Positive end-expiratory pressure: Difference between revisions
Content deleted Content added
m →Negative physiological effects: Added hypotension |
m Fix. |
||
| (131 intermediate revisions by 73 users not shown) | |||
| Line 1: | Line 1: | ||
{{Short description|Pressure in the lungs above atmospheric pressure}} |
|||
'''Positive end-expiratory pressure (PEEP)''' is a term used in [[mechanical ventilation]] to denote the amount of pressure above atmospheric pressure present in the airway at the end of the [[expiratory]] cycle. The equivalent in a spontaneously breathing patient is [[Continuous positive airway pressure|CPAP]]. PEEP is set on the ventilator. |
|||
'''Positive end-expiratory pressure''' ('''PEEP''') is the pressure in the lungs ([[alveolar pressure]]) above [[atmospheric pressure]] (the pressure outside of the body) that exists at the end of [[Exhalation|expiration]].<ref>{{cite web |url= http://medical-dictionary.thefreedictionary.com/positive+end-expiratory+pressure+%28PEEP%29 |work= [[TheFreeDictionary.com]] |title= Positive end-expiratory pressure (PEEP)}} Citing: {{Cite book |title= Saunders Comprehensive Veterinary Dictionary |year= 2007}}</ref> The two types of PEEP are extrinsic PEEP (PEEP applied by a ventilator) and intrinsic PEEP (PEEP caused by an incomplete exhalation). Pressure that is applied or increased during an inspiration is termed [[pressure support]]. PEEP is a therapeutic parameter set in the ventilator (extrinsic PEEP), or a complication of mechanical ventilation with air trapping (auto-PEEP).<ref>{{Cite web |title=UpToDate |url=https://www.uptodate.com/contents/positive-end-expiratory-pressure-peep |access-date=2023-04-01 |website=www.uptodate.com}}</ref> |
|||
== Intrinsic (auto-) PEEP == |
|||
==Positive physiological effects== |
|||
Auto-PEEP is an incomplete expiration prior to the initiation of the next breath causes progressive air trapping ([[Hyperaeration#Hyperaeration|hyperinflation]]). This accumulation of air increases alveolar pressure at the end of expiration, which is referred to as auto-PEEP. |
|||
*Improved gas exchange |
|||
*Alveolar recruitment |
|||
| ⚫ | |||
*Redistribution of fluids in the alveolus |
|||
Auto-PEEP develops commonly in high minute ventilation ([[hyperventilation]]), expiratory flow limitation (obstructed airway) and expiratory resistance (narrow airway). |
|||
==Negative physiological effects== |
|||
*Decreased [[Cardiac output]] |
|||
*Decreased venous return |
|||
*Increased [[Intracranial pressure#Increased_ICP|ICP]] |
|||
*[[Barotrauma]] |
|||
*[[Hypotension]] |
|||
Once auto-PEEP is identified, steps should be taken to stop or reduce the pressure build-up.<ref name="pmid16003057"/> 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"/><ref name="pmid15054570"/> |
|||
==Indications== |
|||
[[Hypoxia (medical)|Hypoxemia]] due to the following: |
|||
*[[ARDS]] |
|||
*[[Pneumonia]] |
|||
*[[Pulmonary edema]] |
|||
*[[Atelectasis]] |
|||
== Extrinsic (applied) PEEP == |
|||
==Contraindications== |
|||
Applied PEEP is usually one of the first [[Modes of mechanical ventilation|ventilator settings]] chosen when [[mechanical ventilation]] is initiated. It is set directly on the [[ventilator]]. |
|||
*Increased Intracranial Pressure |
|||
*[[Pneumothorax]] that has not been treated |
|||
*[[Bronchopleural fistula]] |
|||
Hemodynamic instability |
|||
A small amount of applied PEEP (4 to 5 cmH<sub>2</sub>O) is used in most mechanically ventilated patients to mitigate end-expiratory alveolar collapse.<ref name="pmid18664777"/> A higher level of applied PEEP (>5 cmH<sub>2</sub>O) 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.<ref>{{cite journal |last1= Smith |first1= RA |title= Physiologic PEEP |journal= [[Respir Care]] |year= 1988 |volume= 33 |page= 620}}</ref> |
