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Research ArticleConference Proceedings

Do the NIH ARDS Clinical Trials Network PEEP/FIO2 Tables Provide the Best Evidence-Based Guide to Balancing PEEP and FIO2 Settings in Adults?

Richard H Kallet and Richard D Branson
Respiratory Care April 2007, 52 (4) 461-477;
Richard H Kallet
Cardiovascular Research Institute, and with Respiratory Care Services, Department of Anesthesia, University of California, San Francisco, at San Francisco General Hospital, San Francisco, California.
MSc RRT FAARC
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  • For correspondence: [email protected]
Richard D Branson
Division of Trauma and Critical Care, Department of Surgery, and the College of Pharmacy, University of Cincinnati, Cincinnati, Ohio.
MSc RRT FAARC
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Abstract

Positive end-expiratory pressure (PEEP) and inspired oxygen fraction (FIO2) are the primary means of improving PaO2 during mechanical ventilation. Patients with acute respiratory distress syndrome (ARDS) typically present with a large intrapulmonary shunt, which makes even high FIO2 ineffective in improving PaO2. PEEP decreases intrapulmonary shunt by recruiting collapsed alveoli, but PEEP is associated with important adverse effects, whereas prolonged exposure to high FIO2 may cause oxidative lung injury. The improved survival found in the National Institutes of Health's ARDS Network low-tidal-volume study may suggest that their PEEP/FIO2 titration tables represent the best method for adjusting these variables. Based upon an extensive literature review of PEEP and respiratory system mechanics in ARDS, we conclude that: (1) for most patients the therapeutic range of PEEP is relatively narrow, so the ARDS Network PEEP/FIO2 strategy is reasonable and supported by high-level evidence, (2) how best to adjust PEEP to prevent or ameliorate ventilator-associated lung injury is unknown and still under investigation, and (3) in a small subset of patients with severe lung injury and/or abnormal chest-wall compliance, highly individualized titration of PEEP, based upon the respiratory-system pressure-volume curve, PEEP/tidal-volume titration grids, or a recruitment maneuver and a PEEP decrement trial is a reasonable alternative.

  • acute lung injury
  • acute respiratory distress syndrome
  • fraction of inspired oxygen
  • positive end-expiratory pressure
  • pressure-volume curve
  • respiratory system compliance

Footnotes

  • Correspondence: Richard H Kallet MSc RRT FAARC, Respiratory Care Services, San Francisco General Hospital, NH: GA-2, 1001 Potrero Avenue, San Francisco CA 94110. E-mail: rkallet{at}sfghsom.ucsf.edu.
  • Richard H Kallet MSc RRT FAARC and Richard D Branson MSc RRT FAARC presented a version of this paper at the 38th Respiratory Care Journal Conference, ”Respiratory Controversies in the Critical Care Setting,“ held October 6–8, 2006, in Banff, Alberta, Canada.

  • Copyright © 2007 by Daedalus Enterprises Inc.
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Respiratory Care: 52 (4)
Respiratory Care
Vol. 52, Issue 4
1 Apr 2007
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Do the NIH ARDS Clinical Trials Network PEEP/FIO2 Tables Provide the Best Evidence-Based Guide to Balancing PEEP and FIO2 Settings in Adults?
Richard H Kallet, Richard D Branson
Respiratory Care Apr 2007, 52 (4) 461-477;

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Do the NIH ARDS Clinical Trials Network PEEP/FIO2 Tables Provide the Best Evidence-Based Guide to Balancing PEEP and FIO2 Settings in Adults?
Richard H Kallet, Richard D Branson
Respiratory Care Apr 2007, 52 (4) 461-477;
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Keywords

  • acute lung injury
  • acute respiratory distress syndrome
  • fraction of inspired oxygen
  • positive end-expiratory pressure
  • pressure-volume curve
  • respiratory system compliance

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