What are the main strategies for PEEP titration in ARDS?

Three main approaches: (1) ARDSnet PEEP/FiO2 tables — standardized, low-PEEP or high-PEEP tables matching PEEP to FiO2 for oxygenation targets; (2) Driving pressure minimization — titrate PEEP to achieve the lowest driving pressure (ΔP), reflecting best compliance; (3) Decremental PEEP trial after recruitment maneuver — start at high PEEP and reduce until compliance drops or derecruitment occurs. Electrical impedance tomography or esophageal manometry can guide individualized titration in complex cases.

Does higher PEEP always improve outcomes in ARDS?

Not universally. Meta-analyses (EXPRESS, LOVS trials; Briel et al. meta-analysis) show higher PEEP reduces mortality in moderate-severe ARDS (P/F <200) but may be harmful in mild ARDS. Individual response varies: patients with high recruitability (consolidated, dependent atelectasis) benefit most. Patients with low recruitability (mainly overdistension) may experience harm. Personalized assessment of recruitability is recommended before applying high PEEP strategies.

PEEP Optimization Calculator

Guide PEEP titration in ARDS using ARDSnet PEEP/FiO2 tables, driving pressure minimization, or stress index principles to balance recruitment and overdistension.

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Frequently Asked Questions

What are the main strategies for PEEP titration in ARDS?

Does higher PEEP always improve outcomes in ARDS?