Introducing PEEP

in Emergency Room
Dr Rumaisah Satyawati SpAn, KIC
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