Lung Recruitment

First and foremost, performed to provide an arterial oxygen saturation of 90% or

greater at an Fio2 of less than 60%

Recruitment of nonaerated lung units (open-lung concept) but risk of regional

lung overinflation is a highly controversial issue

*aerated lung means the exchange of carbon dioxide for oxygen by the
blood in the lungs.

The ARDS Lungs

‒ Increase in lung density from alveolar edema and inflammation that

predominates in cephalic parts of the lungs
‒ Loss of aeration (lung collapse) that predominates in caudal and
dependent lung regions in patients lying supine
 External compression of caudal parts of the lungs by an enlarged
heart (myocardial edema, hyperdynamic profile, and pulmonary
hypertension-induced right ventricular dilatation)
 High pressure exerted by the abdominal content
 Accumulation of fluid in the pleural space
 Own increased weight (gravitation forces-weight of the edematous
lung)
‒ Consolidated alveoli - Alveolar flooding: Fluid-filled alveoli (edema fluid or
inflammatory cells) that predominates in caudal and dependent lung
regions in patients lying supine
‒ External forces applied on the lower lobes at end inspiration and end
expiration in a patient in the supine position and mechanically ventilated
with positive end-expiratory pressure.

Recruitment Maneuvers
 Proposed for improving arterial oxygenation and enhancing alveolar
recruitment
 All consisting of short-lasting increases in intrathoracic pressures
‒ Vital capacity maneuver (inflation of the lungs up to 40 cm H2O,
maintained for 15 - 26 seconds)
‒ Intermittent sighs
‒ Extended sighs
‒ Intermittent increase of PEEP
‒ Continuous positive airway pressure (CPAP
 ‒ Increasing the ventilatory pressures to a plateau pressure of 50 cm
H2O for 1-2 minutes
 Effective in improving arterial oxygenation only at low PEEP and small tidal
volumes.
 When alveolar recruitment is optimized by increasing PEEP, recruitment
maneuvers are either poorly effective or deleterious, inducing
overinflation of the most compliant regions, hemodynamic instability, and
an increase in pulmonary shunt resulting from the redistribution of
pulmonary blood flow toward nonaerated lung regions.
 The effect of recruitment may not be sustained unless adequate PEEP is
applied to prevent de-recruitment.

- Multiple methods have been described includes methods of determining

optimal PEEP.
- In ICU, they practices STAIRCASE RECRUITMENT MANOEUVRE (SRM)
approach. This is the approach described by Hodgson et al (2011)

Indications

 severe ARDS of <1 week duration

 other patients considered on an individualised basis

Contraindications

 Circulatory instability – ensure fluid and inotrope resuscitation complete

with stable BP above target
 Pneumothorax or other air leaks (pneumomediastinum, etc) (present or
recent)
 High risk of pneumothorax (e.g. necrotising lung infection, lung cysts, etc)
 ventilated ARDS present >1 week (poor responders) are a relative contra-
indication

Procedure

 using pressure controlled ventilation adjust FiO2 to target SaO2 90-92%

 set Pi to 15 cm H2O above the PEEP and maintain this difference
 increase PEEP in a stepwise manner to 20, then 30 and then 40 cm H2O
with adjustments made every two minutes (i.e. Pi will reach 55 cmH20)
  reduce PEEP to 25, then 22.5, then 20, then 17.5 or then an absolute
minimum of 15 cm H2O every three minutes until a decrease in SaO2 ≥
1% from maximum SaO2 is observed (the de-recruitment point)
 increase PEEP to 40 cm H2O for one minute then return to a PEEP level
2.5 cm H2O above the de-recruitment point (the optimal PEEP)
 then adjust to tidal volume ≤ 6 mls/kg IBW and a plateau pressure ≤ 30 cm
H2O, tolerate permissive hypercapnia if pH >7.15, can increase RR up to
38/min (max)

SRM should be stopped if:

 HR < 60 or > 140/min

 new dysrhythmia
 SBP <80 mmHg
 SaO2 < 85% (mild desaturation during the procedure does not indicate a
failed response to SRM)

CONCLUSION

Recruitment manoeuvres (RM) should not be performed routinely in the

management of ARDS.

 RMs may be performed by clinical experts in select patients (e.g.

refractory hypoxaemia) deemed likely to benefit from the intervention as
part of an open lung approach to ventilation
 Alternative, simpler, RMs (such as 40 cmH20 PEEP for 30s) may be
preferred to SRMs due to increased mortality observed in the ART trial