|||
==References== |
|||
*[http://www3.us.elsevierhealth.com/HS/promo/Kruse/ch225.pdf Chapter 225 Positive End-Expiratory Pressure] |
|||
=== Complications and effects === |
|||
| ⚫ | |||
* Decrease in |
|||
**systemic venous return, cardiac output, cardiac index |
|||
**pulmonary capillary wedge pressure (PCWP), preload, arterial blood pressure |
|||
* Increase in: |
|||
**Intrathoracic pressure, RV afterload (CVP and PAP) |
|||
| ⚫ | |||
*Pulmonary [[barotrauma]] can be caused. Pulmonary barotrauma is lung injury that results from the hyperinflation of alveoli past the rupture point. |
|||
* The effects of PEEP on intracranial pressure (ICP) have been studied. Although PEEP is hypothesized to increase ICP due to impedance of cerebral blood flow, it has been shown that high PEEP does not increase ICP.<ref name="pmid327031"/><ref>{{cite journal |last1= Caricato |first1= A |last2= Conti |first2= G |last3= Della Corte |first3= F |last4= Mancino |first4= A |last5= Santilli |first5= F |last6= Sandroni |first6= C |last7= Proietti |first7= R |last8= Antonelli |first8= M |display-authors= 4 |title= Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: The role of respiratory system compliance |journal= [[The Journal of Trauma and Acute Care Surgery]] |volume= 58 |issue= 3 |pages=571–6 |date= March 2005 |pmid=15761353 |doi= 10.1097/01.ta.0000152806.19198.db|citeseerx= 10.1.1.500.2886 }}</ref> |
|||
*Renal functions and electrolyte imbalances, due to decreased venous return metabolism of certain drugs are altered and acid-base balance is impeded.<ref>{{cite journal |last1= Oliven |first1= A |last2= Taitelman |first2= U |last3= Zveibil |first3= F |last4= Bursztein |first4= S |title= Effect of positive end-expiratory pressure on intrapulmonary shunt at different levels of fractional inspired oxygen |journal= [[Thorax (journal)|Thorax]] |volume= 35 |issue= 3 |pages= 181–5 |date= March 1980 |pmid= 6770485 |pmc= 471250 |doi= 10.1136/thx.35.3.181|url= }}</ref> |
|||
==History== |
|||
[[John Scott Inkster]], an English [[anaesthetist]] and physician, is credited with discovering PEEP.<ref>{{cite journal |last= Craft |first= Alan |title= John Scott Inkster |journal= [[BMJ]] |type= obituary |doi= 10.1136/bmj.d7517 |date= December 13, 2011 |volume= 343 |page= D7517}}</ref> |
|||
When his discovery was published in the proceedings of the World Congress of Anaesthesia in 1968, Inkster called it Residual Positive Pressure. |
|||
==See also== |
==See also== |
||
* {{anli|Continuous positive airway pressure}} (CPAP) |
|||
| ⚫ | |||
* |
* {{anli|Positive airway pressure}} |
||
| ⚫ | |||
== |
==References== |
||
{{reflist|refs= |
|||
* {{MeshName|Positive+End-Expiratory+Pressure}} |
|||
<ref name="pmid18664777">{{cite journal|last1= Manzano |first1= F| title= Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients |journal=[[Crit Care Med]] | year= 2008 | volume= 36 | issue= 8 | pages= 2225–31 | pmid=18664777 | doi=10.1097/CCM.0b013e31817b8a92 |last2= Fernández-Mondéjar |first2= E |last3= Colmenero |first3= M |last4= Poyatos |first4= ME |last5= Rivera |first5= R|last6= Machado |first6= J |display-authors= 4| last7= Catalán |first7= I |last8= Artigas |first8= A}}</ref> |
|||
<ref name="pmid16003057">{{cite journal |last1= Caramez |first1= MP |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 |pmc= 2287196 |last2= Borges |first2= JB |last3= Tucci |first3= MR |last4= Okamoto |first4= VN |last5= Carvalho |first5= CR |last6= Kacmarek |first6= RM |doi= 10.1097/01.CCM.0000168044.98844.30 |last7= Malhotra |first7= A |last8= Velasco |first8= IT |last9= Amato |first9= MB |display-authors= 4}}</ref> |
