VA ICU Report Pearls! – Lung Recruitment Maneuvers in Ventilated Patients with ARDS

What is a Recruitment Maneuver?

You can define recruitment maneuvers as “a voluntary strategy to increase the transpulmonary pressure transiently with the goal to reopen those alveolar units that are not aerated or poorly aerated but re-openable.“

Risks of Recruitment Maneuvers:

Recruitment maneuvers can result in hemodynamic decompensation in the hypovolemic patient (as a consequence of a relatively long period of increased intrathoracic pressure)

Recruitment maneuvers can cause overdistension of the alveoli, ventilator assoc lung injury, and barotrauma, which is thought to be related to the rapid rise in pressures that the lungs are exposed to.

Note: Whether or not it will work depends on how much recruitable lung there is, which is difficult to measure (CT has been tried).

How you do a Recruitment Maneuver:

There is no general consensus on the optimal recruitment maneuver but the general idea is to give a breath which is held at a high airway pressure. A common combination to remember is 40cm of water for 40 seconds (40 for 40). When different pressures and frequencies were studied higher pressures and less frequent holds were thought to lead to improved recruitment.

After the Recruitment Maneuver is Performed:

Improvement in oxygenation in experimental models has been seen when higher PEEP is set after the recruitment maneuver. This seems to make sense since the goal is to keep alveoli that were opened during the recruitment maneuver open to participate in gas exchange whereas before the maneuver the set PEEP was insufficient for those alveoli to be open.

If you’re thinking about ways to improve gas exchange in your ventilated patient ask your friendly neighborhood RT whether a recruitment maneuver might fit the bill!

Gattinoni L Et al. Lung recruitment in Patients with the Acute Respiratory Distress Syndrome. NEJM 5.27.2006;354;1775-1786.

Guerin C Et al. Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome. Ann Intensive Care. 5.19.2011; 1: 9.


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