Lung Recruitment Maneuvers

Lung Recruitment Maneuvers

David Ray Velez, MD

Definition: Temporary Sustained Increases in Airway Pressure to Open (Recruit) Collapsed Alveoli

Clinical Use

  • Primarily Used in Severe ARDS if there is Concern for Alveolar De-Recruitment or Atelectasis
    • De-Recruitment (Alveoli Collapse) Can Be Caused by Low PEEP, Low Tidal Volumes, or High FiO2 (Due to Absorption Atelectasis)
  • Goals:
    • Recruit Alveoli
    • Increase Lung Compliance
    • Reduce Intrapulmonary Shunting to Improve Gas Exchange
  • The Role of Recruitment Maneuvers is Controversial and Should Not Be Part of Routine Practice
    • Benefit is Often Short-Lived
    • There is No Significant Change in the Duration of Mechanical Ventilation, ICU Stay, or Hospital Stay
    • Staircase Recruitment Maneuvers May Actually Increase Mortality in Severe ARDS

Techniques

  • *Generally Done Using Pressure-Controlled Ventilation
  • Increase PEEP to 40 cm H2O for 30-40 Seconds with Respiratory Rate at Zero
  • Set Peak Pressure to 50 cm H2O with PEEP Above the Upper Inflection Point for 2 Minutes
  • RAMP Method: Slowly Increase Inspiratory Pressure Over a Longer Period of Time (Up to 40 cm H2O)
  • Staircase Recruitment Maneuver (SRM): Attempts to Identify the De-Recruitment Point and Optimal PEEP
    • Set Inspiratory Pressure to 15 cm H2O Above PEEP
    • Increase PEEP Every 2 Minutes (20 > 30 > 40 cm H2O)
    • Then Reduce PEEP Every 3 Minutes (25 > 22.5 > 20 > 17.5 cm H2O)
      • Decrease Until SaO2 ≥ 1% from the Maximum SaO2 Observed (De-Recruitment Point)
    • Increase PEEP to 40 cm H2O for One Minute
    • Then Return PEEP to 2.5 cm H2O Above the De-Recruitment Point (Optimal PEEP)

Complications

  • Barotrauma and Ventilator-Induced Lung Injury (VILI)
    • Can Cause Pneumothorax, Pneumomediastinum, or Subcutaneous Emphysema
  • Can Worsen Oxygenation by Shunting Blood to Poorly Aerated Portions
  • Decreased Preload and Cardiac Output
  • Significant Discomfort (May Require Sedation)

Other Options to Recruit Alveoli