High Peak Inspiratory Pressure

Question 1

What is the definition of high peak inspiratory pressure?

Answer 1

Increase in peak inspiratory pressure > 40 cm H20 or an elevation above an established baseline level

Question 2

What are possible etiologies of high peak inspiratory pressure?

Answer 2

1. Circuit or machine problems
2. ETT/supraglottic airway problem
3. decreased pulmonary compliance
4. drug-induced problem
5. laryngospasm (if using supraglottic airway)

Question 3

What circuit or machine problems can cause high peak inspiratory pressure?

Answer 3

1. ventilator/bag switch in wrong position
2. stuck valve (inspiratory/expiratory/APL)
3. O2 flush valve stuck
4. kinked/misconnected hose in circuit/scavenge limb
5. failure of check valves/regulators in machine, allowing high-pressure gas into low-pressure circuit
6. PEEP valve accidentally placed in inspiratory limb

Question 4

What ETT/supraglottic airway problems can cause high peak inspiratory pressure?

Answer 4

1. kinked tube
2. malpositioned supraglottic airway
3. endobronchial, esophageal, submucosal intubation
4. herniated cuff obstructing end of tube
5. foreign body/secretions plugging end of tube
6. dissection of interior surface of tube, leading to airway narrowing
7. laryngospasm (if using supraglottic airway)

Question 5

What are some causes of decreased pulmonary compliance manifesting as high peak inspiratory pressure?

Answer 5

1. increased intra-abdominal pressure
2. pulmonary aspiration
3. bronchospasm not related to aspiration
4. decreased chest wall compliance
5. pulmonary edema
6. pneumothorax

Question 6

What are some drug-related causes of high peak inspiratory pressure?

Answer 6

1. opioid-induced chest wall rigidity
2. inadequate muscle relaxation
3. malignant hyperthermia

Question 7

What is the management of high peak inspiratory pressure?

Answer 7

1. increase FiO2 to 100%
2. Verify the peak inspiratory pressure (check gauge/manometer)
3. Switch to manually using reservoir bag; assess pulmonary and circuit compliance
4. Disconnect circuit from ETT and squeeze bag: if PIP still high, obstruction in the circuit, ventilate using BVM, get help to replace/repair circuit
5. Auscultate chest and neck
6. Examine trachea for deviation, check HR, BP
7. Exclude ETT obstruction: suction tube, if obstructed deflate cuff and resuction, consider FOB to assess further, remove and reintubate if necessary
8. Check for other causes of decreased chest compliance