Positive end-expiratory pressure in acute respiratory distress syndrome; where have we been, where are we going?

PEEP setting in ARDS





ARDS, Lung compliance, Oxygenation, PEEP, Recruitment, Respiratory system compliance


ARDS is a heterogenous syndrome with a high mortality rate and limited therapeutic strategies. PEEP is routinely applied to these patients as a part of a protective lung ventilation strategy because getting it right helps optimize respiratory system compliance and improve oxygenation. However, if the PEEP is too low or too high, it may cause harm. Large clinical trials, focusing on patients with ARDS, have generally compared strategies designed to deliver low PEEP with those designed to deliver higher PEEP. No superior strategy has emerged, perhaps because these studies did not stratify patients based on their likely response to high or low PEEP. Nevertheless, the best strategy to identify optimal PEEP remains controversial, despite many large studies over the past 50 years. In the modern era of personalized medicine, perhaps our PEEP strategy should not be high PEEP or low PEEP but individualized PEEP. In this manuscript, we review the physiological effects of PEEP and the various methods studied and available to determine optimal PEEP at the bedside, providing a guide for physicians who regularly manage mechanically ventilated patients and highlighting new avenues for research. 

Author Biographies

Ross Callum Freebairn, Intensive Care Unit, Hawke’s Bay Hospital, Hastings, New Zealand




Yeong Shiong Chiew, School of engineering, Monash University Malaysia, Subang Jaya, Malaysia



J. Geoffrey Chase, Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand



Matthew Edward Cove, Department of Medicine, National University Hospital, Singapore, Singapore




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How to Cite

Radhi SS, Freebairn RC, Chiew YS, Chase JG, Cove ME. Positive end-expiratory pressure in acute respiratory distress syndrome; where have we been, where are we going? : PEEP setting in ARDS. Clin Crit Care [Internet]. 2023 Jul. 7 [cited 2024 Jun. 24];31(1):2023:e0011. Available from: https://he02.tci-thaijo.org/index.php/ccc/article/view/262904



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