Positive end-expiratory pressure titration in acute respiratory distress syndrome-a practical bedside algorithm

Area of Science:

• Critical Care Medicine
• Respiratory Physiology
• Mechanical Ventilation

Background:

• Positive end-expiratory pressure (PEEP) titration for acute respiratory distress syndrome (ARDS) remains debated.
• Heterogeneity in ARDS, co-interventions, and patient recruitability complicate PEEP selection.
• Advanced monitoring for individualized PEEP is limited in availability and outcome evidence.

Purpose of the Study:

• To review evidence for different PEEP setting strategies.
• To propose a practical 5-step bedside algorithm for individualized PEEP titration.
• To guide clinicians in optimizing PEEP using physiology and ventilator data.

Main Methods:

• Narrative review of existing PEEP setting strategies.
• Development of a 5-step algorithm for bedside PEEP individualization.
• Integration of guideline-protective ventilation, recruitability assessment, prone positioning, and rescue therapies.

Main Results:

• The proposed algorithm integrates physiological principles and readily available ventilator parameters.
• It aims to provide a practical approach for clinicians at the bedside.
• The algorithm considers key factors influencing PEEP effectiveness in ARDS.

Conclusions:

• Individualized PEEP titration is crucial for managing mechanically ventilated ARDS patients.
• The proposed algorithm offers a structured, physiology-guided approach to PEEP selection.
• This bedside tool aims to improve PEEP management using accessible data.