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You are here: Home / 04. Ventilator Management / Recruitment

Maneuvers

Recruitment Maneuvers
July 14, 2011 by CrashMaster

Experimental model in pigs: Schematic diagrams of recruiting

maneuver (RM) methods tested. SI continuous positive airway
pressure (CPAP) held at 45 cm H2O for 40 secs. Incremental positive
end-expiratory pressure (PEEP) with a fixed peak pressure (IP), PEEP
increased in 5 cm H2O increments (allowing 30 secs/step) from a
baseline PEEP of 8 cm H2O to 35 cm H2O while decreasing tidal
volume to limit peak inspiratory pressure to 35 cm H2O. After CPAP of
35 cm H2O was held for 30 secs, PEEP was decremented in 5-cm H2O
steps to the post-RM PEEP setting, while increasing tidal volume
toward the baseline value of 10 mL/kg (as the 35 cm H2O peak
pressure limit allowed). PCV peak pressure = 45 cm H2O, inspiratory
to expiratory ratio = 1:2, and PEEP level = 16 cm H2O for 2 min. (Crit
Care Med 2004, Dec)

An effective recruitment strategy that we have found successful is to:

Select an appropriate patient Ideal patients for recruitment
maneuvers are patients with putative ARDS in the early phase of the
disease (before the onset of fibro-proliferation). Patients should be
poorly oxygenated on a high FiO2. Pre-existing focal lung disease that
may predispose to barotrauma should be regarded as a relative
contra-indication to the maneuver (for example extensive apical
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bullous lung disease). Patients with secondary ARDS (following on, for
example, abdominal sepsis) are thought to be more likely to respond
favourably to the maneuver than patients with primary lung disease
and acute lung injury. Position the patient prone This is easily done
(after some initial resistance from nursing staff)! An important
component of prone positioning for recruitment is to have a pillow
under the upper chest, and another beneath the pelvic area, so the
abdomen hangs down somewhat in between the two pillows. Continue
appropriate mechanical ventilation. The patient must be fully
monitored Monitoring should include (at least) invasive arterial blood
pressure monitoring, pulse oximetry and ECG. The patient must also
be completely paralysed with non-depolarising neuromuscular
blockade, to prevent attempts at respiration during the maneuver. A
baseline arterial blood gas analysis (ABG) should be obtained after the
FiO2 has been increased to 100%. Administer 40cm H2O of PEEP for
90s Set the ventilator to an effective rate of zero (with no machine
breaths) and then immediately raise the PEEP to 40cm H2O for a
carefully timed period of one and a half minutes. Then re-institute
ventilation as before. Wait and recheck the ABG Wait for a period of
five minutes, leaving the patient in the prone position, and obtain a
blood gas analysis. If the PaO2 is under 300mmHg, then consider
repeating the maneuver at PEEPs of 45mmHg and (if this fails)
50mmHg, also for ninety seconds. Prevent de-recruitment The
patient should now be maintained on a PEEP of 15 cmH2O. Often, the
patient can be turned back to a supine position without substantial
worsening of oxygenation. Ventilation should continue with a strategy
that minimises additional alveolar trauma (for example, inverse ratio
pressure-control ventilation, with every attempt to keep transalveolar pressure to under 35cm H2O). Ventilator tidal volumes should
perhaps be limited to approximately 6 ml/kg.
http://www.anaesthetist.com/icu/organs/lung/recruit/index.htm

Shorter Recruitment Maneuver

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Shorter Recruitment Maneuver

Cuff of the endotracheal tube was transiently overinflated to

50cmH2O. Airway pressure was increased at a rate of 5cmH2O/s
from 10 to 40cmH2O, which was sustained for 30 .
Most of recruitment was in the first 10 seconds; hemodynamic
consequences were after 10 seconds. (Intensive Care Med. 2011
Oct;37(10):1588-94)

Prone Positioning
Prone Positioning Improves Oxygenation in Post-traumatic Lung
Injury
A Prospective Randomized Trial
[Original Articles]
Voggenreiter, Gregor MD; Aufmkolk, Michael MD; Stiletto, Raphael J.
MD; Baacke, Markus G. MD; Waydhas, Christian MD; Ose, Claudia;
Bock, Eva; Gotzen, Leo MD; Obertacke, Udo MD; Nast-Kolb, Dieter MD
From the Departments of Trauma Surgery, University Hospital
Mannheim, 68135 Mannheim (Drs. Voggenreiter, and Obertacke),
University Hospital Essen, 45122 Essen (Drs. Aufmkolk, Waydhas and
Nast-Kolb) and Philipps-University Marburg, 35043 Marburg (Drs.
Stiletto, Baacke and Gotzen) and the Institute of Medical Informatics,
Biometry and Epidemiology (Mrs. Ose and Bock), University Hospital
Essen, 45122 Essen, Germany Submitted for publication October 19,
2004. Accepted for publication May 3, 2005. Supported by Deutsche
Forschungsgemeinschaft (DFG grant Vo 694/1-1). Requests should be
sent to: Dr. Gregor Voggenreiter, Department of Trauma Surgery,
University Hospital Mannheim, Ruprecht-Karls University of
Heidelberg, 68135 Mannheim, Germany, Tel. 0049-621-383 2335, Fax.
0049-621-383 2009 Abstract

