Abstract
PEEP has become the mainstay m the treatment of hypoxemic acute respiratory failure (ARF). While PEEP improves oxygenation by decreasing intrapulmonary shunting, it may also impair cardiac output and hence decrease oxygen delivery (O2D) despite increased arterial oxygen content (CaO2). Since optimizing O2D is the goal of therapy in ARF, we sought to determine whether the level of PEEP which results in maximal O2D can be estimated using noninvasive measurements of lung compliance (C). We studied 14 normovolemic children, aged 2 wks to II yrs, with ARF due to pneumonia or ARDS. Indicator dilution cardiac index (CI), arterial O2 partial pressure (PaO2), CaO2, C, and O2D were determined at 0, 3, 6, 9, 12 and 15 cm H2O PEEP. Tidal volume and FiO2 were held constant The level of PEEP (m±SD) at which O2D was maximal was 5.8±5.3 cm, and ranged from 0-15 cm in individual pts. PEEP of maximal C averaged 8.5±6 cm (range 0-15 cm) and was the same as PEEP of maximal O2D in 6 pts (43%) but higher (7 pts) or lower (1 pt) than PEEP of maximal O2D in the remainder; no consistent relationship between O2D and C was observed. PEEP of maximal CI was identical to PEEP of maximal O2D in all pts; higher levels of PEEP were associated with a significant decrease in CI, from 5.47±2 L/min/m2 at PEEP of maximal O2D to 4.39±2 L/min/m2 at PEEP 9 cm above that of maximal O2D. PEEP of maximal PaO2 averaged 12.2±4 cm (range 0-15 cm), and corresponded to PEEP of lowest O2D in 7 pts. At levels of PEEP above that of maximal O2D, PaO2 continued to increase significantly, from 115±40 torr at PEEP of maximal O2D to 145±75 torr at PEEP 9 cm above that of maximal O2D. We conclude that PEEP of maximal C does not reliably predict PEEP of best O2D in children with ARF. Because PaO2 continues to rise at levels of PEEP which cause significant decline in CI, maximizing PaO2 will not optimize O2D unless therapy to maintain CI is also employed.
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Witte, M., Galli, S., Chatham, R. et al. OPTIMAL POSITIVE END-EXPIRATORY PRESSURE (PEEP) IN INFANTS AND CHILDREN WITH ACUTE RESPIRATORY FAILURE. Pediatr Res 21 (Suppl 4), 208 (1987). https://doi.org/10.1203/00006450-198704010-00252
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DOI: https://doi.org/10.1203/00006450-198704010-00252