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- Title
A NOVEL APPROACH TO DETERMINING OPTIMAL PEEP.
- Authors
Dhillon, Pete; Jewers, Dan; Irwin, Andrea; Morton, Sheena; Knight, Gwen; Soo, Andrea; Cyca, Michelle; Bagshaw, Sean; Zuege, Dan; Parhar, Ken
- Abstract
Background: Positive end expiratory pressure (PEEP) is the pressure that remains in the airways at the end of exhalation during invasive mechanical ventilation. This value can be set by the clinician to minimize ventilator-induced lung injury. As with any ventilation parameter, PEEP should be used judiciously and specifically tailored for each patient to promote lung protective ventilation. Determining the optimal PEEP for patients on mechanical ventilation is critical to improve overall oxygenation, pulmonary compliance and lung recruitment. Setting the appropriate PEEP avoids atelectrauma by preventing overstretching and cyclical closing of alveoli further lessening ventilator-induced lung injury (VILI). Despite all of the benefits in determining the optimal PEEP, there are inconsistent methods across intensive care units and many lack a standardized procedure. Objectives: a) To share a novel approach in determining the optimal PEEP via a decremental PEEP study that balances oxygenation, compliance and driving pressure while minimizing ventilator-induced lung injury. b) To demonstrate how it can be performed quickly, safely and accurately in a clinical setting with no specialized equipment. c) To review how to analyze PEEP tables to determine the optimal PEEP by identifying the linear portion of the curve and the upper/lower inflection points. Methods: Our team has developed a novel methodology to determine the optimal PEEP in a step-wise approach that is safe, time-efficient (when compared with conventional techniques), potentially more accurate and requires no specialized equipment. This decremental method incorporates compliance, oxygen saturations, mean airway, plateau and driving pressures as well as the concept of linearity to best choose an optimal PEEP range, while allowing the medical team to consider the patient's pathology and clinical conditions before selecting the optimal PEEP. The study involves a retrospective review of 170 (pre-implementation) PEEP tables comparing traditional techniques to our method on ICU patients. Results: The optimal PEEP selected by clinicians, the time it took to complete the study and the results from our Qualtrics survey data will be reviewed. Currently, we have 23 surveys completed by physicians and respiratory therapists across Alberta with more pending. Our team is planning to launch at pilot sites within Alberta this fall and collect post implementation data. We also plan to analyze post implementation tables performed on real patients across Alberta to observe if there are differences in the "optimal PEEP selections" by frontline therapists with their current method versus the novel algorithm. Discussion: Optimal PEEP can be determined in many ways. Currently, no consistent standardized practice or gold standard exists. We hypothesize that the current methods being used direct to a lower optimal PEEP, an unnecessary use of higher FiO2, impaired ventilation and potentially cause longer days on mechanical ventilation. Our decremental approach using basic ventilating pressure measurements and without the need for specialized equipment will permit the respiratory therapist to efficiently and more accurately determine an optimal PEEP leading to higher compliance and improved oxygenation. Conclusion: Identification of the optimal PEEP using our novel method can be performed safely, efficiently and at the same time minimizing risk for ventilator-induced lung injury. Future studies will be required to determine clinical outcomes associated with the use of this novel PEEP titration method.
- Subjects
CANADA; LUNG injuries; POSITIVE end-expiratory pressure; MECHANICAL ventilators; CONFERENCES &; conventions; TREATMENT effectiveness; REACTIVE oxygen species; OXYGEN in the body; PATIENT safety; EVALUATION
- Publication
Canadian Journal of Respiratory Therapy, 2023, Vol 59, p134
- ISSN
1205-9838
- Publication type
Article