contact me at drvizae@gmail.com

1. Recruitment Maneuvers
Dr. Vijay Kumar
Chennamchetty

2. Case Scenario
 A 23yr female student by occupation
presented with febrile illness of 4days, h/o
sore throat, cough present, no h/o travel, h/o
breathlessness 1day
 o/e
Sensorium normal
 Lungs: rr-40/mt, Spo2: 55% on NRBM
 Hemodynamics: stable
 ABG: type 1 resp failure (po2=25)
 Intubated in EMR & shifted to CCU

3. Case Scenario

4. Recruitment Maneuvers
 Introduction
 Definition
 Physiological Rationale
 Recruitment Maneuvers (RM’s)
 Monitoring The Efficacy
 Factors Influencing The Response
 Clinical Trials
 Limitations

5. Introduction
 Mechanical Ventilation as an essential
supportive measure
 “Lung protective” approach
 DrawbackARDS
work. NEJM
0; 342:1301-08
Gajic et al VALI in
pt’s with no lung
ALI . CCM
2004; 32:1817-24

6. Recruitment Maneuvers
Introduction
Definition

7. Definition
 Recruitment:
“ aeration of un-aerated alveoli”
 Recruitment Maneuver / Re-expansion
Maneuver:
“ denotes the dynamic process of an
intentional transient increase in trans
pulmonary pressure aimed at opening unstable
airless alveoli leading to increase in EELV,
even if it is inadequate to result in effective
alveolar recruitment ”
Pelosi et al,
Review article
Critical Care
2010; p1 - 7

8. Recruitment Maneuvers
Introduction
Definition
Physiological Rationale

9. ARDS: Physiological Rationale
Baby lung
1. Normal
2. Partly aerated
3. Collapsed 1. Lung protection
2. Alveolar stabilization
3. Alveolar recruitment
Gattinoni et al.
Intens Care Med. 1986; 12: 137-42

10. Physiological Rationale
 Atelectasis in normal lungs
 Absorption atelectasis
 Surfactant depletion
 “Lung protective strategy”
 RACE - Biotrauma
Froesse JC
Anesthesiology
1974; 41:242-55
Maggiore et al
AJRCCM 2003;
167:1215-24
Ranieri et al A RCT
JAMA 1999;
282:54 - 61
Over-distension
Atelectasis

11. End-Expiration
Tidal Forces
(Transpulmonary
and Microvascular
Pressures)
Extreme
Stress/Strain
Moderate
Stress/Strain
Mechano signaling via
integrins, cytoskeleton, ion channels
inflammatory cascade
Cellular Infiltration and
Systemic Inflammation
Rupture Signaling
Pathways to VILI
Marini / Gattinoni
CCM 2004
Barotrauma
Volutrauma
Biotrauma
Stress @ interface
MODS
Slutsky et al
Chest,
116 (1): 9s-16s
RACE

12. Opening and Closing Pressures
50
Paw [cmH2O]
0 5 10 15 20 25 30 35 40 45 50
0
10
20
30
40
Opening
pressure
Closing
pressure
“High pressures may be needed to open some lung units,
but once open, many units stay open at lower pressure”
%
Crotti et al
AJRCCM 2001

13. Recruitment Maneuvers
Introduction
Definition
Physiological Rationale
Indications

14. Who needs RM ………
ARDS
Hypoxic
Post suctioning
Post disconnection
Atelectasis related to GA
Cardiogenic Pulmonary EdemaLapinsky &
Sangeeta Mehta
Critical Care
2005; 9:60 - 65

15. Recruitment Maneuvers
 Introduction
 Definition
 Physiological Rationale
 Indications
 Types of Recruitment Maneuvers

16. Pre-requisites to perform RM
Arterial line
 Central line
 Deep Sedation / Paralysis
 Alarm settings

17. Recruitment Maneuvers
“Continuous inflation” technique
Anesthesiology 2002, 96:795–802.
Curr Opin Crit Care 2003; 9:22–27
CPAP : 35-40 cm H20 for 30-40 seconds

18. Continuous Inflation Technique
CPAP 40cm for 40 secs
PEEP set 2cm above LIP
Borges et al
Critical Care
2002; 9:60 - 65
% Collapsed lung Recruitment Steps
63% 05%

19. Continuous Inflation Technique
Anesthesiology 2002, 96:795–802.
Curr Opin Crit Care 2003; 9:22–27
PEEP + Peak pressure:  up to 60 cmH2O

