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Resident in ICU.
Sri B.M.J Hospital,
PEEP – Positive End Expiratory Pressure is the
pressure in the alveolus at the end of the

There are 2 kinds of PEEP – iPEEP (intrinsic)

and ePEEP (extrinsic).
Definition of Auto PEEP

Auto-PEEP (also known as “intrinsic” PEEP)
refers to the positive pressure within alveoli at
end-expiration that has not been generated by
a ventilator.

Also called as intrinsic PEEP, Breath stacking,
occult PEEP.
Where can we see it?
a) Status asthmaticus, Acute Exacerbation of
COPD are examples of auto PEEP in non
ventilated patients.

b) Inadequate expiratory time on mechanically

ventilated patients.
Why does it occur?
In AE of COPD and Status asthmaticus:
Hyperventilation decreased expiratory time
leading to initiation of inspiration before lung
reaches the FRC. This leads to prgressive
alveolar distension and positive pressure at the
end of expiration (iPEEP).
Why does it occur?

Also active airway smooth muscle contraction

causes dynamic hyperinflation and airtrapping
resulting in Auto PEEP.
Why does it occur?
In mechanically ventilated patients:
a. Inadequate expiratory time
b. Unrecognized bronchospasm with high tidal
volume, high minute ventilation(high RR), long
inspiratory times (1:1or 2:1)
c. Small Endotracheal tubes can increase PEEP.
Recognise Auto PEEP

Increased work of breathing in a mechanically

ventilated patient.
Use of accessory muscles of respiration.
Presence of Pulsus paradoxus.
Recognise Auto PEEP
How to measure Auto PEEP
In mechanically ventilated patients without
spontaneous respiratory effort '' end-expiratory
port occlusion method can be applied where the
expiratory port is occluded near the time when
the next inspiration is anticipated. Because the
expiratory flow is blocked, pressure in the
ventilatory tube equilibrates with alveolar
pressure, allowing the level of PEEP to be
measured on the ventilator manometer.
How to measure Auto PEEP
In ventilated patients with spontaneous respiratory
effort esophageal balloon manometry can be
applied. Esophageal pressure is in correlation
with pleural pressures and hence the transmural
distending pressure of the lung can be
Complications of Auto PEEP
Failure of the lung units to return to FRC at the
end of expiration results in progressive increase
in iPEEP and decreased oxygenation. Its also
complicated by the fact that respiratory muscles
work at a disadvantage operating in an
unfavourable position on their length–tension
curve. Positive alveolar pressure can impede
venous return and hence impair circulatory
Complications of Auto PEEP
Continued mechanical ventilation in the presence
of Auto PEEP may result in Pulmonary
barotrauma in the form of pneumothorax,
pneumo mediastinum, subcutaneous
emphysema etc..
How to offset Auto PEEP
Correct reversible parameters like using a larger
ET tube, Bronchdilation, increasing expiratory
time with decreasing tidal volume and
respiratory rate.
Apply ePEEP: Though it appears to be
paradoxical ePEEP helps offsetting auto PEEP
by splinting opening the airways and reducing
airtrapping. The applied ePEEP should not
exceed 85% of the measured auto PEEP.
1. Fishman's Pulmonary Diseases and Disorders
4th edition.

2. Crofton and Douglas's Respiratory Diseases 5 th


3. Dr Azam's Notes in Anesthesiology 2 nd edition.