High-level positive end-expiratory pressure management in trauma-associated adult respiratory distress syndrome.

This study evaluated the effect of high-level positive end-expiratory pressure (PEEP) on mortality, barotrauma, intrapulmonary shunt (Qsp/Qt), and oxygen delivery (DO2) in posttraumatic adult respiratory distress syndrome (ARDS). All hypoxemic trauma patients admitted to the surgical intensive care unit (SICU) in 1989-1990 who received PEEP greater than 15 cm H2O were included. The PEEP was titrated to achieve an intrapulmonary shunt (Qsp/Qt) of approximately 0.20, and FIO2 was weaned to less than 0.50. Hemodynamic and pulmonary variables at four distinct intervals were recorded. Fifty-nine patients received PEEP greater than 15 cm H2O. Of these, 19 patients died of severe head injury or uncontrollable hemorrhage (16 within 48 hours). Forty (29 male, 11 female) were evaluated in detail. The PEEP levels ranged from 18-50 cm H2O with a mean of 27. PaO2/FIO2 ratios and Qsp/Qt improved as PEEP therapy was titrated. Cardiac index and oxygen delivery were maintained or improved throughout PEEP therapy by transfusion and fluid resuscitation, with a mean maximum positive fluid balance of 21.1 L and an average of 51 units of blood and blood products transfused per patients during their SICU stay. Twenty-nine (73%) had evidence of barotrauma, the majority being pneumothoraces clearly related to the initial trauma. Only three (7.5%) had evidence of barotrauma not related to trauma or line insertion. Eight of 40 patients (20%) died. Mean ISS and RTS for the entire group were 32 and 5.88, respectively. We conclude that titration of PEEP to achieve a Qsp/Qt of approximately 0.20 is an attainable goal. This was accomplished with minimal hemodynamic effects or barotrauma and a low mortality rate.