Bedside tip: How to perform a recruitment maneuver

02.10.2017
Author: Clinical Experts Group, Hamilton Medical, Reviewer: Paul Garbarini, David Grooms, Simon Franz

A recruitment maneuver (RM) is a transient increase in transpulmonary pressure applied to reaerate the collapsed lung.

​Several methods have been described for performing recruitment maneuvers, with the most commonly used being the sustained inflation method.

Contraindications for RMs are hemodynamic instability, COPD and lung emphysema, bronchopleural fistula, and acute cor pulmonale. Relative contraindications are increased intracranial pressure and pregnancy.

The P/V Tool® on Hamilton Medical ventilators can be used to perform a sustained inflation RM. The clinician needs to set the following:

Setting of a sustained inflation RM using the P/V Tool
  • Initial PEEP: Usually this equates to the current PEEP.
  • Top pressure (Ptop): In most cases, 40 cmH2O is used. Patients with a heavy chest wall may require a higher top pressure of up to 60 cmH2O (1, 2).
  • End PEEP: PEEP after the recruitment maneuver. This setting is of major importance to keep the lung aerated.
  • Ramp speed: The setting can range from 2 to 5 cmH2O/s. A slower ramp may be tolerated better, but increases the total duration of the maneuver.
  • Time of the pause (Tpause): The optimal duration for application of the top pressure is 10 s (3).

Note that if esophageal pressure measurement is available, the top pressure can be titrated to target a transpulmonary pressure of 20 cmH2O during the RM (4).

Before starting the maneuver, the cuff of the endotracheal tube should be overinflated to prevent any air leakage during the maneuver. If using the integrated IntelliCuff pressure controller, this step will be performed automatically.

During the maneuver, the clinician should monitor the mean arterial pressure. A decrease in mean arterial pressure indicates a decrease in cardiac output due to high thoracic pressure. The RM can be stopped at any time in the case of severe hemodynamic compromise.

The volume increase during the pause represents the volume of lung that was reaerated

The basis for assessing the efficacy of the RM is the increase in volume during the RM. This volume increase can be measured using the cursor and represents the volume of lung that was reaerated during the RM, assuming there was no air leakage. A volume increase of more than 2 ml/kg predicted body weight (PBW) is considered significant. 

A successful RM followed by an appropriate PEEP setting is associated with an increase in static compliance, as well as an improvement in oxygenation and CO2 elimination. 

 

References:

  1. Borges JB, Okamoto VN, Matos GF, Caramez MP, Arantes PR, Barros F, Souza CE, Victorino JA, ... Amato MBP. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 2006;174(3):268-78.
  2. Cressoni M, Chiumello D, Algieri I, Brioni M, Chiurazzi C, Colombo A, Colombo A, Crimella F, ... Gattinoni L. Opening pressures and atelectrauma in acute respiratory distress syndrome. Intensive Care Med 2017;43(5):603-611. (Abstract only)
  3. Arnal JM, Paquet J, Wysocki M, Demory D, Donati S, Granier I, Corno G, Durand-Gasselin J. Optimal duration of a sustained inflation recruitment maneuver in ARDS patients. Intensive Care Med 2011;37(10):1588-94. (Abstract only)
  4. Baedorf Kassis E, Loring SH, Talmor D. Recruitment maneuvers: using transpulmonary pressure to help Goldilocks. Intensive Care Med 2017;43(8):1162-1163. 

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Lung recruitment maneuvers
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2016-12-16

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recruitment, recruitment maneuver, ARDS, PEEP, sustained inflation, PV Tool
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Date of Printing: 24.04.2018
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