Australian Critical Care (2009) 22, 155—162

RESEARCH PAPER

Lung recruitment—–A guide for clinicians

Jacqui I. Jauncey-Cooke RN, MNRS,
Grad Dip Crit Care, PhD Candidate a,b,∗,
Fiona Bogossian RN, RM, PhD, Assoc. Professor a,
Christine E. East RN, RM, PhD, Research Consultant, Senior Lecturer a,c

a The University of Queensland, School of Nursing and Midwifery, Herston, Australia

b Clinical Nurse, PICU Mater Children’s Hospital, Brisbane, Queensland, Australia
c Dept of Perinatal Medicine and Dept of Obstetrics & Gynaecology, The University of Melbourne,

Royal Women’s Hospital, Australia

Received 2 February 2009 ; received in revised form 12 May 2009; accepted 4 June 2009

KEYWORDS Summary Recruitment manoeuvres play an important role in minimising ventilator

Mechanical ventilation; associated lung injury (VALI) particularly when lung protective ventilation strategies
Recruitment; are employed and as such clinicians should consider their application. This paper pro-
Positive end expiratory vides evidence-based recommendations for clinical practice with regard to alveolar
pressure;
recruitment. It includes recommendations for timing of recruitment, strategies of
recruitment and methods of measuring the efficacy of recruitment manoeuvres and
Sustained inflation;
contributes to knowledge about the risks associated with recruitment manoeuvres.
Paediatric;
There are a range of methods for recruiting alveoli, most notably by manipu-
Lung protective lating positive end expiratory pressure (PEEP) and peak inspiratory pressure (PIP)
ventilation with consensus as to the most effective not yet determined. A number of studies
have demonstrated that improvement in oxygenation is rarely sustained following a
recruitment manoeuvre and it is questionable whether improved oxygenation should
be the clinician’s goal. Transient haemodynamic compromise has been noted in a
number of studies with a few studies reporting persistent, harmful sequelae to
recruitment manoeuvres. No studies have been located that assess the impact of
recruitment manoeuvres on length of ventilation, length of stay, morbidity or mor-
tality. Recruitment manoeuvres restore end expiratory lung volume by overcoming
threshold opening pressures and are most effective when applied after circuit dis-
connection and airway suction. Whether this ultimately improves outcomes in adult
or paediatric populations is unknown.
© 2009 Australian College of Critical Care Nurses Ltd. Published by Elsevier
Australia (a division of Reed International Books Australia Pty Ltd).
All rights reserved.

∗ Corresponding author. Tel.: +61 0418335634.

E-mail addresses: jacqui.jauncey-cooke@mater.org.au, j.jauncey-cooke@uqconnect.edu.au (J.I. Jauncey-Cooke).

