Intensive Care Med

https://doi.org/10.1007/s00134-024-07351-5

EDITORIAL

Assessing lung recruitability: does it help

with PEEP settings?
Luciano Gattinoni1* , Francesca Collino2 and Luigi Camporota3

© 2024 The Author(s)

Recruitment is a process expressing a transition from only to the reaeration of gasless atelectasis or if we
status A to status B. In acute respiratory distress syn- include the greater inflation of poorly aerated alveoli
drome (ARDS), status A (initial) is the level of inflation (Fig. 1).
of the pulmonary units at end-expiration, while status B
(final) is their level of inflation at end-inspiration follow- Recruitment maintenance
ing an increase in transpulmonary pressure. In the ARDS To keep the newly recruited units open, two conditions
literature, under the term ‘recruitment’, two different must be satisfied. First, the level of positive end-expira-
conditions are included: (1) the regaining of aeration in tory pressure (PEEP) should be sufficient to lift the chest
atelectatic units at end-inspiration; (2) the recruitment of wall and to overcome the compressive forces on the
atelectatic and poorly aerated units to an overall better lung parenchyma [4]. Unfortunately, the PEEP required
inflation status at end-inspiration. to maintain the recruitment of a fully open lung (open-
ing pressure 45–60 ­cmH2O) is in the order of 20–25 of
Opening pressures ­cmH2O [3]. Second, the tidal volumes should be ade-
The recruitment is an inspiratory phenomenon which quate, as low tidal volumes, even in the presence of high
occurs continuously over a range of pressures from zero PEEP, are likely to cause marked hypoventilation and
up to 50–60 ­cmH2O. The pressure–recruitment relation- reabsorption atelectasis overtime.
ship exhibits a sigmoidal shape like the pressure–vol-
ume curve [1]. Therefore, the distribution of opening Interaction between opening pressure and positive
pressures may be represented by a Gaussian curve, with end‑expiratory pressure
a ‘mode’ of ~ 25–30 ­ cmH2O, and with only few units From this perspective, it is evident that recruitment, as
(2–5%) opening at pressures > 45 ­cmH2O [2, 3]. Indeed, intended in clinical practice, depends on the relationship
the pressure necessary to open an atelectatic pulmonary between the pressures needed to open alveolar units and
unit needs to overcome three forces [4]: (1) the superim- that required to maintain recruitment. Therefore, the
posed pressure (~ 10–15 ­cmH2O); (2) the surface forces effects of recruitment will wane if PEEP levels are not set
(~ 15–20 ­cmH2O)]; 3) the pressure needed to move the above the closing threshold pressure [3]. In this sense,
chest wall (~ 10–15 ­ cmH2O). These forces affect the the PEEP level should not be set based on the amount of
opening threshold of an alveolus depending on the rela- potentially recruitable lung, but on the pressure needed
tive inflation status of neighboring alveoli within an iso- to prevent the closing of newly opened alveolar units [5].
gravitational plane (i.e., crowding effect).
The kind of recruitment measured must be clearly Available methods to assess recruitment
specified as there is a substantial difference if we refer
Gas exchange‑based methods
These methods are widely used and rely on oxygenation,
*Correspondence: [email protected] PEEP/FiO2 tables or to the changes in oxygenation when
1
Department of Anesthesiology, University Medical Center Göttingen, decreasing alveolar pressure after a full inflation. How-
Robert Koch Straße 40, 37075 Göttingen, Germany
Full author information is available at the end of the article ever, these methods may be misleading, as oxygenation is
deeply affected by hemodynamic changes (i.e., decreasing
 Fig. 1 Effect of recruitment as a function of the method used and effect of the PEEP applied. Panel A: In the right lung of the figures the different
percentages (%) of pulmonary units in a typical ARDS patient are depicted (consolidated 24%, atelectatic 14%, poorly ventilated 34%, normally
ventilated 28%). The left lung of the figure displays a single isolated atelectatic unit. (Panel B–upper) Using the percentages as in panel A, if the
recruitment is assessed as reinflation of atelectatic unit (CT method) the resultant recruitment is 14%. (Panel B–lower) If the recruitment is assessed
by the gas method, (which also includes increased aeration of poorly aerated units) the measured recruitment is of 48%. Panel C: The maintenance
of recruitment is independent of the number of lung units recruited but depends on their physical characteristics such as closing pressures which
are independent on the recruitability (intensive property of the system). Although the PEEP necessary to maintain the recruitment may be the same
(independent of recruitment) the gain from the application of PEEP will be affected by recruitment and higher in the patients with higher potential
for lung recruitment

