Positive end-expiratory pressure

@article{Gattinoni2010PositiveEP,
  title={Positive end-expiratory pressure},
  author={Luciano Gattinoni and Eleonora Carlesso and Luca Brazzi and Pietro Caironi},
  journal={Current Opinion in Critical Care},
  year={2010},
  volume={16},
  pages={39–44}
}
Purpose of review In the last 2 years, several reports have dealt with recruitment/positive end-expiratory pressure (PEEP) selection. Most of them confirm previous results and few add new information. Recent findings It has been definitely confirmed that opening pressures are different throughout the acute respiratory distress syndrome lung parenchyma, ranging from 5–10 up to 30–40 cmH2O. The highest opening pressures are required to open the most dependent lung regions. It has been found that… 
Effects of increasing Positive End-Expiratory Pressure (PEEP) values on intraabdominal pressure and hemodynamics: A prospective clinical study
TLDR
It is recommended that the PEEP level is considered when interpreting the Intra-Abdominal Pressure (IAP) values in patients who receive mechanical ventilation, because it brings with it several hemodynamic complications.
Different patterns of lung recruitment maneuvers in primary acute respiratory distress syndrome: effects on oxygenation and central hemodynamics.
BACKGROUND The aim of this study was to test if different recruitment maneuver (RM) patterns, that achieve the same maximum pressure for the same length of time in humans, have a similar efficacy on
Can we estimate transpulmonary pressure without an esophageal balloon?-yes.
TLDR
The most crucial factors of ventilator induced lung injury can be determined by a simple PEEP step procedure and the measurement procedure can be repeated with short intervals, which makes it possible to follow the course of the lung disease closely.
Lung imaging for titration of mechanical ventilation
TLDR
Whereas quantitative CT remains the gold standard to assess lung morphology, recruitment and hyperinflation of lung tissue at different inflation pressures, EIT and LUS have emerged as valuable, radiation-free, noninvasive bedside lung imaging tools that should be used together with global parameters like lung mechanics and gas exchange to acquire additional information on recruitability and ventilation distribution.
C URRENT OPINION Lung imaging for titration of mechanical ventilation
TLDR
Whereas quantitative CT remains the gold standard to assess lung morphology, recruitment and hyperinflation of lung tissue at different inflation pressures, EIT and LUS have emerged as valuable, radiation-free, noninvasive bedside lung imaging tools that should be used together with global parameters like lung mechanics and gas exchange to acquire additional information on recruitability and ventilation distribution.
Electrical impedance tomography in the clinical assessment of lung volumes following recruitment manoeuvres
TLDR
This paper has demonstrated that with an understanding of the strengths and limitations of the device, EIT can be used successfully at the bedside by clinicians to guide recruitment and other clinical techniques.
Effect of transpulmonary pressure-guided positive end-expiratory pressure titration on lung injury in pigs with acute respiratory distress syndrome
TLDR
In a pig model of ARDS, ventilation with low VT and transpulmonary pressure-guided PEEP adjustment was associated with improved compliance, reduced dead space ventilation, increased cardiac output, and relieved lung injury, as compared to maximum oxygenation-guide PEP adjustment.
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References

SHOWING 1-10 OF 44 REFERENCES
Regional effects and mechanism of positive end-expiratory pressure in early adult respiratory distress syndrome.
TLDR
The increased SPL causes compression atelectasis; this is prevented when PEEP to a given lung region is equal to or greater than the SPL.
Use of dynamic compliance for open lung positive end‐expiratory pressure titration in an experimental study
TLDR
In this experimental model, the continuous monitoring of dynamic compliance identified the beginning of collapse after lung recruitment, and this method might become a valuable bedside tool for identifying the level of PEEP that prevents end‐expiratory collapse.
Recruitment and derecruitment during acute respiratory failure: a clinical study.
TLDR
The rules governing recruitment and derecruitment equally apply in an oleic acid model and in human ALI/ARDS, showing that positive end-expiratory pressure (PEEP) and tidal volume (VT) are interactive variables that determine the extent of lung recruitment.
Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.
TLDR
In patients with acute lung injury and ARDS who receive mechanical ventilation with a tidal-volume goal of 6 ml per kilogram of predicted body weight and an end-inspiratory plateau-pressure limit of 30 cm of water, clinical outcomes are similar whether lower or higher PEEP levels are used.
Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial.
TLDR
A strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation did not significantly reduce mortality, but it did improve lung function and reduced the duration of mechanical ventilation and theduration of organ failure.
Two Methods of Setting Positive End-expiratory Pressure in Acute Lung Injury: An Experimental Computed Tomography Volumetric Study
TLDR
Setting the PEEP based on the deflation limb of the PV curve was useful in improving oxygenation and lung volumes in a canine lung injury model and was associated with significantly higher PaO2 and Lung volumes, and significantly lower shunt fraction and cardiac index when compared to PEEPINF.
Lung recruitment in patients with the acute respiratory distress syndrome.
TLDR
In ARDS, the percentage of potentially recruitable lung is extremely variable and is strongly associated with the response to PEEP, which may decrease ventilator-induced lung injury by keeping lung regions open that otherwise would be collapsed.
Differences in regional pulmonary pressure–impedance curves before and after lung injury assessed with a novel algorithm
TLDR
A simple curve-fitting technique is employed to automatically define inflection points on both pressure–volume (PV) and pressure–impedance (PI) curves to asses the differences between global PV and regional PI estimates in animals before and after induced lung injury and demonstrates a clear increase in lower inflection point (LIP) along the gravitational axis.
A decremental PEEP trial identifies the PEEP level that maintains oxygenation after lung recruitment.
TLDR
A decremental PEEP trial identifies a PEEP setting that sustains for 4 h the oxygenation benefit of a 40-cm H2O, 40-s lung-recruitment maneuver.
Mechanical ventilation guided by esophageal pressure in acute lung injury.
TLDR
A ventilator strategy using esophageal pressures to estimate the transpulmonary pressure significantly improves oxygenation and compliance and Multicenter clinical trials are needed to determine whether this approach should be widely adopted.
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