and will contribute to
Ptp. In addition, gentle spontaneous breathing leads
to more physiologic distribution of aeration in
&
dependent lung fields [18 ]. Caution is called for,
however, as during pressure controlled modes
vigorous efforts may cause Ptp to be markedly
underestimated by airway pressure. There is also risk
of tidal derecruitment if, as a result of active exha-
lation, lung volume drops below the FRC associated
with passive exhalation.
Other chest wall modifications include decom-
pression of the abdomen, drainage of pleural effu-
sion, relaxation of the thoracic and abdominal
muscles, cessation of expiratory muscle activity,
initiation of diaphragmatic activity, and using
upright or prone positioning. These changes of pos-
ition and muscle activity tend to be applied for
lengthy periods, so that the boost in Ptp that results
from them is sustained, producing a PEEP-like effect.
A recent experimental study demonstrated that the
application of negative pressure ( 5 cmH2O) to the
abdominal wall might aid recruitment and increase
&
PaO2 [19 ]. However, sustained use was associated
with hemodynamic depression and lactic acidosis.
Positioning
The prone position acts as a regional recruitment
maneuver, increasing Ptp in dorsal regions and
causing a shift in heart weight from the lung
beneath it onto the ventral chest wall [20]. More-
over, this redistribution of Ptp is maintained, pro-
ducing a regional ‘PEEP-like’ effect that consolidates
the dorsal recruitment associated with the position
change [21]. In addition to increasing aerated
volume, prone position improves ventilation–
perfusion matching and may aid in clearance of
secretions. A recent prospective study in patients
with early ARDS demonstrated that a recruitment
maneuver (45 cmH2O extended sigh) combined
with prone positioning led to a significant and
durable improvement in oxygenation, as compared
to the same recruitment maneuver in the supine
position [20].
Despite optimistic findings regarding prone
position, many patients with ARDS are managed
in the supine position. Semi-Fowler’s and further
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 Respiratory system
movements in the sagittal plane towards sitting
upright shift the heart and abdominal contents
caudally, increasing the effective Ptp, especially in
peri-diaphragmatic regions. Such changes tend to
relieve compressive forces that otherwise may cause
small airway compression with airflow obstruction
&
and tissue collapse [22 ].
COMPARISON AMONG METHODS
Sighs imposed on a ventilation pattern with
unchanged PEEP have been found to have a rela-
tively short duration of effectiveness [23]. Methods
using frequencies of up to 180/h were associated
with elevated serum levels of inflammatory markers
in experimental models [24]. Decreasing frequency
decreased markers of inflammation. The lack of
maintained post-recruitment maneuver improve-
ment in aeration, a key to decreasing VILI, helps
explain the current lack of enthusiasm for periodic
sighs.
Stepwise or extended sigh maneuvers improve
lung aeration as effectively as sustained inflation with
lower mean airway pressures and consequently, less
risk of hemodynamic compromise and hyperinfla-
tion [11,25]. Recent experimental models of pulmon-
ary and extrapulmonary ARDS compared different
&
recruitment maneuver strategies [26 ,27,28]. All
methods improved respiratory system elastance,
but sustained inflation produced more severe epi-
thelial and messenger RNA markers of alveolar dam-
age, and less surfactant protein in the pulmonary
ARDS model. In the extrapulmonary model, both
sustained inflation and the stepwise increase to sus-
tained inflation caused endothelial injury and
increased vascular cell adhesion molecule 1.
Although sustained inflation and periodic sighs
appear to increase the release of inflammatory
markers, the practical significance of such differ-
ences, if any, remains to be clarified.
MONITORING RECRUITMENT MANEUVER
RESPONSE
Changes of oxygenation and tidal respiratory sys-
tem elastance are frequently used to evaluate
recruitment maneuver responses. However, neither
precisely reflects lung status. Judgment regarding
recruitment success or failure should be withheld
until the recruitment maneuver is completed or
terminated. As a value subject to hemodynamic as
well as airspace dynamics, arterial oxygenation is
influenced by maneuver-related transient factors.
Pulse oximetry is relatively insensitive to improve-
ments in arterial oxygen tension, but better in
detecting maneuver-related desaturation [29].
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More detailed, location-specific and precise
evaluations can be attained in the research setting
through the use of quantitative computed tomogra-
phy (CT) [30]. Bedside impedance tomography also
allows visualization of distribution and dynamics of
aeration, but lacks the precision of CT [31]. Measures
of exhaled CO2 and dead-space are influenced by the
enormous and changeable contributions of body-
stored CO2 and do not reliably reflect the effects of
&
recruitment [32 ].
