PEEP in thoracic anesthesia: pros and cons

Area of Science:

• Critical Care Medicine
• Respiratory Physiology

Background:

• Protective ventilation strategies aim to minimize lung injury during mechanical ventilation.
• Positive end-expiratory pressure (PEEP) is used during one-lung ventilation (OLV) to prevent alveolar collapse and improve oxygenation.

Purpose of the Study:

• To evaluate the risks and benefits of using PEEP during OLV.
• To determine optimal PEEP titration strategies for improved patient outcomes.

Main Methods:

• Review of literature on PEEP application during OLV.
• Analysis of PEEP's effects on ventilation/perfusion (V/Q) matching, pulmonary vascular resistance, and hemodynamics.
• Discussion of PEEP titration methods based on driving pressure and respiratory compliance.

Main Results:

• PEEP can prevent atelectrauma but may increase pulmonary vascular resistance and worsen V/Q mismatch in hyperoxic conditions.
• PEEP use is associated with potential hemodynamic instability and increased need for fluids and vasoactive drugs.
• Titrating PEEP to optimize respiratory and pulmonary system compliance, particularly using driving pressure, may improve outcomes.

Conclusions:

• The potential for harm necessitates judicious PEEP use during OLV, even when titrated.
• PEEP should be applied only as needed to ensure adequate gas exchange under protective ventilation settings.
• Individualized PEEP titration based on driving pressure is recommended to balance benefits and risks.