1036-7314/ $ — see front matter © 2009 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.aucc.2009.06.004
156
Introduction
The concept of lung recruitment has evolved as
a consequence of the conceptual shift towards
lung protective ventilation strategies.1,2 Low tidal
volume and higher positive end expiratory pres-
sure (PEEP) benefit the patient by minimising
parenchymal injury. This reduces the incidence
of ventilator associated lung injury (VALI).3,4 A
well documented iatrogenic phenomenon caused
by high transpulmonary pressures at the end of
inspiration and inadequate alveolar recruitment
at end expiration.3,5—10 The occurrence of VALI
is significant as it impacts on length of venti-
lation, length of stay and may lead to chronic
pulmonary impairment.8,11 An experimental study
by Kornecki et al. compared adult, adolescent and
infant rats’ lungs both in vivo and ex vivo to
their susceptibility to lung injury via positive pres-
sure ventilation.12 Both hyperinflation and cytokine
release were greater in adult lungs compared to
infant lungs.12 However, in humans Wolf et al.
demonstrated similar end expiratory lung volume
(EELV) loss in children as in adults.13 This may sug-
gest that the prevalence of VALI in both adult and
paediatric populations is clinically significant.
As a consequence of using lung protective venti-
lation strategies the chronic derecruitment of distal
and dependant regions of the lung occurs.1—5,8,12
The need to periodically and deliberately re-recruit
alveoli becomes apparent, more so following dis-
connection from the circuit and the application
of suction.7 Hence, the concept and practice of
recruitment manoeuvres has evolved. This review
aims to compare the most common methods of
recruiting alveoli — by manipulating PEEP, sustained
inflation, or a combination of these strategies — and
discusses their application in the clinical setting
along with potential harmful sequelae. Searches
were undertaken using the following databases:
Medline via Ovid; Embase; Cinahl; Joanna Briggs;
and the Cochrane Central Register of Controlled
Trials from their inception to July 2008. The
Fig. 1 Global and regional impedance change demonstrating disconnection from circuit, hand ventilation, suction
and reconnection to circuit with no recruitment.
J.I. Jauncey-Cooke et al.
following keywords were used: mechanical ventila-
tion; alveolar ventilation; recruitment; recruitment
manoeuvres; overdistension; hyperinflation; ven-
tilator induced lung injury; acute respiratory
distress syndrome; paediatrics; mechanotransduc-
tion; airway suction; acute lung injury; positive
end-expiratory pressure. Further to this elec-
tronic search, citation tracking was undertaken.
Randomised controlled trials, quasi randomised
controlled trials and observational studies of both
clinical and experimental studies were included.
These methods yielded 189 papers of which 120
were excluded as they were beyond the scope of
this paper. A total of 29 experimental and 40 clinical
studies were utilised.
Timing of recruitment
Derecruitment of alveoli occurs rapidly within sec-
onds of airway pressure release in addition to
chronic derecruitment secondary to low tidal vol-
ume ventilation.15,16 This is not homogenous; there
are significant regional differences in the degree of
derecruitment with distal and dependant regions
being the first to rapidly collapse.2,3,7,13,14,17 The
application of sub-atmospheric pressure via suction
to the airways further attenuates this derecruit-
ment and results in alveolar injury.3,13 Fig. 1
illustrates the reduction in relative impedance
reflecting the drop in EELV secondary to disconnec-
tion and suction and the subsequent period of time
required to restore previous impedance levels.
Secretion clearance is essential in the care of
any intubated patient and those patients with a
primary acute lung injury (ALI) commonly have an
increased need for secretion elimination. With each
disconnection and suctioning, alveolar derecruit-
ment occurs, exacerbating the ALI and contributing
to VALI.4,13 Additionally, the instillation of saline
increases threshold opening pressures and worsens
derecruitment.18 A study by Heinze et al. reported
that irrespective of the mode of ventilation used
Lung recruitment
or the employment of open or closed suctioning,
a significant loss of functional residual capacity
(FRC) occurred.19 This supports the earlier find-
ings of Cereda et al.20 In a study by Lindgren
et al. FRC as measured by electrical impedance
tomography (EIT) was decreased by 58 ± 24% of
baseline by disconnection of the endotracheal tube
(ETT) from the circuit and a further 22 ± 10% during
open suction.21 A number of studies demonstrate
that the use of a closed suction system combined
with a recruitment manoeuvre restores lung vol-
ume promptly and minimises derecruitment.7,22—24
However, the use of closed suction systems has limi-
