Critical Care Medicine-Pulmonary Disorders>>>>>Respiratory Diagnostic Modalities and Monitoring
Question 15#

A 67-year-old patient (BMI 40 kg/m2 ) is admitted to the ICU in acute respiratory failure.

What is the best way to optimize the patient’s end expiratory lung volume?

A. PEEP setting guided by measurement of transpulmonary pressures
B. Recruitment maneuver followed by PEEP optimization guided by measurements of transpulmonary pressures
C. Zero PEEP
D. PEEP set by clinician preference

Correct Answer is B

Comment:

Correct Answer: B

Generally, clinicians set a lower PEEP than what was used during a recruitment maneuver. This becomes more important in obese individuals where the transpulmonary pressure is higher. It has been shown that measurement of transpulmonary pressures by esophageal balloon following a recruitment maneuver lead to same PEEP settings as after a decremental PEEP trial. In obese patients, the latter strategies had no negative hemodynamic effects but improved lung mechanics as well as oxygenation significantly.

References:

  1. Pirrone M, Fisher D, Chipman D, et al. Recruitment maneuvers and positive end-expiratory pressure titration in morbidly obese ICU patients. Crit Care Med. 2016;44(2):300-307.
  2. Goligher EC, Hodgson CL, Adhikari NK, et al. Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc. 2017;14(suppl 4):S304-S311.