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Background: In a prospective randomized trial the effect of prone

positioning on the duration of mechanical ventilation was evaluated in
multiple trauma patients and was compared with patients ventilated in
supine position.
Method: Multiple trauma patients of the intensive care units of two
university hospitals were considered eligible if they met the criteria
for acute lung injury or the acute respiratory distress syndrome.
Patients in the prone group (N = 21) were kept prone for at least eight
hours and a maximum of 23 hours per day. Prone positioning was
continued until a PaO 2:FiO2 ratio of more than 300 was present in
prone as well as supine position over a period of 48 hours. Patients in
the supine group (N = 19) were positioned according to standard care
guidelines.
Results: The duration of ventilatory support did not differ significantly
(30 17 days in the prone group and 33 23 days in the supine group).
Worst case analysis (death and deterioration of gas exchange)
displayed ventilatory support for 41 29 days in the prone group and
61 35 days in the supine group ( p = 0.06). The PaO2:FiO2 ratio
increased significantly more in the prone group in the first four days (
p = 0.03). The prevalence of Acute Respiratory Distress Syndrome
(ARDS) following acute lung injury (p = 0.03) and the prevalence of
pneumonia (p = 0.048) were reduced also. One patient in the prone
and three patients in the supine group died due to multi organ failure
(p = 0.27).
Conclusions: Intermittent prone positioning was not able to reduce
the duration of mechanical ventilation in this limited number of
patients. However the oxygenation improved significantly over the
first four days of treatment, and the prevalence of ARDS and
pneumonia were reduced. (J Trauma 2005;Volume 59(2):333-343)SR
shows decreased mortality with proning (Intensive Care Med (2010)
36:585
599)
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Meta-analysis of prone positioning (Crit Care Med 2008;36:603)

Recruitment Maneuvers
Anesthesiologists routinely perform such maneuvers in the operating
room, albeit in a slightly uncontrolled manner (a tidal volume is
delivered through a manual breathing system and held, the airway
pressure is not measured). There are many methods of performing
sustained inflation maneuvers in intensive care while being in
complete control of the airway pressure. Two factors influence
whether or not recruitment maneuvers are successful: the pressure
applied must be in excess of the current plateau pressure, and the
pressure must be sustained, in order to inflate lung units with long
time constants. The most effective method of doing this is to apply
CPAP to the airway. Amato (1998) applied CPAP at 10cmH2O above the
plateau pressure for 30 to 60 seconds to restore alveolar recruitment.
Following the period of sustained inflation, the ventilation settings are
returned to previous levels. It is not necessary to increase the PEEP, as
the lung volumes from the same amount of PEEP as before should be
higher. A successful procedure will result in improved oxygenation,
reduced end-tidal CO2 and improved compliance.
On occasion, it may be necessary to increase the CPAP further to
guarantee recruitment
up to 20cmH2O above the pressure limit.
Indeed sometimes very high pressures are required to recruit
collapsed lung tissue: Medoff (2000) and colleagues have reported a
case where 40cmH2O of PEEP and 20cmH2O of pressure control was
required to reinflate the lungs of a young woman with Streptococcal
sepsis. Interestingly, the PEEP required to prevent derecruitment in
this patient was significantly higher than that predicted by Pflex.
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Performance of Recruitment Maneuvers:

1. Ensure hemodynamic stability.
2. Set the FiO2 to 1.0
3. Wait 10 minutes.
4. Recruit with 30* cmH2O CPAP for 30-40 seconds (* or 10 cmH2O
above the plateau pressure level).
5. If unresponsive, wait 15 minutes and then recruit with 35 cmH2O
CPAP for 30 to 40 seconds.
6. If unresponsive, wait 15 minutes and then recruit with 40 cmH2O
CPAP for 30 to 40 seconds.
7. If unresponsive, wait 15 minutes and then recruit with 20 cmH2O
pressure control and 40 cmH2O CPAP for 2 minutes.
8. If the patient remains unresponsive, consider prone positioning.

Our protocol is to assess recruitability to start with. We do this by

using high pressures on the Pressure Controlled Mode for a minute
would use a Ppeak of about 40 to 50. If there is any sign of improved
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saturation within 5 minutes or so, we would do a sustained inflation

using a pressure of 40 for 40 seconds and crank up the PEEP to 15 to
20. If the initial assessment shows no recruitability, ie, no
improvement in saturation, we do not to ahead with sustained
inflation. Not much of scientific evidence Im afraid to justify what we
do, but seems to work OK. I have also seen a few patients who didnt
seem to recruit at all by any mechanism, going on to improve
oxygenation dramatically after proning. Jose

Review article (Brit J Anaes 2006;96(2):156)

prone positioning led to reduced ICU stay and hospital stay and better
oxygenation, survival trend was there but study was stopped prior to
stat sig (Inten Care Med 2008;34:1487)

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