P/V Tool®. Assess recruitability and perform recruitment maneuvers

Yellow balloons in different stages to represent different lung conditions

Recruiter or non-recruiter? A diagnostic tool

The Protective Ventilation Tool (P/V Tool) performs a respiratory mechanics maneuver that records a quasi-static pressure-volume curve, which describes the mechanical behavior of the lungs and chest wall during inflation and deflation.

This method can be used to assess lung recruitability and determine the recruitment strategy to apply (Demory D, Arnal JM, Wysocki M, et al. Recruitability of the lung estimated by the pressure volume curve hysteresis in ARDS patients. Intensive Care Med. 2008;34(11):2019-2025. doi:10.1007/s00134-008-1167-81).

Pressure and volume curves with the P/V Tool

What is the right strategy? Use a recruitment tool

The P/V Tool can also be used to perform a sustained inflation recruitment maneuver and measure the increase in lung volume (Lung recruitment maneuvers whitepaper2). You can set the pressure ramp, maximum pressure, duration, and PEEP level after the maneuver to suit the individual patient.

This is particularly helpful in ARDS patients, as selecting an appropriate lung‑recruitment strategy and the correct PEEP setting as an anti‑derecruiting force are critical for this patient group (Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354(17):1775-1786. doi:10.1056/NEJMoa0520523).

How to perform a recruitment maneuver with the P/V Tool (article)

NutriVent multifunction nasogastric catheter

Can it improve your ventilaton strategy? A lung-protection tool

In combination with esophageal pressure measurement, the P/V Tool can give you a clearer understanding of the lung and chest-wall mechanics.

This enables you to apply a lung-protective ventilation strategy by titrating the PEEP level (Caironi P, Cressoni M, Chiumello D, et al. Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2010;181(6):578-586. doi:10.1164/rccm.200905-0787OC4) and optimizing the parameters for the recruitment maneuver, then subsequently optimizing driving pressure and tidal volume.

How does it work? P/V Tool principles

You can perform P/V Tool maneuvers without making any changes to the mode or ventilator settings. Normal ventilation can be resumed at any time. The P/V Tool records the pressure-volume relation of the lungs at low-flow conditions (2–5 cmH2O/s).

The breathing circuit is pressurized linearly to the operator-set pressure target. When the pressure reaches the target, pressure is reduced back to the starting pressure.

Statistic graphic: Amato MB. Nengl J Med. 1998 Feb 5;338(6):347-54

Do you have proof? A look at the evidence

Lung protection is one of the major objectives when mechanically ventilating a patient.

In terms of changes in oxygenation, recruited volume, or hyperinflation, lung characteristics and morphology are strong predictors of the response to PEEP settings or recruitment maneuvers (Constantin JM, Futier E, Cherprenet AL, et al. A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit patients: a randomized controlled study. Crit Care. 2010;14(2):R76. doi:10.1186/cc89895).

A personalized strategy may decrease mortality in moderate-to-severe-ARDS patients if lung morphology is correctly assessed (Constantin JM, Jabaudon M, Lefrant JY, et al. Personalised mechanical ventilation tailored to lung morphology versus low positive end-expiratory pressure for patients with acute respiratory distress syndrome in France (the LIVE study): a multicentre, single-blind, randomised controlled trial. Lancet Respir Med. 2019;7(10):870-880. doi:10.1016/S2213-2600(19)30138-96). Lung protection not only reduces mortality in ARDS patients (Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308. doi:10.1056/NEJM2000050434218017), but also reduces the risk of secondary ARDS in normal-lung patients (Determann RM, Royakkers A, Wolthuis EK, et al. Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trial. Crit Care. 2010;14(1):R1. doi:10.1186/cc82308) and of complications in post-surgery patients (Costa Leme A, Hajjar LA, Volpe MS, et al. Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial. JAMA. 2017;317(14):1422-1432. doi:10.1001/jama.2017.22979, Hu MC, Yang YL, Chen TT, Chen JT, Tiong TY, Tam KW. Recruitment maneuvers in patients undergoing thoracic surgery: a meta-analysis. Gen Thorac Cardiovasc Surg. 2021;69(12):1553-1559. doi:10.1007/s11748-021-01673-7 10) .

Graphic illustration: student holding certificate in his hand

Good to know! P/V Tool training resources

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Availability

The P/V Tool Pro is available as an option on the HAMILTON-C3/C6 and HAMILTON-G5.

HAMILTON-C6

HAMILTON-C3

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P/V Tool®. Assess recruitability and perform recruitment maneuvers

Recruiter or non-recruiter? A diagnostic tool

What is the right strategy? Use a recruitment tool