Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance.
BACKGROUND
Positive end-expiratory pressure (PEEP) can be effective in improving oxygenation, but it may worsen or induce intracranial hypertension. The authors hypothesized that the intracranial effects of PEEP could be related to the changes in respiratory system compliance (Crs).


METHODS
A prospective study investigated 21 comatose patients with severe head injury or subarachnoid hemorrhage receiving intracranial pressure (ICP) monitoring who required mechanical ventilation and PEEP. The 13 patients with normal Crs were analyzed as group A and the 8 patients with low Crs as group B. During the study, 0, 5, 8, and 12 cm H2O of PEEP were applied in a random sequence. Jugular pressure, central venous pressure (CVP), cerebral perfusion pressure (CPP), intracranial pressure (ICP), cerebral compliance, mean velocity of the middle cerebral arteries, and jugular oxygen saturation were evaluated simultaneously.


RESULTS
In the group A patients, the PEEP increase from 0 to 12 cm H2O significantly increased CVP (from 10.6 +/- 3.3 to 13.8 +/- 3.3 mm Hg; p < 0.001) and jugular pressure (from 16.6 +/- 3.1 to 18.8 +/- 3.2 mm Hg; p < 0.001), but reduced mean arterial pressure (from 96.3 +/- 6.7 to 91.3 +/- 6.5 mm Hg; p < 0.01), CPP (from 82.2 +/- 6.9 to 77.0 +/- 6.2 mm Hg; p < 0.01), and mean velocity of the middle cerebral arteries (from 73.1 +/- 27.9 to 67.4 +/- 27.1 cm/sec; F = 7.15; p < 0.001). No significant variation in these parameters was observed in group B patients. After the PEEP increase, ICP and cerebral compliance did not change in either group. Although jugular oxygen saturation decreased slightly, it in no case dropped below 50%.


CONCLUSIONS
In patients with low Crs, PEEP has no significant effect on cerebral and systemic hemodynamics. Monitoring of Crs may be useful for avoiding deleterious effects of PEEP on the intracranial system of patients with normal Crs.
Caricato
Anselmo
A
Department of Anesthesia and Intensive Care, Catholic University School of Medicine, Policlinico A. Gemelli, Rome, Italy. anselmo.caricato@fastwebnet.it
Conti
Giorgio
G
Della Corte
Francesco
F
Mancino
Aldo
A
Santilli
Federico
F
Sandroni
Claudio
C
Proietti
Rodolfo
R
Antonelli
Massimo
M
D000328:Adult; D000704:Analysis of Variance; D001783:Blood Flow Velocity; D001794:Blood Pressure; D002496:Central Venous Pressure; D002536:Cerebral Arteries / Q000503:physiopathology; D002560:Cerebrovascular Circulation; D006259:Craniocerebral Trauma / Q000503:physiopathology / Q000628:therapy; D005260:Female; D015600:Glasgow Coma Scale; D006439:Hemodynamics; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000517:prevention & control; D007427:Intracranial Pressure; D007601:Jugular Veins / Q000503:physiopathology; D008170:Lung Compliance; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods; D011446:Prospective Studies; D015656:Respiratory Mechanics; D013345:Subarachnoid Hemorrhage / Q000503:physiopathology / Q000628:therapy; D016896:Treatment Outcome