|||
| ⚫ | |||
| ⚫ | |||
<ref name="pmid3053583">{{cite journal |last1= Smith |first1= TC |last2= Marini |first2= 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= 10.1152/jappl.1988.65.4.1488 }}</ref> |
|||
{{med-stub}} |
|||
<ref name="pmid15054570">{{cite journal |last1= Kondili |first1= E |last2= Alexopoulou |first2= C |last3= Prinianakis |first3= G |last4= Xirouchaki |first4= N |last5= Georgopoulos |first5= D |display-authors= 4 |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|doi-access= free }}</ref> |
|||
[[de:Positiver endexspiratorischer Druck]] |
|||
[[nl:PEEP]] |
|||
<ref name="pmid327031">{{cite journal |last1= Frost |first1= EA |title= Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain-injured patients |journal= [[J Neurosurg]] |year= 1977 |volume= 47 |issue= 2 |pages= 195–200 |pmid= 327031 |doi= 10.3171/jns.1977.47.2.0195}}</ref> |
|||
| ⚫ | |||
}} |
|||
<!--not used |
|||
<ref name="pmid21851022">{{cite journal|author1=Eremenko AA |author2=Borisov RIu |author3=Egorov VM |journal=Anesteziol Reanimatol | year= 2011 |pages= 43–7 | pmid=21851022| title=Evaluating the effectiveness of "open lung" maneuvre| issue=3 }}</ref> |
|||
<ref name="pmid21856815">{{cite journal|vauthors=Hillman NH, Nitsos I, Berry C, Jane Pillow J, Kallapur SG, Jobe AH | title=Positive end-expiratory pressure and surfactant decrease lung injury during initiation of ventilation in fetal sheep| journal=Am J Physiol Lung Cell Mol Physiol | year= 2011 | volume= 301 | issue= 5 | pages= L712–20 | pmid=21856815 | doi=10.1152/ajplung.00157.2011| pmc=3290453}}</ref> |
|||
<ref name="pmid7804800">{{cite journal| author=Kaczmarczyk G| title=Pulmonary-renal axis during positive-pressure ventilation| journal=New Horiz | year= 1994 | volume= 2 | issue= 4 | pages= 512–7 | pmid=7804800 }}</ref> |
|||
<ref name="pmid20446776">{{cite journal|vauthors=Dehne MG, Meister M, Röhrig R, Katzer C, Mann V | title=Effects of inverse ratio ventilation with PEEP on kidney function| journal=Renal Failure | year= 2010 | volume= 32 | issue= 4 | pages= 411–6 | pmid=20446776 | doi=10.3109/08860221003672176 }}</ref> |
|||
<ref name="pmid12352486">{{cite journal|vauthors=Huynh T, Messer M, Sing RF, Miles W, Jacobs DG, Thomason MH | title=Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury| journal=J Trauma | year= 2002 | volume= 53 | issue= 3 | pages= 488–93 | pmid=12352486 | doi= 10.1097/00005373-200209000-00016}}</ref> |
|||
<ref name="pmid7037709">{{cite journal|vauthors=Hasan FM, Beller TA, Sobonya RE, Heller N, Brown GW | title=Effect of positive end-expiratory pressure and body position in unilateral lung injury | journal=J Appl Physiol | year= 1982 | volume= 52 | issue= 1 | pages= 147–54 | pmid=7037709 }}</ref> |
|||
--> |
|||
[[Category:Respiratory system procedures]] |
|||
| ⚫ | |||
[[Category:Modes of mechanical ventilation]] |
|||
| ⚫ | |||
Latest revision as of 20:19, 19 June 2024
Positive end-expiratory pressure (PEEP) 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 PEEP are extrinsic PEEP (PEEP applied by a ventilator) and intrinsic PEEP (PEEP caused by an incomplete exhalation). Pressure that is applied or increased during an inspiration is termed pressure support. PEEP is a therapeutic parameter set in the ventilator (extrinsic PEEP), or a complication of mechanical ventilation with air trapping (auto-PEEP).[2]
Intrinsic (auto-) PEEP
[edit]Auto-PEEP is an 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-PEEP.