20. Recruitment Maneuvers
Anesthesiology
2002, 96:795–802.
Curr Opin Crit Care
2003; 9:22–27
Crit Care Med
2004; 32: 2371–77
Intermittent Sigh
Intermittent PEEP
Progressive PEEP
Slide Courtesy: Dr. Ram Echambadi Rajagopalan

21. Anatomical Recruitment
 No recruitment PEEP + 5 40 cm recruitment + PEEP above LIP 60 cm recruitment PEEP + 25AJRCCM 2006;174: 268 – 78.
26 patients
Slide Courtesy: Dr. Ram Echambadi Rajagopalan

22. Recruitment Maneuvers
Introduction
Definition
Physiological Rationale
Indications
Recruitment Maneuvers
Monitoring The Efficacy

23. Monitoring The Efficacy
Malbouisson et al
PEEP-RM / CT
AJRCCM 2001;
163:1444-50
Richard JC et al
Role of PEEP & RM
AJRCCM 2001;
163:1609-13
Enrique & Vilagra
Effects of RM
CC Forum
2004; 8:115-121
ATS
loop C: Sustained inflation on
high PEEP favored alveolar
over-distension

24. Interpreting the PV Curve
 Measurement is not practical clinically
 A single inflation probably does not provide useful information
to determine safe ventilator settings
 Whole lung P/V curve is a composite of multiple regional P/V
curves (LIP varies widely)
Kunst PW et al
CCM 2000

25.  PaO2 improves
 No change EVLW
 Decrease in
atelectasis rather
than EVLW
 Change in CI -
Significant
 Continuous Scvo2
 Changes in CVP, HR
& MAP - insignificant
Tamas Leiner et al
CCM 2007;
Vol 35,
No.3
n = 18

26. Viviane R. S,
MD ;et al
CCM 2010;
Vol. 38, No 11
n = 36
40 cm/40secAnaesthesia, NMB
& Protective Ventilation
ABG &
Lung mechanics
ABG &
Lung mechanics

27.  After RM,
Static lung elastance & alveolar collapse
lung, liver, and kidney cell apoptosis, and
type 3 pro-collagen and interleukin-6
mRNA expressions
Electron microscopic images of lung
parenchyma were assessed
 Alveolar edema is seen only in severe
ALI
 Alveolar collapse were similar in both
ALI groups
Viviane R. Santiago,
MD ;et al
CCM 2010;
Vol. 38, No 11

28.  Conclusions
RM seems to promote modest but
consistent increase
alveolar stress & inflammation
fibrogenic responses
worsening lung function &
potentiating injury to alveolar and kidney
epithelium
 lower in moderate ALI than in severe
ALI
IL-6
Type 3 Collagen

29. Recruitment Maneuvers
Introduction
Definition
Physiological Rationale
Indications
Recruitment Maneuvers
Monitoring The Efficacy
Factors Influencing The Response

30. Factors Influencing The Response
Non uniformity & Variable outcome
Underlying lung disease
Baseline ventilation & volume history
Duration of Illness
Prone position
Type of RM & Post-recruitment PEEP

31. Underlying lung disease
Douglas R.Riva et al
CCM 2008;
Vol.36 163:1900-08
Malbouisson et al
PEEP-RM / CT
AJRCCM 2001;
163:1444-50
“more effective at opening collapsed alveoli in extra-
pulmonary ARDS, thus improving lung mechanics,
oxygenation, with limited damage to alveolar epithelium”

32. Underlying lung disease
Douglas R.Riva et al
CCM 2008;
Vol.36 163:1900-08
Malbouisson et al
PEEP-RM / CT
AJRCCM 2001;
163:1444-50 “greater PCIII mRNA expression in ALI pulmonary”
RILI

33. Baseline ventilation & “Volume history”
 Proportion of atelectatic lung
 Ventilatory settings that promote
derecruitment
Volume history: time dependant
manner
Bates JH et al
Time dependency;
Theoritical model
Journal of
Physiology 2002
Vander Kloot et al
RM in oleic acid
injury model
AJRCCM 2000;
161:1949-56

34. Duration of Illness
 “Less is More” & “More is Less”
 Less compliance of Lung & Chest
wall
Grasso S et al
Anesthesiology
2002; 96: 795-802

35. Prone position
 RM by itself
“Mule” or Complimentory effect
 No incerase in EELV
 Makes lung expansion more uniform
by the attenuation of heterogeneous
compressive forces
Pelosi et al
AJRCCM
2003; 167: 521-527