tations in relation to secretion clearance and raises
significant concerns about the negative pressures
generated in pressure modes of ventilation.25,26
Maintenance of PEEP helps stabilise and maintain
alveolar patency at the end expiration but is insuf-
ficient to overcome the threshold opening pressure
following circuit disconnection.27—30 A recruitment
manoeuvre is essential to overcome this pressure
and should be applied whenever a patient’s end
expiratory level drops below the critical closing
pressure.29,30
Keypoint #1
Recruitment manoeuvres should be per-
formed after each disconnection from the
ventilator circuit +/− suction to restore end
expiratory lung volume.
Method of recruitment
The aim of a recruitment manoeuvre is to peri-
odically and briefly raise transpulmonary pressure
to higher levels than are achieved during tidal
ventilation, thereby minimising physiological dead
space.31 It is imperative to preserve EELV to secure
alveolar stability. Recruitment manoeuvres that are
performed with an anaesthetic circuit are limited
by the EELV loss when the circuit is reconnected to
the ventilator circuit, effectively losing any gains
achieved from the recruitment manoeuvre. The
ventilator should be used to recruit alveoli and
disconnected only when necessary.13,15—18 Alveolar
recruitment is commonly achieved by manipulat-
ing PEEP or using sustained inflation or employing a
combination of these strategies.
Manipulating PEEP
Manipulating PEEP allows the clinician to con-
trol FRC and minimise physiological dead space.
157
Many of the reviewed studies suggest increasing
the peak inspiratory pressure (PIP) alongside the
PEEP rather than sacrificing tidal volume. There
are two common methods of manipulating PEEP:
with a sharp increase in expiratory pressure or
incremental increases with a decremental decrease
back to baseline.32—34 An experimental study by
Odenstedt et al. demonstrated the greatest effi-
cacy in alveolar recruitment by slowly increasing
PEEP to 15 cmH2 O combined with two 7 s end-
inspiratory pauses every minute for 15 min.34 This
was achieved with relatively low plateau pressures
(27 ± 0.9 cmH2 O) and minimal haemodynamic side
effects.34 Other studies have manipulated PEEP
and tolerated an escalation of PIP with positive
results in regard to compliance, gas exchange and
EELV. 35,36 A clinical study by Povoa et al. used
incremental increases up to 60/45 cmH2 O in adults
with severe adult respiratory distress syndrome
(ARDS).36 Whilst it is unlikely that clinicians would
use PIP’s of 60 cmH2 O in either adults or children it
can be surmised from the literature that clinicians
could be more liberal in their use of PEEP and peri-
odic PEEP levels around 20 cmH2 O should not cause
harm in adults.36 Therefore, it is unlikely that they
would cause harm in the more compliant chest of
a child.12 Higher peak pressures may also be toler-
ated beyond those pressures to which clinicians are
currently accustomed.34—36
An alternative method of manipulating PEEP may
be achieved by reducing the expiratory time and
thereby generating intrinsic PEEP. Neumann et al.
reported expiration times of less than 0.6 s avoided
cyclic alveolar collapse in three models of porcine
lung injury without extrinsic PEEP.16 A later study by
Schreiter et al. in 2004 combined a rapid respiratory
rate, inverse I:E ratio and incremental increases
in PEEP and PIP.37 They succeeded in gaining aer-
ated lung volumes from 1742 mL (range 774—2941)
to 2971 mL (range 1270—5232). Non-aerated regions
decreased from 604 mL (range 147—1538) to 106 mL
(range 0—736).37 Fig. 2, a global and regional time
course array diagram, demonstrates the time taken
to restore baseline EELV following a double PEEP
recruitment manoeuvre. Immediately upon return
to baseline PEEP the EELV is in excess of the pre-
disconnection level and this is maintained. This is
in contrast to Fig. 1 where the baseline EELV was
yet to be achieved 200 s post-disconnection.
Inspiratory hold—–sustained inflation
Sustained inflations or inspiratory holds are a
combination of two factors: the peak pressure
and the period of time maintained at that peak
pressure. The goal of sustained inflation is to
158
Fig. 2 Time course array demonstrating regional and global impedance change during suctioning, reconnection to
circuit, recruitment using a double PEEP manoeuvre and return to baseline PEEP.
inflate alveoli with an elevated threshold open-
ing pressure. By overcoming threshold opening
pressure, alveoli literally pop open and par-
ticipate in gas exchange. A clinical trial by
Marcus et al. used a timed re-expansion inspi-
ratory manoeuvre or TRIM whereby a constant
pressure of 30 cmH2 O for 10 s resulted in signif-
icantly higher pulmonary compliance and lower
airway resistance (P < 0.0001).38 They demon-
strated that TRIM reversed changes in compliance
and airway resistance associated with anaesthetic