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.[3] When auto-PEEP persists despite management of its underlying cause, applied PEEP may be helpful if the patient has an expiratory flow limitation (obstruction).[4][5]
Extrinsic (applied) PEEP
[edit]Applied PEEP 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 (4 to 5 cmH2O) is used in most mechanically ventilated patients to mitigate end-expiratory alveolar collapse.[6] A higher level of applied PEEP (>5 cmH2O) 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.[7]
Complications and effects
[edit]Positive end-expiratory pressure can contribute to:
- Decrease in
- systemic venous return, cardiac output, cardiac index
- pulmonary capillary wedge pressure (PCWP), preload, arterial blood pressure
- Increase in:
- Intrathoracic pressure, RV afterload (CVP and PAP)
- lung functional residual capacity
- Pulmonary barotrauma can be caused. Pulmonary barotrauma is lung injury that results from the hyperinflation of alveoli past the rupture point.
- The effects of PEEP on intracranial pressure (ICP) have been studied. Although PEEP is hypothesized to increase ICP due to impedance of cerebral blood flow, it has been shown that high PEEP does not increase ICP.[8][9]
- Renal functions and electrolyte imbalances, due to decreased venous return metabolism of certain drugs are altered and acid-base balance is impeded.[10]
History
[edit]John Scott Inkster, an English anaesthetist and physician, is credited with discovering PEEP.[11] When his discovery was published in the proceedings of the World Congress of Anaesthesia in 1968, Inkster called it Residual Positive Pressure.
See also
[edit]- Continuous positive airway pressure – Form of ventilator which applies mild air pressure continuously to keep airways open (CPAP)
- Positive airway pressure – Mechanical ventilation in which airway pressure is always above atmospheric pressure
- Positive pressure ventilation – Mechanical ventilation in which airway pressure is always above atmospheric pressure
References
[edit]- ^ "Positive end-expiratory pressure (PEEP)". TheFreeDictionary.com. Citing: Saunders Comprehensive Veterinary Dictionary. 2007.
- ^ "UpToDate". www.uptodate.com. Retrieved 2023-04-01.
- ^ Caramez, MP; Borges, JB; Tucci, MR; Okamoto, VN; 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. doi:10.1097/01.CCM.0000168044.98844.30. PMC 2287196. PMID 16003057.
- ^ 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. doi:10.1152/jappl.1988.65.4.1488. PMID 3053583.
- ^ Kondili, E; Alexopoulou, C; Prinianakis, G; Xirouchaki, N; et al. (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.
- ^ Manzano, F; Fernández-Mondéjar, E; Colmenero, M; Poyatos, ME; 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.
- ^ Smith, RA (1988). "Physiologic PEEP". Respir Care. 33: 620.
- ^ Frost, EA (1977). "Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain-injured patients". J Neurosurg. 47 (2): 195–200. doi:10.3171/jns.1977.47.2.0195. PMID 327031.
- ^ Caricato, A; Conti, G; Della Corte, F; Mancino, A; et al. (March 2005). "Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: The role of respiratory system compliance". The Journal of Trauma and Acute Care Surgery. 58 (3): 571–6. CiteSeerX 10.1.1.500.2886. doi:10.1097/01.ta.0000152806.19198.db. PMID 15761353.
- ^ Oliven, A; Taitelman, U; Zveibil, F; Bursztein, S (March 1980). "Effect of positive end-expiratory pressure on intrapulmonary shunt at different levels of fractional inspired oxygen". Thorax. 35 (3): 181–5. doi:10.1136/thx.35.3.181. PMC 471250. PMID 6770485.
- ^ Craft, Alan (December 13, 2011). "John Scott Inkster". BMJ (obituary). 343: D7517. doi:10.1136/bmj.d7517.