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Review
. 2024 Feb 1;30(1):53-60.
doi: 10.1097/MCC.0000000000001119. Epub 2023 Nov 17.

Setting positive end-expiratory pressure: lung and diaphragm ultrasound

Amne Mousa  1   2   3 , Peter Klompmaker  1   2   3 , Pieter R Tuinman  1   2   3
Affiliations
Review

Setting positive end-expiratory pressure: lung and diaphragm ultrasound

Amne Mousa et al. Curr Opin Crit Care. .

Abstract

Purpose of review: The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed.

Recent findings: Lung ultrasound can accurately diagnose the cause of acute respiratory failure, including acute respiratory distress syndrome and can identify focal and nonfocal lung morphology in these patients. This is essential in determining optimal ventilator strategy and PEEP level. Assessment of the effect of PEEP on lung recruitment using lung ultrasound is promising, especially in the perioperative setting. Diaphragm ultrasound can monitor the effects of PEEP on the diaphragm, but this needs further validation. In patients with an acute exacerbation of chronic obstructive pulmonary disease, diaphragm ultrasound can be used to predict noninvasive ventilation failure. Lung and diaphragm ultrasound can be used to predict weaning outcome and accurately diagnose the cause of weaning failure.

Summary: Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Box 1
Box 1
no caption available
FIGURE 1
FIGURE 1
Effects of low and high PEEP on the lungs and diaphragm. PEEP increases expiratory lung volume, thereby changing the fluid to gas ratio, resulting in change of detected lung ultrasound pattern (B-profile to A-profile). In addition, PEEP causes the diaphragm to be shortened, resulting in a thicker end-expiratory muscle with potentially less efficient contractility. ∗indicates individual B-lines. 1: pleura, 2: diaphragm muscle, 3: peritoneum. | shows thickness measurement of the diaphragm muscle. PEEP, positive end-expiratory pressure.
FIGURE 2
FIGURE 2
Lung or diaphragm ultrasound findings for common causes of respiratory failure and corresponding guidelines for setting PEEP. ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; DE, diaphragm excursion; PEEP, positive end-expiratory pressure; PEEPi, intrinsic positive end-expiratory pressure; TFdi, diaphragm thickening fraction.
FIGURE 3
FIGURE 3
The Amsterdam method for lung ultrasound assessment to differentiate between focal and nonfocal lung morphology in patients with acute respiratory distress syndrome. Adapted from Pierrakos et al. (2021).
FIGURE 4
FIGURE 4
Effect of PEEP on reaeration of the lung. Increase of PEEP can result in recruitment of lung tissue which can be seen on lung ultrasound as a smaller consolidation when PEEP is increased from PEEP 5 (left) to PEEP 15 (right). The lines indicate the border of the consolidations. PEEP, positive end-expiratory pressure.
See this image and copyright information in PMC

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References

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