To the Editor.—
The article by Stringfield et al (235:744, 1976) points out the difficulty of the differential diagnosis of pneumoperitoneum in a patient requiring ventilatory support and positive end-expiratory pressure (PEEP). All three cases demonstrated the pulmonary barotrauma (pneumothorax, pneumomediastinum, and subcutaneous emphysema) common after controlled ventilation with PEEP. Since pneumoperitoneum is also a sequela, its appearance soon after one of the aforementioned complications makes it extremely likely that it is a result of pulmonary barotrauma rather than ruptured viscus. We have seen this on three occasions recently in our own institution, all initially due to pulmonary causes.In addition, these problems are more likely with controlled ventilation than with intermittent mandatory ventilation (IMV). In fact, using the combination of low IMV rate or CPAP, our incidence of pulmonary barotrauma is no higher on PEEP greater than 20 mm Hg than when it is less than 20 mm Hg.
Gallagher TJ. Pneumoperitoneum and Mechanical Ventilation. JAMA. 1976;235(26):2814. doi:10.1001/jama.1976.03260520014009
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