Recruitment maneuvers in acute respiratory distress syndrome: The safe way is the best way

Abstract

Acute respiratory distress syndrome (ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers (RMs) are a simple, low-cost, feasible intervention that can be performed at the bedside in patients with ARDS. RMs are characterized by the application of airway pressure to increase transpulmonary pressure transiently. Once non-aerated lung units are reopened, improvements are observed in respiratory system mechanics, alveolar reaeration on computed tomography, and improvements in gas exchange (functional recruitment). However, the reopening process could lead to vascular compression, which can be associated with overinflation, and gas exchange may not improve as expected (anatomical recruitment). The purpose of this review was to discuss the effects of different RM strategies - sustained inflation, intermittent sighs, and stepwise increases of positive end-expiratory pressure (PEEP) and/or airway inspiratory pressure - on the following parameters: hemodynamics, oxygenation, barotrauma episodes, and lung recruitability through physiological variables and imaging techniques. RMs and PEEP titration are interdependent events for the success of ventilatory management. PEEP should be adjusted on the basis of respiratory system mechanics and oxygenation. Recent systematic reviews and meta-analyses suggest that RMs are associated with lower mortality in patients with ARDS. However, the optimal RM method (i.e., that providing the best balance of benefit and harm) and the effects of RMs on clinical outcome are still under discussion, and further evidence is needed.

Keywords: Recruitment maneuvers, Acute respiratory distress syndrome, Positive end-expiratory pressure, Transpulmonary pressure, Lung ultrasonography

Core tip: Experimental and clinical studies show that stepwise recruitment maneuvers (RMs) improve oxygenation and lung aeration and are associated with less hemodynamic instability and inflammatory impact on lung tissue compared to traditional abrupt maneuvers. Patients with severe acute respiratory distress syndrome, characterized by increased edema and atelectasis, are good candidates for RMs. Patients whose oxygenation improves with increased pressure are at lower risk of death. Post-recruitment positive end-expiratory pressure (PEEP) titration is critical to maintaining stabilization of alveolar units and avoiding derecruitment. The use of individualized PEEP based on lung compliance might move clinical management forward.