induction.38
The safety and efficacy of using sustained
inflation pressures of 30—45 cmH2 O in paediatrics
has been established in recent studies.39,40 In
an experimental study, Frank and Matthay used
the inspiratory hold method41 and demonstrated
increases in dynamic and quasistatic compli-
ance in subjects ventilated with recruitment
manoeuvres.41 Oxygenation was improved and per-
sisted throughout the duration of the study. Similar
results were noted in a study conducted by Tugrul
et al. using sustained inflation up to 45 cmH2 O for
30 s followed by substantial PEEP.42 In contrast, a
study by Henzler et al. used a similar recruitment
strategy of inflation to 45 cmH2 O for 40 s in which
aerated lung increased substantially but did not
correlate with an increase in PaO2 .43 Dyhr et al.
used two hyperinflations to 45 cmH2 O, held for 20 s
with an interval of 1 min in between in patients with
ARDS post-suctioning.22 They reported that the use
of a recruitment manoeuvre, when combined with
adequate ongoing PEEP, improved both oxygena-
tion and EELV as measured by a wash in/washout
method.22,44
Keypoint #2
Lung recruitment can be achieved by either
manipulating positive end expiratory pressure
or peak inspiratory pressure.
J.I. Jauncey-Cooke et al.
Efficacy of recruitment manoeuvres
The goal or endpoints clinicians use to measure
the efficacy of recruitment manoeuvres are varied.
EIT offers the potential for accuracy and allows for
real time assessment of the effect of recruitment
manoeuvres. It provides data on efficacy and dis-
tribution of ventilation and is gaining popularity
as a bedside tool to measure lung dynamics.14,45
Another tool clinicians may use at the bedside
is the pressure—volume (P—V) curve. Many venti-
lators have the capacity to measure P—V curves
and these provide the clinicians with information
on lung dynamics. The P—V curve is considered
to be an accurate non-invasive means to mea-
sure lung dynamics and determine lower and upper
inflection points (LIP and UIP) which will in turn
guide the most appropriate PEEP level.43 P—V
curves provide valuable information particularly
in patients with an ALI and/or ARDS as the P—V
curve is significantly altered compared with normal
subjects.47 This finding was further validated by
Riedel et al. in an experimental study.48 There are
limitations to using the P—V curve to assess recruit-
ment. A study by Henzler et al. determined the
stress index derived from the pressure—time curve
(Paw—t) did not indicate recruitment but rather
hyperinflation.43
Whilst oxygenation may be improved by an
increase in EELV and this could be a reli-
able measure of the efficacy of the manoeu-
vre, contradictory evidence is reported in the
literature.12,46,47,49,50 A study by Lim et al. on
adult ARDS patients demonstrated an increase
in oxygenation following a sigh-style recruitment
manoeuvre that was combined with an extended
period of elevated PEEP.51 Similarly a number of
studies have demonstrated an extended period of
improved oxygenation following a sustained infla-
tion procedure and that PaO2 reliably correlated
with the amount of lung parenchyma taking part
in gas exchange.52—54 Yet a study by Villagra et al.
Lung recruitment
observed that recruitment manoeuvres only pro-
duced a transient increase in PaO2 that did not
extend beyond the recruitment period.15 There
does not appear to be a consistent correlation
between EELV and oxygenation. A plausible expla-
nation is the reduction in cardiac output (CO) that
occurs secondary to the raised intrathoracic pres-
sure associated with recruitment manoeuvres. The
oxygen delivery equation (DO2 ) relies heavily on
CO.55
DO2 = [1.39 × Hb × SaO2 + (0.002 × PaO2 )] × CO
This explanation suggests that transient improve-
ment in oxygenation should not be the primary
goal or sole outcomes to determine the efficacy of
recruitment manoeuvres.
A study by Borges et al. measured the efficacy of
lung recruitment by several methods namely multi-
slice computerised tomography (CT) but also by an
index of PaO2 ± PaCO2 ≥ 400 (at 100% oxygen) which
they determined was a reliable indicator of max-
imum lung recruitment, R = −0.91; p < 0.0001.56
However, this is an impractical method of assess-
ment within the clinical setting given the arduous
task of transporting patients to CT coupled with
the radiation load.56 Additionally, a study by Vieira
et al. demonstrated that the quality of the CT is
important when measuring lung inflation.47 Low
spatial resolution was inaccurate and commonly
underestimated lung inflation compared to high
spatial resolution.47
Keypoint #3
Electrical impedance tomography and high
spatial resolution computed tomography are
reliable methods of measuring regional and
global lung mechanics.
Pulmonary sequelae of recruitment
manoeuvres
Irrespective of method, all recruitment manoeu-
vres carry the potential to cause harm. Elevated
