Setting and Titrating Positive End-Expiratory Pressure

Although maintaining some amount of positive end-expiratory pressure (PEEP) seems essential, selecting and titrating a specific level for patients with ARDS remains challenging despite extensive research on the subject. Although an "open lung" approach to ventilation is popular and has some degree of biological plausibility, it is not without risk. Furthermore, there is no clear evidence-based guidance regarding initial PEEP settings or how to titrate them early in the course of the illness. Many busy clinicians use a "one-size-fits-all" approach based on local medical culture, but an individualized approach has the potential to offer significant benefit. Here we present a pragmatic approach based on simple measurements available on all ventilators, focused on achieving balance between the potential risks and benefits of PEEP. Acknowledging "best PEEP" as an impossible goal, we aim for a straightforward method to achieve "better PEEP."