Standardized Lung Recruitment and Positive End-expiratory Pressure Titration in Acute Respiratory Distress Syndrome

Acute Respiratory Distress Syndrome (ARDS) is characterized by diffuse alveolar injury, refractory hypoxemia, and high mortality. Lung recruitment maneuvers (RMs) aim to reopen collapsed alveoli and improve oxygenation, while positive end-expiratory pressure (PEEP) titration prevents decruitment and maintains alveolar stability. This protocol outlines five clinically feasible RM strategies: sigh, sustained inflation, stepwise PEEP recruitment, APRV-based recruitment, and prone positioning-assisted recruitment. Each maneuver is described with step-by-step procedures, parameter settings, monitoring targets, and termination criteria. Additionally, we present a structured approach to PEEP maintenance and de-escalation based on respiratory mechanics, gas exchange, and bedside imaging (e.g., Static Compliance, Electrical Impedance Tomography, or lung ultrasound). Dynamic assessment of oxygenation and compliance helps identify optimal PEEP and supports lung-protective ventilation. The protocol prioritizes patient safety, with criteria for preparation, exclusion, and real-time monitoring. This comprehensive guide supports standardized and individualized implementation of RMs and PEEP strategies in ARDS patients across critical care settings.