Peep

Used to splint the lower airways and alveoli open, this increases the area available for gaseous exchange.

Indicated for use in those over 50kg requiring assisted breathing except in cardiac arrest. It is attached to the bag
mask and has a range of settings, we use PEEP set at 10 in most instances. Arrghh cannot remember any more, wait
set at 5 in a head injury? And what does the number represent.......pressure of water as it turns out

From the book

If the pt weighs 50kg and a manual ventilation bag is being used:

 Do not attach PEEP if CPR is in progress

 Attach PEEP set to 5 if pt has TBI
 Attach PEEP set to 10 for all other patients.

If the pt has CPO and severe resp distress that is not improving.

 Apply PEEP set to 10. Focus on ensuring a tight seal with the mask. Do not assist pt’s breathing unless
ineffective
 Increase the PEEP to 15 if the pt does not improve.

Notes

PEEP increases the pressure to exhalation and increases intra thoracic pressure. The application of PEEP:

a) Helps expand collapsed alveoli, improving oxygenation and ventilation

b) Splints medium sized airways open during exhalation, improving ventilation
c) Reduces the preload of the left ventricle by reducing the afterload of the right ventricle. This reduces the
amount of fluid entering the lungs by reducing the pressure within lung blood vessels.

PEEP is not applied during CPR because an increase in thoracic pressure reduces the blood flow achieved during CPR.
If a pt in cardiac arrest gains ROSC it is appropriate to attach PEEP but this is not an immediate priority.

PEEP increases ICP in pts with TBI by reducing venous return from the brain. In this setting there is a balance
between the benefit of PEEP improving oxygenation and the risk of PEEP increasing ICP. This is why PEEP is set to 5
for these pts.

PEEP reduces cardiac output by increasing the afterload of the right ventricle and reducing the preload of the left
ventricle. This reduction in CO may be substantial if PEEP is combined with positive pressure ventilation in a pt with:

a) An underlying problem reducing right ventricle preload, such as hypovolemia, tension pthx, or cardiac
tamponade.
b) An underlying problem increasing right ventricular afterload such as pulmonary embolism.

Patients with the above underlying problems require correction of the underlying problem (if poss) and expansion of
thier intra vascular volume with NaCl. This shoud occur prior to the application of positive pressure ventilation and
PEEP provided this is feasible.
VQ mismatch

Is ventilation perfusion mismatch usually resulting in shunting – this is when deoxygenated blood from the body
does not receive 02 from the capillaries of the pulmonary system and is moved back into the left atria then body
unoxygenated and still holding C02. Most common cause of hypoxemia

Reasons are, barrier to gas exchange such as in CHF where fluid sits in the alveoli, structural damage as in
emphysema, one more here........

From the book

WIKI - In respiratory physiology, the ventilation/perfusion ratio (or V/Q ratio) is a measurement used to assess the
efficiency and adequacy of the matching of two variables: [1] It is defined as: the ratio of the amount of air reaching the
alveoli to the amount of blood reaching the alveoli.

 "V" – ventilation – the air that reaches the alveoli

 "Q" – perfusion – the blood that reaches the alveoli
These two variables constitute the main determinants of the blood oxygen concentration

Inadequate Ventilation -

Shunting causes the movement of unoxygenated blood from the right side of the heart to the left side of the heart. A
shunt may occur from a physical defect that allows unoxygenated blood to bypass fully functioning alveoli. It may
also result when airway obstruction prevents 02 from reaching an adequately perfused area of the lung.
Pulmonary circulation is adequate but not enough 02 is available to the alveoli for normal perfusion. A portion of the
blood flowing through the pulmonary vessels doesn’t become oxygenated.

.Inadequate Perfusion -

Book- Dead Space ventilation occurs when alveoli don’t have adequate blood supply for gas exchange to occur. This
occurs with pulmonary emboli, pulmonary infarction, and Cardiogenic shock – reduced blood flow (CO)

BOTH Silent Unit indicates an absence of ventilation and perfusion to the lung area. May be in only one part of the
lung and deliver blood flow to a better ventilated area.