Positive end-expiratory pressure: Difference between revisions

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Positive end-expiratory pressure (P_EEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration.^[1] The two types of P_EEP are extrinsic PEEP (PEEP applied by a ventilator) and intrinsic P_EEP (P_EEP caused by a non-complete exhalation).

Extrensic PEEP (Applied)

Applied (Extrinsic) P_EEP — Applied P_EEP is usually one of the first ventilator settings chosen when mechanical ventilation is initiated. It is set directly on the ventilator.

A small amount of applied PEEP (3 to 5 cm H2O) is used in most mechanically ventilated patients to mitigate end-expiratory alveolar collapse^[2]. A higher level of applied PEEP (>5 cm H2O) is sometimes used to improve hypoxemia or reduce ventilator-associated lung injury in patients with acute lung injury, acute respiratory distress syndrome, or other types of hypoxemic respiratory failure^[3].

Contraindications

Contraindications — There are no absolute contraindications to applied P_EEP. However, applied P_EEP can have adverse consequences (especially at high levels) and should be used cautiously in patients who have intracranial abnormalities, unilateral or focal lung disease, hypotension, hypovolemia, pulmonary embolism, dynamic hyperinflation without airflow limitation, or a bronchopleural fistula^[4]. It may also have undesirable consequences in patients undergoing prone ventilation^[5].

Intrinsic PEEP (Auto)

Auto (Intrinsic) P_EEP — Incomplete expiration prior to the initiation of the next breath causes progressive air trapping (hyperinflation). This accumulation of air increases alveolar pressure at the end of expiration, which is referred to as auto-P_EEP.

Auto-PEEP develops commonly in high minute ventilation (hyperventilation), expiratory flow limitation (obstructed airway) and expiratory resistance (narrow airway).

Once auto-PEEP is identified, steps should be taken to stop or reduce the pressure build-up^[6]. When auto-PEEP persists despite management of its underlying cause, applied PEEP may be helpful if the patient has an expiratory flow limitation (obstruction)^[7]^[8].

References

^ thefreedictionary.com > positive end-expiratory pressure (P_EEP) Citing: Saunders Comprehensive Veterinary Dictionary, copyright 2007
^ Manzano F, Fernández-Mondéjar E, Colmenero M, Poyatos ME, Rivera R, Machado J; et al. (2008). "Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients". Crit Care Med. 36 (8): 2225–31. doi:10.1097/CCM.0b013e31817b8a92. PMID 18664777. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
^ Smith, RA. Physiologic PEEP. Respir Care 1988; 33:620.
^ Hasan FM, Beller TA, Sobonya RE, Heller N, Brown GW (1982). "Effect of positive end-expiratory pressure and body position in unilateral lung injury". J Appl Physiol. 52 (1): 147–54. PMID 7037709.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Huynh T, Messer M, Sing RF, Miles W, Jacobs DG, Thomason MH (2002). "Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury". J Trauma. 53 (3): 488–92, discussion 492-3. doi:10.1097/01.TA.0000025657.37314.2F. PMID 12352486.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM; et al. (2005). "Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation". Crit Care Med. 33 (7): 1519–28. PMC 2287196. PMID 16003057. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: PMC format (link) CS1 maint: multiple names: authors list (link)
^ Smith TC, Marini JJ (1988). "Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction". J Appl Physiol. 65 (4): 1488–99. PMID 3053583.
^ Kondili E, Alexopoulou C, Prinianakis G, Xirouchaki N, Georgopoulos D (2004). "Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease". Intensive Care Med. 30 (7): 1311–8. doi:10.1007/s00134-004-2255-z. PMID 15054570.{{cite journal}}: CS1 maint: multiple names: authors list (link)

External links

Positive+End-Expiratory+Pressure at the U.S. National Library of Medicine Medical Subject Headings (MeSH)

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[1] thefreedictionary.com > positive end-expiratory pressure (P_EEP) Citing: Saunders Comprehensive Veterinary Dictionary, copyright 2007

[pmid18664777-2] Manzano F, Fernández-Mondéjar E, Colmenero M, Poyatos ME, Rivera R, Machado J; et al. (2008). "Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients". Crit Care Med. 36 (8): 2225–31. doi:10.1097/CCM.0b013e31817b8a92. PMID 18664777. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

[3] Smith, RA. Physiologic PEEP. Respir Care 1988; 33:620.

[pmid7037709-4] Hasan FM, Beller TA, Sobonya RE, Heller N, Brown GW (1982). "Effect of positive end-expiratory pressure and body position in unilateral lung injury". J Appl Physiol. 52 (1): 147–54. PMID 7037709.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[pmid12352486-5] Huynh T, Messer M, Sing RF, Miles W, Jacobs DG, Thomason MH (2002). "Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury". J Trauma. 53 (3): 488–92, discussion 492-3. doi:10.1097/01.TA.0000025657.37314.2F. PMID 12352486.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[pmid16003057-6] Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM; et al. (2005). "Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation". Crit Care Med. 33 (7): 1519–28. PMC 2287196. PMID 16003057. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: PMC format (link) CS1 maint: multiple names: authors list (link)

[pmid3053583-7] Smith TC, Marini JJ (1988). "Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction". J Appl Physiol. 65 (4): 1488–99. PMID 3053583.

[pmid15054570-8] Kondili E, Alexopoulou C, Prinianakis G, Xirouchaki N, Georgopoulos D (2004). "Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease". Intensive Care Med. 30 (7): 1311–8. doi:10.1007/s00134-004-2255-z. PMID 15054570.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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 ==Intrinsic PEEP (Auto)==
 '''Auto (Intrinsic) P<sub>EEP</sub>''' — Incomplete expiration prior to the initiation of the next breath causes progressive air trapping ([[hyperinflation]]). This accumulation of air increases alveolar pressure at the end of expiration, which is referred to as auto-P<sub>EEP</sub>.
+Auto-PEEP develops commonly in high minute ventilation ([[hyperventilation]]), expiratory flow limitation (obstructed airway) and expiratory resistance (narrow airway).
+Once auto-PEEP is identified, steps should be taken to stop or reduce the pressure build-up<ref name="pmid16003057">{{cite journal| author=Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM et al.| title=Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation. | journal=Crit Care Med | year= 2005 | volume= 33 | issue= 7 | pages= 1519-28 | pmid=16003057 | doi= | pmc=PMC2287196 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16003057  }} </ref>.  When auto-PEEP persists despite management of its underlying cause, applied PEEP may be helpful if the patient has an expiratory flow limitation (obstruction)<ref name="pmid3053583">{{cite journal| author=Smith TC, Marini JJ| title=Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. | journal=J Appl Physiol | year= 1988 | volume= 65 | issue= 4 | pages= 1488-99 | pmid=3053583 | doi= | pmc= | url= }} </ref><ref name="pmid15054570">{{cite journal| author=Kondili E, Alexopoulou C, Prinianakis G, Xirouchaki N, Georgopoulos D| title=Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease. | journal=Intensive Care Med | year= 2004 | volume= 30 | issue= 7 | pages= 1311-8 | pmid=15054570 | doi=10.1007/s00134-004-2255-z | pmc= | url= }} </ref>.
 ==See also==