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

Positive end-expiratory pressure (PEEP) selection and titration is a longstanding debate in management of mechanically ventilated patients with acute respiratory distress syndrome (ARDS). Although multiple strategies have been tested, heterogeneity in ARDS physiology, co-interventions, and variable recruitability have limited clear conclusions. Advanced monitoring may support individualized titration, but availability and outcome evidence remain limited. In this article we present a narrative review of the evidence behind different PEEP setting strategies and propose a practical bedside algorithm in 5 steps to individualize PEEP settings. It incorporates guideline-protective ventilation, assessment of recruitability, prone position and consideration of rescue therapies. The proposed algorithm is guided by physiology and readily available ventilator-derived parameters, intended to be used by any clinician at the bedside.