pressures, whilst effective at overcoming threshold
opening pressures may result in barotrauma. Pres-
sure limits are essential. Hyperinflation of easily
distensible regions of the lung is an acknowl-
edged limitation of recruitment manoeuvres.57
This overdistension of alveolar units contributes to
mechanical stress and tissue damage.57 In clini-
cal studies, pressures in adults have been limited
159
to 60 cmH2 O. One subject in Borges study devel-
oped subcutaneous emphysema post-participation
when ventilated with pressures of 60 cmH2 O.56 In
an experimental study by Carvalho et al., hyper-
inflated regions of the lung shifted to normally
aerated areas at PEEP levels of 8 cmH2 O (mean
of 30% decrease) and yet hyperinflated areas still
appeared at zero end expiratory pressure.58 Marini
suggests that greater than 75% of lung units in
ARDS may be too oedematous or infiltrated to
inflate and are neither aeratable nor recruitable at
any pressure.59 PEEP may result in overdistension
rather than recruitment.
An absence of LIP on the P—V curve in Vieira’s
study resulted in lung overdistension rather than
alveolar recruitment in patients with ALI as opposed
to a more homogenous gas distribution in those
patients with an identifiable LIP.47 There are limi-
tations to using P—V curves to assess lung dynamics
as they only present a global picture whereas lung
disease processes and VALI present a heterogenous
distribution of ventilation.13 Additionally, in a study
by Henzler et al., the act of establishing P—V curves
induced pneumothoraces when using the ventila-
tor’s inbuilt software.43
Keypoint #4
Few clinical studies have reported pul-
monary adverse events associated with recruit-
ment manoeuvres.
Systemic sequelae of recruitment
manoeuvres
A number of studies have explored the impact of
recruitment manoeuvres on other systems and the
evidence indicates whilst they do have an impact
on haemodynamics, this effect is transitory.33 A
study by Syring et al. demonstrated a reduction
in CO by 13% following a recruitment manoeu-
vre using PEEP compared to increasing respiratory
rate.60 Dorinsky et al. reported decreased CO out-
put but insignificant effects on regional blood flow
at high PEEP levels for up to 60 min in an experimen-
tal study.61 Similar findings have been reported by
other studies.41—43,61—65
Gut perfusion has also been measured dur-
ing recruitment manoeuvres. A study by Nunes
et al. produced a marked yet transitory impair-
ment in splanchnic circulation for up to 8 min
post-manoeuvre. This consisted of a sustained infla-
tion up to 40 cmH2 O for 20 s.62 In contrast a
160
clinical study by Claesson et al. demonstrated
that lung recruitment manoeuvres involving PIPs
up to 44 cmH2 O did not decrease gastric mucosal
perfusion.63
An experimental study by David et al. aimed
to compare the effect of lung recruitment in
both pressure controlled ventilation (PCV) and high
frequency oscillation ventilation (HFOV) on a num-
ber of physiological measures including systemic
haemodynamics, intracranial pressure, cerebral
perfusion pressure, and organ blood flow.33 They
found that whilst there was a systemic decrease
in blood pressure, organ blood flow was not com-
promised to the brain, kidneys, the jejunum or
heart.33 An overall improvement in oxygenation
was also noted for both modalities of ventilation.33
Translocation of bacteria has also been noted
in two studies employing pressures in excess of
45 cmH2 O without adequate(≥5 cmH2 O) baseline
PEEP.66,67 Circulating cytokines have also been
noted to increase with mechanical ventilation yet
their number is not exaggerated by recruitment
manoeuvres.67
Keypoint #5
Systemic sequelae of recruitment manoeu-
vres are moderate and transient.
Conclusion
Whilst valuable, lung protective ventilation strate-
gies do result in chronic, low level derecruitment
particularly in distal and dependant lung regions.
Consequently, clinicians must consider that recruit-
ment manoeuvres are an essential adjunct to
ventilatory management. Recruitment manoeuvres
are essential to preserve EELV and are most effec-
tive when applied following disconnection of the
ETT from the circuit and following airway suc-
tioning. The optimal method of recruitment that
improves EELV in ventilated patients is yet to
be determined and the clinician should individ-
ualise recruitment per patient. The correlation
between oxygenation and EELV has not been estab-
lished and whether recruitment manoeuvres are
appropriate for all patients is unknown. Haphazard
application of recruitment manoeuvres may cause
harm.
Whether the consistent use of recruitment
manoeuvres will reduce length of ventilation,
length of stay, and improve post-mechanical ven-
tilation lung function is yet to be determined.
J.I. Jauncey-Cooke et al.
Acknowledgment
Thank you to Ms Susan Kellett for her editorial assis-
tance.
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