Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: The role of respiratory system compliance

Background: Positive end-expiratory pressure (PEEP) can be effective in improving oxygenation, but it may worsen or induce intracranial hypertension. The authors hypothesized that the intracranial effects of PEEP could be related to the changes in respiratory system compliance (Crs). Methods: A prospective study investigated 21 comatose patients with severe head injury or subarachnoid hemorrhage receiving intracranial pressure (ICP) monitoring who required mechanical ventilation and PEEP. The 13 patients with normal Crs were analyzed as group A and the 8 patients with low Crs as group B. During the study, 0, 5, 8, and 12 cm H₂O of PEEP were applied in a random sequence. Jugular pressure, central venous pressure (CVP), cerebral perfusion pressure (CPP), intracranial pressure (ICP), cerebral compliance, mean velocity of the middle cerebral arteries, and jugular oxygen saturation were evaluated simultaneously. Results: In the group A patients, the PEEP increase from 0 to 12 cm H ₂O significantly increased CVP (from 10.6 ± 3.3 to 13.8 ± 3.3 mm Hg; p < 0.001) and jugular pressure (from 16.6 ± 3.1 to 18.8 ± 3.2 mm Hg; p < 0.001), but reduced mean arterial pressure (from 96.3 ± 6.7 to 91.3 ± 6.5 mm Hg; p < 0.01), CPP (from 82.2 ± 6.9 to 77.0 ± 6.2 mm Hg; p < 0.01), and mean velocity of the middle cerebral arteries (from 73.1 ± 27.9 to 67.4 ± 27.1 cm/sec; F = 7.15; p < 0.001). No significant variation in these parameters was observed in group B patients. After the PEEP increase, ICP and cerebral compliance did not change in either group. Although jugular oxygen saturation decreased slightly, it in no case dropped below 50%. Conclusions: In patients with low Crs, PEEP has no significant effect on cerebral and systemic hemodynamics. Monitoring of Crs may be useful for avoiding deleterious effects of PEEP on the intracranial system of patients with normal Crs.