of cardiac output independently to alveolar recruitment) compliance, “recruitment” is said to have occurred and
[6]. is quantified accordingly. This method includes the dual
pressure–volume curve and the recruitment-to-inflation
CT‑scan‑based methods ratio [9].
These methods quantify the amount of lung recruit- All these methods estimate the recruitment to a better
ment, but their absolute value depends on the method inflation status of previously non-aerated and poorly aer-
used for the analysis. One method measures the differ- ated pulmonary units. The recruitment values are unre-
ence between the non-aerated tissue before and after lated with ones measured by CT scan [10].
the increase in airway pressure (on average 12%, ranging
from 0% to 35%) [7]; the second, measures the change in Other methods
the anatomical distribution of aerated and non-aerated The use of systems such as electric impedance tomogra-
tissue, where the non-aerated tissue includes atelectatic phy and ultrasound may give—through different physical
and poorly aerated tissue [8]. Indeed, the first method principles—a quantitative or semi-quantitative estima-
provides values markedly lower than the values resulting tion of the gas and tissue ratio of the lung before and after
from the second method. a recruitment pressure [11].

Gas‑volume‑based methods Clinical implications

These methods define recruitment as the difference The potential for lung recruitment, i.e., the absolute
between the expected change in lung volume at a given amount of atelectatic lung that can be inflated on inspi-
pressure and the measured volume changed. If the lat- ration, is generally considered the physiological basis for
ter is greater than expected based on the baseline PEEP selection. In accordance with this concept, patients
with greater recruitability would necessitate the applica- you give appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons licence, and indicate if changes were made. The
tion of higher PEEP levels. images or other third party material in this article are included in the article’s
However, as recognized by the recent guidelines from Creative Commons licence, unless indicated otherwise in a credit line to the
the European Society of Intensive Care Medicine [12], material. If material is not included in the article’s Creative Commons licence
and your intended use is not permitted by statutory regulation or exceeds the
PEEP selection does not have precise rules, beyond the permitted use, you will need to obtain permission directly from the copyright
fact that PEEP levels > 15 ­ cmH2O in association with holder. To view a copy of this licence, visit http://creativecommons.org/
routinely performed recruitment maneuvers is associ- licenses/by-nc/4.0/.
ated with worst outcomes. Therefore, the assertion of
an association between recruitability and PEEP levels is Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
questionable from both physiological and physical per- lished maps and institutional affiliations.
spectives. This is because the opening pressure and PEEP
are ‘intensive’ properties of a physical system, mean- Received: 5 February 2024 Accepted: 9 February 2024
ing that its magnitude is independent on the size of the
system. Consequently, the PEEP level is independent of
the overall amount of potentially recruitable units and
identical pressures are required to open and maintain References
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1
Department of Anesthesiology, University Medical Center Göttingen, Robert ajrccm.​163.6.​20050​01
Koch Straße 40, 37075 Göttingen, Germany. 2 Department of Surgical Sciences, 9. Chen L, Del Sorbo L, Grieco DL, Junhasavasdikul D et al (2020) Potential
University of Turin, Turin, Italy. 3 Department of Adult Critical Care, Centre for Lung recruitment estimated by the recruitment-to-inflation ratio in
for Human and Applied Physiological Sciences, Guy’s and St. Thomas’ NHS acute respiratory distress syndrome: a clinical trial. Am J Respir Crit Care
Foundation Trust, King’s College London, London, UK. Med 201(2):178–187. https://​doi.​org/​10.​1164/​rccm.​201902-​0334OC
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Funding recruitment assessed by respiratory mechanics and computedtomog-
Open Access funding enabled and organized by Projekt DEAL. raphy in patients with acute respiratory distress syndrome. What is the
relationship? Am J Respir Crit Care Med 193(11):1254–1263. https://​doi.​
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This article is licensed under a Creative Commons Attribution-NonCommercial tion, phenotyping and respiratory support strategies. Intensive Care Med
4.0 International License, which permits any non-commercial use, sharing, 49:727–759. https://​doi.​org/​10.​1007/​s00134-​023-​07050-7
adaptation, distribution and reproduction in any medium or format, as long as