The Use of High Positive End-Expiratory Pressure for Respiratory Failure in Abdominal Compartment Syndrome

We report a case in which a non-trauma patient suffering hematemesis and undergoing massive volume resuscitation developed abdominal compartment syndrome (ACS). The abdominal distension severely compromised his pulmonary functioning: a chest radiograph showed low lung volumes and dense bilateral parenchymal opacities. His blood oxygen saturation reached as low as 32%. Because he was hemodynamically unstable and coagulopathic, decompressive surgery was not possible. We gradually raised the ventilator settings to reinflate the lungs (positive end-expiratory pressure [PEEP] was raised to 50 cm H₂O, peak inspiratory pressure to 100 cm H₂O, and plateau inspiratory pressure to 80 cm H₂O) and continued fluid resuscitation, and within an hour his blood oxygen saturation increased to 100%. In this case high PEEP was beneficial in a situation in which decompressive surgery was not feasible, but we do not suggest that high PEEP necessarily improves survival or that high PEEP is better than surgical decompression. On the contrary, high-pressure ventilation can be harmful in the setting of acute lung injury and acute respiratory distress syndrome, so we do not advocate high PEEP for all patients with hypoxemia and ACS, especially considering that many of the conditions associated with ACS can also precipitate acute lung injury and acute respiratory distress syndrome. As well, high-pressure ventilation can increase the risk of hypotension by impairing venous return. However, our case suggests that high PEEP may temporize in certain situations in which ACS causes life-threatening hypoxia but surgical decompression is not possible.