36. RM type & Post-RM PEEP
 Evidence little for type of RM
 Animal experiments
 Pressure targeted appears promising
 Post recruitment PEEP level – most
important determinant to prevent RACE
Lim et al
CCM
2003; 167: 521-527

37. Recruitment Maneuvers
 Introduction
 Definition
 Physiological Rationale
 Indications
 Recruitment Maneuvers
 Monitoring The Efficacy
 Factors Influencing The Response
 Clinical Trials

38. EXPRESS TRIAL
A RCT : JAMA 2008
768 patients, RCT
Minimal distension:
PEEP & Plat : as low as possible
Without affecting saturation targets
Increased Recruitment group:
“PEEP titration based on Plateau”
Oxygenation is not the goal
L. Brochard

39. EXPRESS TRIAL
A RCT : JAMA 2008
 Conclusion:
“strategy aimed at increased alveolar
recruitment while limiting hyperinflation didn’t
significantly reduced mortality”
 Better lung mechanics
 Reduced duration of MV
 Reduced duration of organ failure
 Post hoc analysis:
“ ALI may be associated with less benefits &
more adverse effects from high levels of PEEP”
L. Brochard

40. Lung Open Ventilation Study
JAMA 2008
985 pts enrolled, RCT
Control group: protective ventilation
Volume Control
Experimental group:
PC mode + RM (40/40) + Pplat 40
 Tidal volumes were similar
 Mean PEEP : 10 Vs 15 in first 72hrs
 Barotrauma rates were similar

41. Lung Open Ventilation Study
JAMA 2008
Conclusion:
“open strategy did appear to
improve secondary end points related
to hypoxemia & use of rescue
therapies”
Low rates of
Refractory hypoxemia,
Death with refractory hypoxemia &
Need of “Rescue therapy”

42. Recruitment Maneuvers
 Introduction
 Definition
 Physiological Rationale
 Indications
 Recruitment Maneuvers
 Monitoring The Efficacy
 Factors Influencing The Response
 Clinical Trials
 Limitations

43. Limitations
Brower, et al.:
RMs in ALI
Review article
AJRCCM
2008; 176: 521-527

44. In a nut shell……….
Hemodynamic compromise
Intracranial blood flow
VILI / RILI
Bacterial translocation
Clinical benefits ????

45. Hemodynamic Effects
 Lung inflation by positive pressure causes
 Increased pleural pressure and impeded venous return
 Increased pulmonary vascular resistance
 Compression of the inferior vena cava
 Retardation of heart rate increases
 These effects are much less obvious in the presence of
 Adequate circulating volume
 Adequate vascular tone
 Spontaneous breathing efforts
 Preserved adrenergic responsiveness

46. “With More Lung Compliance, High Levels of
PEEP are Generally Not Well Tolerated”
Hemodynamic Effects

47. Capillaries in the alveolar walls undergo compression even
as interstitial vessels dilate. The net result is usually an increase
in pulmonary vascular resistance, unless recruitment of collapsed
units occurs.
Hemodynamic Effects
On Pulmonary vasculature:

48. Recruitment Maneuvers
Introduction
Definition
Physiological Rationale
Recruitment Maneuvers
Monitoring The Efficacy
Factors Influencing The Response
Limitations
 Summary

49. Summary………..
Transient increase in trans pulmonary
pressure to increase in EELV
“Lung protective strategy”
Bio-trauma facilitates MODS
ARDS – commonest indication
Prerequisites
CPAP – most widely studied & PEEP
titration in PC mode is user &
hemodynamic friendly

50. Summary………..
 Pao2 is a surrogate marker for monitoring
 Continuous Scvo2 & CCO monitor is
recommended as CVP is poor predictor of CI
 RM worsens the inflammation in Pulmonary ALI
 Volume history is important before attempting a
RM
 Prone has complimentary effect
 Titrate PEEP based on compliance &
oxygenation

51. Summary………..
Studies
Did not reveal any mortality benefits
Did appear to improve secondary end points &
its role as rescue therapy
Adverse events
Hypotension & Arrhythmias
Barotraumas & De-saturation

52. Controversies
Which patients will benefit?
How long to recruit?
What is optimum level of Post
recruitment PEEP?
When to use: routine or only during
hypoxic episodes?

53. Thank u so…… much

54. Diseased Lungs Do
Not Fully Collapse,
Despite Tension Pneumothorax
…and
They cannot always
be fully “opened”
Dimensions of a fully
Collapsed Normal Lung