I understand that if a patient is ventilated in a controlled mode (AC-VC) or (AC-PC) you temporarily switch them over to PSV mode and complete recruitment. But what if they are already in PSV mode and on higher levels of pressure support. For example, a patient is on a PEEP of 10 and Pressure Support of 16. What is the best way to do recruitment on them with 30 PEEP x 30 seconds?

Melp,
Lung recruitment maneuvers can be effective means of improving oxygenation at least temporarilly in certain cases. They should not be done without a specific policy to support you in the process. There are many different ways of applying the general concepts of this manuever. There is potential side effects and you need to be clearly aware of your goals, potential side effects and steps in the process. I would not execute this unless you have educated yourself and have the support of the patient's physician and management of the RT department. Generally speaking most facilities I have communicated with that do this use a 30cm for 30 seconds or a 40cm for 40 second manuever. With the 30 for 30 some places will add 10 cm of PS on top, but with the 40 for 40 the patient has to be pretty sedated or will not tolerate. Adding PS on a 40 cm PEEP maneuver will probably not add much in VT and you are into some pretty dangerous pressure ranges I would think. Once you have completed a recruitment maneuver it is very important to return the PEEP to a level that maintains most of the recuitmemt gain. So it should be lowered back incrementally based on the specific steps in the procedure. There are other facilities that utilize prolonged periods of Phigh in APRV or insp pressure in PCV with high Plow or PEEPs. With the experiences I have had in the last couple of years I believe the best form of lung recruitment is high levels of continuous negative pressure (CNEP) via Biphasic Cuirass Ventilator use along with PPV. This can safely be extended for prolonged periods without shutting down cardiac output as would a 40 for 40 or other standard positive pressure LRM. These devices are not very common yet, but I have seen some dramatic improvements with this thechnique.