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On today’s TIRBO: A sinister pitfall that may lead you to injuring lungs and worsening outcomes.
4 thoughts on “TIRBO #26: RadioPEEP discordance”
I want to say that I just had a same scenario in my ICU where there was a patient on FiO2 100 and PEEP 14 and still hypoxic sO2 80%
And an RT intern he decrease the PEEP to 8 ,and do you know want ? His oxygenation jumped to 96% ..
And His CXR WAS OK
Yes!! This is the scenario for sure. When you start looking for it, it is not too uncommon.
I listened to you podcast on “radioPEEP” this a.m. and found it intriguing. Prior to leaving my comment, I must reveal that I am a Respiratory Therapist with 31 years clinical experience at a tertiary care center and currently 12 years in an academic/college setting so my opinion might be a tad biased.
While I agree “radioPEEP” as presented on the podcast can be perplexing, I believe we were only given a small piece of the puzzle. For example, although the CXR was “clear” there was no indication as to how distended the lung fields were expanded, i.e., was the R-hemidiaphragm at 8-1/2 ribs, 10 ribs, or 7-1/2 ribs. Also most modern mechanical ventilators have graphical interfaces. What data did the P vs V loop on ventilator indicate, e.g., overdistension, an inflection point showing too little PEEP, decreased compliance, or increased airway resistance. Also with respect to the increased PEEP and Peak Inspiratory Pressure (PIP) effectively decreasing cardiac output, was the patient in need of fluid volume, or blood to increase hemoglobin, or inotropic agents to increase contractility. I agree, just given the interpretation of a “clear” CXR with a high level of PEEP and no other data, there would be a discordance. Thoughts?
Hey John! Agree there are a number of considerations, and even other “discordances” that might make one pause. I actually just recorded another TIRBO to come, looking at various physiologic ways of determining best PEEP, such as the ones you mentioned. I like using driving pressure, but I think any good method will help avoid pitfalls like this one. But I think the main message here, and one that doesn’t even require a great deal of expertise with the ventilator, is simply recognizing that the rule “hypoxia = more PEEP” can be a real error in certain patients, andcan lead you to a spiral that’s hard to escape, unless you have some cognitive checkpoints like this (“hang on, this patient should not need this much PEEP; maybe we should try going down, not up.”)