CLINICAL USE
Sustained recruitment is understood to be of value in
ARDS, but indications as well as methods for achiev-
ing it differ significantly among centers. In some
practices, recruitment maneuvers are considered
innately hazardous and therefore shunned or used
only as a rescue attempt in the setting of refractory
hypoxemia or to reduce postsuctioning atelectasis. In
others, recruitment maneuvers are routine prerequi-
sites for setting PEEP decrementally.
Some patients without primary lung disease
may benefit from recruitment as well. Atelectasis
is often present in patients with abnormally high
chest wall elastance, including those with massive
obesity and ascites. On the basis of data during
laparoscopic surgery, recruitment can improve
&
FRC, elastance, and oxygenation [33 ]. Patients with
normal surfactant activity would be expected to
tolerate some degree of atelectasis well – as exem-
plified by normal obese patients and those with
congestive heart failure who do not develop VILI.
However, a recent clinical study found improved
outcomes using a low tidal volume strategy during
abdominal surgery, suggesting that an open lung
strategy, including recruitment, could improve out-
comes in mechanically ventilated patients without
&
ARDS [34 ].
PREDICTING RESPONSE
Recruitment maneuver is not without risks and
predicting its response could decrease the number
of patients exposed unnecessarily. The earlier or
‘exudative’ phase of ARDS has a better chance of
successful recruitment than the late or ‘fibrotic’
phase [10]. Patient-specific characteristics include
the primary pathology driving ARDS: in general,
extrapulmonary ARDS is more recruitable [35].
Patients with diffuse changes on imaging have
better chance of successful recruitment than those
with markedly focal changes. A higher baseline PEEP
level is associated with decreased effectiveness of
recruitment maneuvers [36]. Severe ARDS is more
recruitable than mild or moderate ARDS, and high
Volume 20  Number 1  February 2014

respiratory system elastance was associated with
increased recruitability in clinical studies [13]. In
contrast, patients with low chest wall elastance are
less likely to successfully recruit [10], and a meta-
analysis suggested that high respiratory system ela-
stance predicted less improvement in oxygenation
with recruitment [4].
CLINICAL EVIDENCE: BEDSIDE ADVERSE
EFFECTS
Vital sign abnormalities are frequently encountered
during the recruitment maneuver, but are often
self-limited following its discontinuation. High
Paw decreases preload and increases afterload of
the right ventricle. This leads to underfilling of the
left ventricle and hypotension, especially if there
is no increase in aerated lung [10]. Hypoxia results
from increased distension of already open alveoli and
redirection of blood flow towards nonaerated
lung. Successful recruitment, however, re-opens
viable channels for pulmonary blood flow and
reduces hypoxic vasoconstriction – events that
may improve right-ventricular function, attenuate
adverse responses, and improve cardiac performance.
Barotrauma is a common concern given the
high Paw applied during aggressive recruitment
maneuvers. Fortunately, prospective trials reported
a very low incidence of recruitment maneuver-
associated pneumothorax [3,4].
The perceived need for increased sedation and
occasionally neuromuscular blockade has been
noted in reviews as a possible concern, as deep
sedation might increase times on the ventilator
and in the ICU [4]. However, the need to deeply
sedate in advance of applying a recruitment maneu-
ver has not been documented.
FUTURE DIRECTIONS AND UNSETTLED
QUESTIONS
There can be little question that the high Paw of
recruitment maneuvers invariably overdistend
some areas as they recruit others. It is unclear
whether transient injury instituted or exacerbated
by a time-limited recruitment maneuver represents
a risk for development of VILI. It is possible that
these changes represent a one-time ‘adaptation’
injury rather than the initiation of a clinically
significant process.
CONCLUSION
Recruitment maneuvers are used frequently, but
optimal technique that balances benefit and harm
is still under discussion. Future studies targeting
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Best strategy for lung recruitment in ARDS Keenan et al.
meaningful clinical outcomes will be helpful in
achieving consensus regarding their appropriate
place in medical practice. In the meantime, appli-
cation to selected patients will be determined by
clinicians at the bedside based on their own
interpretation of available data.
Acknowledgements
None.
Conflicts of interest
The authors have no conflicts of interest to report.
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