Abstract

Positive End-Expiratory Pressure (PEEP) is a critical component of mechanical ventilation, particularly in managing acute respiratory distress syndrome (ARDS) and other forms of hypoxemic respiratory failure. Choosing the optimal PEEP is essential to improve oxygenation, prevent alveolar collapse, and minimize ventilator-induced lung injury (VILI). However, determining the most appropriate PEEP level involves a balance between maintaining alveolar recruitment and avoiding overdistension, which can lead to barotrauma, hemodynamic compromise, and impaired gas exchange.

Several strategies guide PEEP selection, including using oxygenation-based protocols, driving pressure assessment, and advanced imaging techniques like electrical impedance tomography (EIT) or CT scans to evaluate lung recruitment. Individualized approaches, such as titration based on compliance, stress index, or esophageal pressure monitoring, are gaining prominence to optimize lung mechanics while minimizing strain. High PEEP strategies may benefit patients with severe ARDS, enhancing recruitment, but may not be suitable for all, particularly those with focal lung involvement or hemodynamic instability.

Clinical trials and guidelines suggest that the choice of PEEP should be patient-specific, taking into account factors such as lung morphology, disease progression, and comorbidities. Current conscious underscores the importance of a tailored approach in selecting PEEP, integrating bedside tools and multidisciplinary expertise to achieve the best outcomes for critically ill patients.