Introducing PEEP

in Emergency Room
Fahrul Razi
PEEP
Positive End Expiratory Pressure

The maintenance of positive pressure

within the lungs at the end of expiration
 Role of PEEP
Ventilator Induced Lung Injury
Reduction /prevention

Lung Protective Ventilation

Reduce

Shift lung water

from alveoar spase
to perivascular intertstiial space
Ventilator Induced Lung Injury

Healty Lung with low PIP

does not cause lung injury

PEEP provides protection

from alveolar edema due to
high PIP

Ventilation with high PIP &

no PEEP produces
perivascular edema & leads
to severe injury
 PEEP Lung Protective Ventilation

Source : semin respir crit care med 2013

PEEP : Shift lung water from alveoar spase to
perivascular interstitial space

Indication for :
ARDS
Cardiogenic pulmonary Oedema
Non Cardiogenic pulmonary Oedema
Congestive Heart Failure
The effects of alveolar capillary leak and positive end-
expiratory pressure (PEEP) on pulmonary gas exchange.
PEEP - Lung Protective Srategies

Beneficial if used optimally with low tidal

volume
Provide acceptable 02 level to reduce FiO2 to
non toxic level (0,5)
PEEP - Management Airway
 PEEP

Automatic Ventilasi
Bag Valve Mask NIPPV
Resuscitator Mekanik
Bag Valve Mask with PEEP

Consider positive
pressure if pre intubation
SaO2 < 95% with 100%
oxygen.
Slow small, easy squeeze,
low volume ( 6-7 cc/kg ),
slow rate ( 8/min )
Distend alveoli, opening
more surface area for
oxygen absorption
Video BVM with PEEP
 NIPPV
Respiratory support
given without an ETT
Spontaneously
breathing patients
CPAP
High flow oxygen plus PEEP
Raises FRC away from residual volume
Splints alveoli open
- Reduce work of breating
- Increase PaO2
Re-expabds acteletasis
Resolution of pulmonary edema
Video CPAP
Automatic Resuscitator / Vortran

Provides consistent,
more efficient ventilation
Control of delivered
pressure (and volume)
Control of delivered rate
Reduce hyperinflation
barotrauma, volutrauma
respiratory alkalosis

Ability to provide PEEP

Minimizes aerophagia
and aspiration
Vortran Automatic Resuscitator / VAR
Non-Respiratory Pathologies Suitable
for VAR

Head injury or trauma

Stroke or CVA
Cardiac arrest
Heart failure
e.g., Left Ventricular Failure
Accidental poisonings / drug overdose
e.g., Sedatives, anti-depressants, narcotics, pesticides
Ventilator Protocol - ARDS NET
Variabel Protocol
Mode ventilator volume assist control
Tidal Volume < 6 mg/kg PBW
Plateu pressure < 30 cm H20
Ventilation Set rate / pH 6-36 breats/min , pH = 7.30-740
goal

Inspiratory flow I;E 1,1-1:3

Oxigenation goal PaO2 = 55-80 mmHg. SpO2 88 - 95%
FiO2 /PEEP 0.3/5 ,0.4/5. 0,4/8, 0,5/8. 0,5/10 0,6/10 ,
mmHg 0,7/10 0,7/12 . 0,7/ 14, 0,8/14 0,9/14, 0,9/16,
0,9/18 , 1,0/18, 1.0/20, 1.0/22
Weaning attempt with pessure support
Mechanical Ventilation
Lung Protective Strategy
Focuses on low tidal volume ventilation to reduce VILI
( barotrauma & volutrauma )
Based on the ARDSNet ARMA study
Immediately after intubation, decrease the FiO2 to
30% to 40% & assign the patient a PEEP of 5 cm H2O
Using the cart ( FiO2 & PEEP scale from ARDSnet
ARMA trial ) rapidly titrate to PEEP-FiO2
combinations that result in an SpO2 of 88% to 95%
severe acute lung injury (PaO2/FiO2 <200 mmHg,
rapid titrarion of the tidal volume to 6mL/kg should
occur even if the plateau pressure are acceptable
Video setting LPS