Positive end-expiratory pressure (PEEP)
- Rommel Sagana, MD
Rommel Sagana, MD
- Assistant Professor, Division of Pulmonary and Critical Care Medicine
- University of Michigan Medical Center
- Robert C Hyzy, MD
Robert C Hyzy, MD
- Associate Professor of Medicine
- University of Michigan Medical Center
Positive end-expiratory pressure (PEEP) is used therapeutically during mechanical ventilation (extrinsic PEEP). It can also be a complication of incomplete expiration and airtrapping (intrinsic PEEP).
Clinical aspects of extrinsic and intrinsic and PEEP are discussed in this topic review. High levels of PEEP that have been investigated in patients with acute respiratory distress syndrome as well as the application of PEEP in patients with dynamic hyperinflation from asthma and chronic obstructive pulmonary disease are described separately. (See "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'High PEEP' and "Invasive mechanical ventilation in acute respiratory failure complicating chronic obstructive pulmonary disease", section on 'Dynamic hyperinflation' and "Invasive mechanical ventilation in adults with acute exacerbations of asthma", section on 'Adding extrinsic PEEP to offset intrinsic PEEP'.)
Positive end-expiratory pressure (PEEP) is the alveolar pressure above atmospheric pressure that exists at the end of expiration. There are two types of PEEP:
●Extrinsic PEEP – PEEP that is provided by a mechanical ventilator is referred to as applied PEEP
●Intrinsic PEEP – PEEP that is secondary to incomplete expiration is referred to as intrinsic PEEP or auto-PEEP
- Smith, RA. Physiologic PEEP. Respir Care 1988; 33:620.
- Manzano F, Fernández-Mondéjar E, Colmenero M, et al. Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med 2008; 36:2225.
- Lucangelo U, Zin WA, Antonaglia V, et al. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med 2008; 36:409.
- Goligher EC, Kavanagh BP, Rubenfeld GD, et al. Oxygenation response to positive end-expiratory pressure predicts mortality in acute respiratory distress syndrome. A secondary analysis of the LOVS and ExPress trials. Am J Respir Crit Care Med 2014; 190:70.
- Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 2008; 359:2095.
- Fellahi JL, Valtier B, Beauchet A, et al. Does positive end-expiratory pressure ventilation improve left ventricular function? A comparative study by transesophageal echocardiography in cardiac and noncardiac patients. Chest 1998; 114:556.
- Wetterslev J, Hansen EG, Roikjaer O, et al. Optimizing peroperative compliance with PEEP during upper abdominal surgery: effects on perioperative oxygenation and complications in patients without preoperative cardiopulmonary dysfunction. Eur J Anaesthesiol 2001; 18:358.
- PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology, Hemmes SN, Gama de Abreu M, et al. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet 2014; 384:495.
- Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369:428.
- Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology 2013; 118:1307.
- Good JT Jr, Wolz JF, Anderson JT, et al. The routine use of positive end-expiratory pressure after open heart surgery. Chest 1979; 76:397.
- Georgiadis D, Schwarz S, Baumgartner RW, et al. Influence of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure in patients with acute stroke. Stroke 2001; 32:2088.
- Muench E, Bauhuf C, Roth H, et al. Effects of positive end-expiratory pressure on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation. Crit Care Med 2005; 33:2367.
- Huynh T, Messer M, Sing RF, et al. Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury. J Trauma 2002; 53:488.
- Hasan FM, Beller TA, Sobonya RE, et al. Effect of positive end-expiratory pressure and body position in unilateral lung injury. J Appl Physiol Respir Environ Exerc Physiol 1982; 52:147.
- Pinsky MR. Cardiovascular issues in respiratory care. Chest 2005; 128:592S.
- Bruhn A, Hernandez G, Bugedo G, Castillo L. Effects of positive end-expiratory pressure on gastric mucosal perfusion in acute respiratory distress syndrome. Crit Care 2004; 8:R306.
- Sundaresan A, Chase JG, Hann CE, Shaw GM. Cardiac output estimation using pulmonary mechanics in mechanically ventilated patients. Biomed Eng Online 2010; 9:80.
- Petersson J, Ax M, Frey J, et al. Positive end-expiratory pressure redistributes regional blood flow and ventilation differently in supine and prone humans. Anesthesiology 2010; 113:1361.
