recruitment maneuver ppt

recruitment maneuver definition

administration of high vent pressure briefly to re-inflate collapsed lung and recruit. desired outcome is to improve oxygenation and increase compliance.

What are the two physiological factors/forces acting on alveoli?

1. collapsing: surface tension and recoil pressure of lungs

2. inflating: surfactant and negative pleural pressure

Causes of alveolar collapse

1. loss of surfactant (ALI, ARDS)

2. + pleural pressure (pneumo)

3. - alveolar pressure (sxn)

4. gas reabsorption (mucus plugs)

5. loss of N2 splinting (O2 takes up less space than N2, so when on 100% FiO2, takes up less space and decreases SA)

Indications

1. ARDS (secondary)

2. atelectasis during anesthesia

3. after sxn’ing ETT

contraindications

1. hemodynamic compromise (causes transient loss of venous return which lowers CO

2. existing barotrauma

3. increased ICP

4. predisposition to barotrauma (apical bullies lung disease or focal lung pathology)

determining recruitability

1. CT scans on low + high PEEP (compare volume of aerated regions)

2. effect on PEEP (change in PaO2/FiO2 ratio)

3. pressure-volume curves

consequences

1. increased O2 + releases more surfactant (stretch causes type II to release more, good until TOO much)

2. increased shunt, PAP and ICPs

3. decreases cardiac output

4. barotrauma, overdistension

some basic protocols

1. 40 for 40s or 30 for 30s

2. PCAC w/ pplat 45cmH2O, +5, I:E 1.1, RR10

3. VCAC w/ +20, 2min, gradually reduce it

Either revert back to original PEEP or LOWER (better)

steps

1. preox

2. check SpO2 + BP

3. check pressures

4. PS mode → 0 PS, set PEEP, apnea 60s

5. hit time goal + get vitals (increased HR, decreased BP + SpO2? turn off!)

6. place back on + LOWER PEEP

PEEP afterwards

no one agrees on how to determine appropriate PEEP, however this is current practice:

gradually decrease +2 every 4min until fall in FiO2 by 10%.

Jen recommends to decrease until BELOW OG PEEP (e.g., start @14 → 40 → 10).

Discontinue when:

1. systolic BP decreases by 30mmHg

2. SaO2 decreases 5%

3. HR increases 20bpm

4. arrhythmia

who most likely benefits from this?

1. atelectatic post op patient

2. after sxn

3. early ARDS

who is least likely to benefit

1. pneumonia

2. primary ARDS (pneumonia, toxic gas inhalation, lung contusion)

3. late ARDS w/ organization/fibrosis (increased pplat)

did this truly improve outcomes?

temporarily. it caused improved oxygenation for brief periods but did not sustain.