Highest PEEP you've seen?

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I had a patient the last 2 days on 25 of PEEP. The docs were concerned about her lungs

"popping," so for a while- we didn't move her. Finally, got it down to 15. What's the highest PEEP you've seen, and have you ever had a patient's lungs pop?

Specializes in Critical Care, ER.

We usually go to APRV in true ARDS. Haven't seen much above 15 of PEEP in CMV where I've practiced.

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Specializes in Critical Care, Pulmonary Educator.

I've seen 25cm PEEP, but it's pretty scary. The patient was a 23 yr old postpartum amniotic fluid embolus ARDS patient. Multiple chest tubes for pneumothoraces. Could not tolerate suctioning back in the day before closed suction systems. She survived and we were quite pleased. She still sees the doc that managed her ventilator! That was at least 28 years ago! This is how she looked some days: :(

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Specializes in Neurology, Neurosurgerical & Trauma ICU.

I'm with Gwenith on this one.....

On neuro patients, we rarely ever go above 5, but have seen as high as 10...then other vent. methods start being used....i.e. pressure control ventilation or whatever is appropriate. Now with these patients, our intensivists handle their vents, etc.

On trauma patients, I've seen as high as 15, but that's about it. With those, the trauma service tends to handle all their own stuff.....medical management, etc....but I do see a little change coming with that. They've been using the intensivists more now too.

Our intensivists are also pulmonologists (dual specialties), so our vent management is some of the best you'll ever see....those guys are AMAZING!!! IMHO, we have some of the BEST critical care medical management you'll ever see!!

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Specializes in ER, ICU, Infusion, peds, informatics.

37.5

which was as high as the vent would go.

yes, she blew out her lung (or......we blew out her lung)..... and was asystole pretty quickly afterwards.

she was young and otherwise healthy, in an mva.

she had been in the hospital

we all knew she wasn't going to live, but she was only 19 so we were doing whatever we could. my shift was almost over and i had decided that i was going to have to do the admission paperwork since it looked like she was going to live through my shift. i had just sat down with her mom to get her nursing history done -- and the vent started alarming. she was asystole before i could get up and walk the five steps into the room.

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Specializes in CCU/CVU/ICU.
37.5

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37.5?

wow. i think my lung just popped! :typing

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My question would be....what the heck was this pt's ICP????? With a peep of 25 (great for ARDS...BAD for brain) I would expect the ICP to be, oh say, 50! I mean think about the pathophys of this...peep increases intrathoracic pressure which impends venous flow from the jugulars & therefore creating increased ICP, right? At a peep of 25 I have to wonder why the neurosurgeon wasn't having a coronary over this! (assuming the pt had a head injury) In our unit we often have high peeps when it's last ditch effort to overcome ARDS but very rarely because of the ICP issue.

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37.5

>

i can't imagine a possible scenario that a level of peep that high would help. what are the units of measure?

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Specializes in ICU/CVICU/CICU/MSICU/CathLab.

28, last ditch effort, pt died anyway

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Specializes in ER, ICU, Infusion, peds, informatics.
>

i can't imagine a possible scenario that a level of peep that high would help. what are the units of measure?

cm h2o? isn't that what peep is usually measured in?

i never said it was helpful ... in fact, i think it directly contributed to her (immediate) death. she would have died anyway, though.

but, she was young and healthy pre-mva, and they were trying everything/anything they could.

it didn't help that they didn't really know what her injuries were.

it was a long time ago (>5years), so i may be forgetting some details, but she went straight to the or from the er. her xlap was negative. i don't think she ever made it to ct (too unstable).

she did have a bolt in place, but i remember it not working well. i remember talking with neurosurgery on call that night, and they pretty much told me she wasn't going to live.

she had a pa catheter, and the svo2 wouldn't measure (too low to measure), hence the increase in the peep. i don't remember what the po2 on the abgs were, but i do remember that they were low enough to validate the svo2 being too low to measure. her fio2 was already 1.00, so increasing peep was the only thing they could do. the vent wouldn't go any higher than 37.5.

but, the question was "highest peep you've seen," not "highest peep you've seen that has been beneficial."

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Specializes in Advanced Practice, surgery.

I've nurse patients with PEEP of 20 (this was a long time ago mind) but not neuro patients we try to keep those to below 5 if possible. If higher PEEP is needed we tend to Oscilate our patients

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Specializes in CVICU, ICU, RRT, CVPACU.

Usually at levels of 15 cmH20 significant hypotension occurs. APRV is a great alternative mode however you need very skilled practitioners to use it (Properly) and to understand and Identify the changes that are need and occur. As someone else mentioned, usually when a patient requires more than 15 cmH20 of PEEP, alternative ventilation strategies are employed such as prone ventilation and/or permissive hypercapnia with ARDS settings (high RR with Low Vt) or pressure control. ARDS and someone requiring a PEEP of greater than 15 is going to have a significant mortality rate.

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I was an ICU nurse a bazillion years ago so I know things have changed, but I routinely saw PEEPs of 40-50 even 60. Of course these people had full blown ARDS, most did not get pneumos, and I even saw a few recover!

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