MICU/SICU - HIGHEST PEEP you've seen?

Artemis2 · Nov 3, 2007

In the old days (25 years ago) we only had IMV ventilation with PEEP. There was no pressure support, SIMV or any of the other modern vent settings. There was very little we could change on a vent when a person was not doing well. After you had maxed out TV, FiO2 & rate all you could do was go up on the PEEP. 25 is about the highest I have seen but in those days it was much more common and yes, we caused quite a few pneumos.

Ventilators are so much more sophisticated these days that rarely do you have to go that high but every once in a while....

elizabells, BSN, RN · Nov 3, 2007

Six. But that's babies. Our standard is five, and yes, we do get the occasional pneumo, but again, babies. Most of our iatrogenic pneumos occur during the intubation process.

cardiacRN2006, ADN, RN · Nov 3, 2007

We just had one with 22. He has ARDS.

TheNuttyNurse · Nov 6, 2007

28 of PEEP is my highest. We usually try and switch those folks over to pressure control ventilation instead of volume control. Have seen a few pneumos...not too many.

PageRespiratory! · Nov 6, 2007

The docs were concerned about her lungs
"popping," ...............have you ever had a patient's lungs pop?

Ugh, almost as bad as calling it a "respirator"! :lol2:

26cmH2O, on a 21 y/o with some wierd cardiomyopathy. Crazy pulmonary edema.

ready4crna? · Nov 6, 2007

25 here..

Worked with a surgeon once who would put in bilat. chest tubes at the 20cm PEEP mark "just in case"... I kid you not, prophylactic chest tubes.

elizabells, BSN, RN · Nov 7, 2007

25 here..
Worked with a surgeon once who would put in bilat. chest tubes at the 20cm PEEP mark "just in case"... I kid you not, prophylactic chest tubes.

Okay, it may be because I just finished a horrific shift and I'm too tired to be tactful, but... that's the dumbest d*** thing I've ever heard. What a silly surgeon. How would you know where you exactly wanted the chest tube if there wasn't a pneumo yet? Or do adults always blow in the same place?

ready4crna? · Nov 7, 2007

No tact necessary, I agree with you. As for the chest tube placement- the pleural space is always present, and when you punch a hole in the cavity (whether by stabbing, GSW, or surgically) air is let in and the space expands,lung deflates, instant pneumotx. Place CT,repeat.

VandyNurse714 · Nov 7, 2007

Then how come you see patients with 2, 3, 4 chest tubes? What you (Ready4CRNA) said about the pleural space makes sense, of course...but now my brain's a-wandering...

nurseabc123 · Nov 7, 2007

Then how come you see patients with 2, 3, 4 chest tubes? What you (Ready4CRNA) said about the pleural space makes sense, of course...but now my brain's a-wandering...

To everyone: I guess I'm just wondering then -- Is APRV not being used by your facilities? Highest PEEP theoretically one can use on APRV is 35 cm H20. No concerns of pneumo. It has done wonders for our transplant program.

ready4crna? · Nov 8, 2007

MSU-

APRV is a different animal altogether. Your P-low is analogous to your "PEEP"- usually 0-5 in APRV. The P-high (35mmHg) is analogous to "CPAP"-the inflation pressure if you will. The danger of pneumo is in higher PEEP because of higher Mean Airway pressures that the chest wall has to work against. (Picture sitting on a super inflated balloon that is laying against sidewalk where the balloon is your lung and the sidewalk+butt=chest wall.) APRV is used to accomodate the decreased compliance of diseased lungs. It is also relatively new to the scene and I believe you will find it used with more frequency in facilities that both have the capability to do it (Newer vents), and practitioners that are comfortable with using new ideas.

And just to make clear- if you truly used 35mmHg of PEEP, the next sound you would hear would be your high pressure alarms followed rapidly by the patients lungs popping.

http://www.aacn.org/pdfLibra.NSF/Files/ci120205/$file/ci120205.pdf

The above link is to an AACN article that explains APRV far better than I can.

Vandy-

As for multiple chest tubes, I would assume you are asking why more than one would be needed on one side. I'll use a common example-Lets say you have a patient that is post thoracotomy for a wedge resection. The surgeon has created a pneumo and modified the lung anatomy as well. s/he might place one chest tube aimed at the anterior superior apex of the pleural space(where air should accumulate in a slightly inclined supine patient.) and also decide to place another aimed more posterior/inferior (where blood/fluid is more likely to accumulate in a patient.)