Respiratory distress syndrome and its treatment with high positive end-expiratory pressure ventilation

In a 25-month period, nine patients developed a severe, rapidly progressive respiratory distress syndrome (RDS) and did not respond adequately to conventional respiratory therapy despite the application of positive end-expiratory pressure ventilation (PEEP) up to an upper limit of 15 cm H2O. Treatment with high PEEP was instituted up to 35 cm H2O, in order to achieve a PaO2 higher than 70 mmHg. Massive infusion of electrolyte solutions, colloids and red blood cells were necessary to maintain an adequate circulation that could be monitored by simple parameters such as arterial blood pressure, peripheral skin temperature and urine production. Seven patients (78%) survived. Sepsis was the cause of death in two patients. There were no pulmonary functional or radiological abnormalities, one to 14 months after discharge from the hospital. The upper limit for PEEP should be abandoned and PEEP should be administered according to the needs of each individual patient. As an adequate oxygenation can always be achieved with high-PEEP ventilation, in surgical patients there is hardly, if ever, an indication for ECMO.