UMEM Educational Pearls

Title: Stop looking for the "Best PEEP", aim for a "Better PEEP"

Keywords: mechanical ventilation, ARDS, PEEP (PubMed Search)

Posted: 3/24/2015 by John Greenwood, MD (Updated: 11/22/2024)
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Stop looking for the “Best PEEP”, aim for a “Better PEEP”

Mechanical ventilation settings in the patient with acute respiratory distress syndrome (ARDS) need to provide adequate gas exchange and prevent ventilator induced lung injury (VILI). Positive end-expiratory pressure (PEEP) is often prescribed with consideration of the patient’s FiO₂requirement, estimated chest wall compliance, and hemodynamic tolerance.

So what is the best strategy for PEEP prescription?

In a recent review, Gattinoni & colleagues analyzed a number of the recent studies examining PEEP optimization. In this paper, the authors conclude that there is no “Best PEEP,” and regardless of the level chosen there will be some degree of intratidal recruitment-derecruitment and VILI. They go on to recommend a PEEP prescription strategy that reflects the severity of ARDS using the patient’s PaO₂/FiO₂ or P/F ratio.

Mild ARDS (P/F 200 – 300): 5-10 cm H₂O
Moderate ARDS (P/F 100 – 200): 10-15 cm H₂O
Severe ARDS (P/F < 100): 15-20 cm H₂O

Bottom line: There is no “Best PEEP” however, a “Better PEEP” is one that is primarily tailored to the severity of the patient’s ARDS, but also compensates for chest wall resistance and minimizes hemodynamic compromise.

References

Gattinoni L, Carlesso E, Cressoni M. Selecting the 'right' positive end-expiratory pressure level. Curr Opin Crit Care. 2015;21(1):50-7.
ARDSnet PEEP table: http://www.ardsnet.org/system/files/Ventilator%20Protocol%20Card.pdf

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