Lifeinthefastlane

ARDS Lung Recruitment Maneuvers

OVERVIEW
Recruitment manoeuvres are transient increases in transpulmonary pressure designed to open up
collapsed airless alveoli
Primarily used in severe acute respiratory distress syndrome (ARDS)
They can be used as part of an open lung approach to mechanical ventilation
Their role, and how they should be performed, remains controversial
RATIONALE
De-recruitment can occur due to:
low tidal volume (TV) ventilation
inadequate postive end-expiratory pressure (PEEP)
or use of high FiO2 (absorption atelectasis)
During tidal ventilation 3 distinct lung zones are produced, associated with different types of ventilatorinduced lung injury (VILI):
dependent: collapsed throughout tidal ventilation despite high levels of PEEP, causes chronic collapse
injury
intermediate: cyclic collapse and re-expansion with each breath, causes shear induced injury
(atelectrauma)
least dependent: regions that remain inflated through out tidal ventilation and can be over inflated by TV
of > 6mL/kg and plateau pressures exceeding > 30-35cmH2O, causes volutrauma and barotrauma
all of these mechanisms can increase cytokine release (biotrauma) and contribute to risk of multi-organ
failure and mortality
Recruitment manoeuvres are used to open up collapsed lung, and PEEP is used to prevent cyclic collapse
as part of an open lung approach to ventilation to:
increase end-expiratory lung volume
improve gas exchange
decrease VILI
METHODS
Multiple methods have been described
40cmH20 for 40-60 seconds
3 consecutive sighs/min with a plateau pressure of 45cmH2O
2 minutes of peak pressure of 50cmH2O and PEEP above upper inflection point (obese/trauma patients
may require >60-70cmH2O)
long slow increase in inspiratory pressure up to 40 cmH2O (RAMP)
stepped increase in pressure (e.g. Staircase Recruitment Manoeuvre)
Proning can also be considered a recruitment manoeuvre, and other recruitment manoeuvres are more
more effective in the prone position

ADVANTAGES
improved gas exchange
improved compliance
cheap
quick
easy
can reduce conversion to adjuncts: iNO, prostacycline, ECMO, oscillation
DISADVANTAGES
may require heavy sedation or paralysis
benefit may be transient
haemodynamic instability (decrease in preload)
only some disease states respond
hypercapnia
may worsen oxygenation by shunting blood to poorly aerated regions
may contribute to ventilator-induced lung injury (VILI) due to overdistension and repeated opening of
lung
risk of pneumothorax
EVIDENCE
The evidence base for recruitment manoeuvres is conflicting
animal data: disparity in the effect of lung mechanics and gas exchange
extra-pulmonary ARDS may be more amenable to recruitment than pulmonary ARDS
oxygenation benefits found to be short lived and of uncertain longterm significance
no studies showing patient-orientated outcome benefits
studies confounded by by presence or absence of protective lung ventilation
how to differentiate responders from non-responders is uncertain
controversies: who, when, how often and for how long!
The ANZICS CTGs PHARLAP study is currently in progress: a MCRCT looking at daily recruitment
manoeuvres with protective ventilation strategy.
STAIRCASE RECRUITMENT MANOEUVRE (SRM)
Indications
severe ARDS of <1 week duration
other patients considered on an individualised basis
Contraindications
Circulatory instability ensure fluid and inotrope resuscitation complete with stable BP above target
Pneumothorax or other air leaks (pneumomediastinum, etc) (present or recent)
High risk of pneumothorax (e.g. necrotising lung infection, lung cysts, etc)
ventilated ARDS present >1 week (poor responders) are a relative contra-indication
Procedure

using pressure controlled ventilation adjust FiO2 to target SaO2 90-92%

set Pi to 15 cm H2O above the PEEP and maintain this difference
increase PEEP in a stepwise manner to 20, then 30 and then 40 cm H2O with adjustments made every two
minutes (i.e. Pi will reach 55 cmH20)
reduce PEEP to 25, then 22.5, then 20, then 17.5 or then an absolute minimum of 15 cm H2O every three
minutes until a decrease in SaO2 1% from maximum SaO2 is observed (the derecruitment point)
increase PEEP to 40 cm H2O for one minute then return to a PEEP level 2.5 cm H2O above the
derecruitment point (the optimal PEEP)
then adjust to tidal volume 6 mls/kg IBW and a plateau pressure 30 cm H2O, tolerate permissive
hypercapnia if pH >7.15, can increase RR up to 38/min (max)
SRM should be stopped if:
HR < 60 or > 140/min
new dysrhythmia
SBP <80 mmHg
SaO2 < 85% (mild desautration during the procedure does not indicate a failed response to SRM)
This is the approach described by Hodgson, Tuxen and colleagues.