A positive response to a recruitment maneuver with PEEP titration in patients with ARDS, regardless of transient oxygen desaturation during the maneuver.
Recruitment maneuvers (RMs) can expand collapsed alveoli in ventilated patients. The optimal method for delivering RMs is unknown.


OBJECTIVE
To evaluate the safety and the respiratory and hemodynamic effects of a staircase recruitment maneuver (SRM) with decremental positive end expiratory pressure (PEEP) titration and the consequences of desaturation during the SRM in patients with early acute lung injury (ALI).


METHODS
In total, 20 consecutive patients with early ALI were enrolled and received an SRM. Patients were given 15 ± 3 cm H(2)O pressure-controlled ventilation. Positive end expiratory pressure was increased from baseline (range 10-18) to 20, 30, and 40 cm H(2)O every 2 minutes to achieve maximum alveolar pressure of 55 ± 3 cm H(2)O, then decreased at 3-minute intervals to 25, 22.5, 20, 17.5, and 15 cm H(2)O until a decrease of 1% to 2% oxygen saturation from maximum was detected. Positive end expiratory pressure was left at the level where the fall in oxygen saturation occurred. Standard respiratory and circulatory variables, arterial and central venous gases were measured before, during, and after the SRM.


RESULTS
There were significant improvements in shunt fraction (36.3% ± 10% to 26.4% ± 14%, P < .001), oxygen saturation (93.4% ± 2% to 96.8% ± 3%, P = .007), partial pressure of oxygen, arterial (PaO(2))/fraction of inspired oxygen ([FIO(2)]; 150 ± 42 to 227 ± 100, P = .004), lung compliance (33.9 ± 9.1 to 40.1 ± 11.4 mL/cm H(2)O, P < .01), and chest x-ray (CXR) after the SRM. Briefly, 80% of the patients responded and the response was maintained at 1 hour. In total, 8 patients desaturated 6.1% ± 2.8% in SaO(2) during the SRM but 5 of those improved SaO(2) relative to baseline by the end of the SRM.


CONCLUSIONS
In all, 80% of the patients with early ALI responded to the SRM with decremental PEEP titration. Desaturation during the SRM did not indicate a failed response 1 hour later.
The Alfred Hospital, Melbourne, Australia, Monash University, Melbourne, Australia. carol.hodgson1@bigpond.com
Carol L
CL
Hodgson
David V
DV
Tuxen
Michael J
MJ
Bailey
Anne E
AE
Holland
Jenny L
JL
Keating
David
D
Pilcher
Kenneth R
KR
Thomson
Dinesh
D
Varma
D018806:APACHE; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D010366:Peak Expiratory Flow Rate; D010865:Pilot Projects; D011175:Positive-Pressure Respiration / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000097:blood / Q000503:physiopathology / Q000628:therapy*; D056152:Respiratory Rate; D013990:Tidal Volume; D016896:Treatment Outcome
D010100:Oxygen