Lung recruitment maneuver

Background

• Controversial in terms of safety and efficacy
  • No mortality/morbidity outcome benefits
  • May be of more benefit to extra-pulmonary ARDS than to pulmonary ARDS
• Multiple methods reported
  • Below is only one method
  • Refer to your RT for hospital protocol
• Severe ARDS in which PaO2 recalcitrant to maximal ventilator settings, APRV, PCV
• Biotrauma and cytokine release occur due to:
  • Dependent areas of airway are collapsed throughout TVs
  • Cyclic collapse causes shear injury atelectrauma with each breath
  • Least dependent areas inflated throughout TVs are also easily hyperinflated causing volutrauma and barotrauma, especially in:
    • TVs > 6 cc/kg
    • Pplat > 30-35 cmH2O
• Derecruitment of alveoli occurs due to:
  • Standard low TV ventilation in ARDS
  • Insufficient PEEP
  • High FiO2 absorptive atelectasis
• Goals to recruit alveoli and maintain with PEEP to prevent cyclic collapse
  • Improving hypoxemia
  • Decrease ventilator-induced lung injury

Risks

• May only be temporary benefit
• Hemodynamic instability with drop off in preload
• CO2 retention
• May worsen oxygenation by shunting blood to poorly aerated lung (opposing physiological hypoxic pulmonary vasoconstriction)
• May worsen ventilator-induced lung injury with volutrauma/barotrauma
• Pneumothorax
• Contraindications
  • Unstable BP
  • Ptx or high risk of ptx (blebs, necrotising pna)
  • ARDS > 1 wk (relative contraindication)

Procedure

Preparation

• May require increased sedation or paralysis
• Optimize preload (maneuver decreases preload)
• Pressure control ventilation using current rate, PEEP, FiO2
  • I:E to 1:1
  • Adjust FiO2 to SaO2 90-92%
• Record baseline VSs and vent settings
• 14 ga needles x2 in case of pneumothorax

Adjuncts

• Inhaled nitric oxide (iNO)
• Prostacyclins, epoprostenol (Flolan)
• ECMO
• Oscillation ventilation, High frequency oscillation ventilation (HFOV)

See Also

• ARDS
• Mechanical ventilation
• APRV
• PCV
• Ventilator-induced lung injury