- Armaganidis A, Stavrakaki-Kallergi K, Koutsoukou A, et al. Intrinsic positive end-expiratory pressure in mechanically ventilated patients with and without tidal expiratory flow limitation. Crit Care Med 2000; 28:3837.
- Gay PC, Rodarte JR, Hubmayr RD. The effects of positive expiratory pressure on isovolume flow and dynamic hyperinflation in patients receiving mechanical ventilation. Am Rev Respir Dis 1989; 139:621.
- Valta P, Corbeil C, Lavoie A, et al. Detection of expiratory flow limitation during mechanical ventilation. Am J Respir Crit Care Med 1994; 150:1311.
- Gurevitch MJ, Gelmont D. Importance of trigger sensitivity to ventilator response delay in advanced chronic obstructive pulmonary disease with respiratory failure. Crit Care Med 1989; 17:354.
- Kress JP, O'Connor MF, Schmidt GA. Clinical examination reliably detects intrinsic positive end-expiratory pressure in critically ill, mechanically ventilated patients. Am J Respir Crit Care Med 1999; 159:290.
- Leatherman JW, Ravenscraft SA. Low measured auto-positive end-expiratory pressure during mechanical ventilation of patients with severe asthma: hidden auto-positive end-expiratory pressure. Crit Care Med 1996; 24:541.
- Lessard MR, Lofaso F, Brochard L. Expiratory muscle activity increases intrinsic positive end-expiratory pressure independently of dynamic hyperinflation in mechanically ventilated patients. Am J Respir Crit Care Med 1995; 151:562.
- Zakynthinos SG, Vassilakopoulos T, Zakynthinos E, Roussos C. Accurate measurement of intrinsic positive end-expiratory pressure: how to detect and correct for expiratory muscle activity. Eur Respir J 1997; 10:522.
- Brochard L. Intrinsic (or auto-) positive end-expiratory pressure during spontaneous or assisted ventilation. Intensive Care Med 2002; 28:1552.
- Alvisi V, Romanello A, Badet M, et al. Time course of expiratory flow limitation in COPD patients during acute respiratory failure requiring mechanical ventilation. Chest 2003; 123:1625.
- Smith TC, Marini JJ. Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol (1985) 1988; 65:1488.
- Kondili E, Alexopoulou C, Prinianakis G, et al. Pattern of lung emptying and expiratory resistance in mechanically ventilated patients with chronic obstructive pulmonary disease. Intensive Care Med 2004; 30:1311.
- Caramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation. Crit Care Med 2005; 33:1519.
- Rossi A, Santos C, Roca J, et al. Effects of PEEP on VA/Q mismatching in ventilated patients with chronic airflow obstruction. Am J Respir Crit Care Med 1994; 149:1077.
- Guerin C, LeMasson S, de Varax R, et al. Small airway closure and positive end-expiratory pressure in mechanically ventilated patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997; 155:1949.
- Glérant JC, Leleu O, Rose D, et al. Oxygen consumption and PEEPe in ventilated COPD patients. Respir Physiol Neurobiol 2005; 146:117.
- Tuxen DV. Detrimental effects of positive end-expiratory pressure during controlled mechanical ventilation of patients with severe airflow obstruction. Am Rev Respir Dis 1989; 140:5.
- Ranieri VM, Giuliani R, Cinnella G, et al. Physiologic effects of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. Am Rev Respir Dis 1993; 147:5.
- Marini JJ. Should PEEP be used in airflow obstruction? Am Rev Respir Dis 1989; 140:1.
- APPLIED (EXTRINSIC) PEEP
- - Routine mechanical ventilation
- - Acute respiratory distress syndrome
- - Patients with auto-peep
- - Cardiogenic pulmonary edema
- - Intraoperative patients
- - Postoperative patients
- - Other
- - Intracranial disease
- - Focal lung disease
- - Hypotension
- - Hyperinflation without flow limitation
- - Prone patients
- AUTO (INTRINSIC) PEEP
- - High minute ventilation
- - Expiratory flow limitation
- - Expiratory resistance
- Potential sequelae
- - Applied PEEP
- SUMMARY AND RECOMMENDATIONS
- Applied PEEP