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PEEP Titration in ARDS

PEEP Titration in ARDS: ARDS - PEEP Titration Needed → Baseline Ventilator Settings → PEEP Strategy Selection → ARDSNet Low PEEP/FiO2 Table → Monitor Re...

Interactive Decision Tree

Mini Map

Algorithm Steps

  1. ▶
    Start

    ARDS - PEEP Titration Needed

    Setting appropriate PEEP based on severity

    1. ●
      Action

      Baseline Ventilator Settings

      Start with lung protective ventilation

      • Vt: 6 mL/kg PBW
      • RR: adjust for pH
      • Mode: Volume or Pressure targeted
      • Plateau pressure <30 cmH2O
      1. ◆
        Decision

        PEEP Strategy Selection

        Choose based on ARDS severity and recruitability

        1. ●
          Action

          ARDSNet Low PEEP/FiO2 Table

          Standard starting approach

          • FiO2 0.3 → PEEP 5
          • FiO2 0.4 → PEEP 5-8
          • FiO2 0.5 → PEEP 8-10
          • FiO2 0.6 → PEEP 10
          • FiO2 0.7 → PEEP 10-14
          • FiO2 0.8 → PEEP 14
          • FiO2 0.9 → PEEP 14-18
          • FiO2 1.0 → PEEP 18-24
          1. ●
            Action

            Monitor Response to PEEP

            Assess oxygenation and mechanics

            • P/F ratio improvement
            • Plateau pressure (keep <30)
            • Driving pressure (Pplat - PEEP, target <15)
            • Hemodynamics (PEEP can reduce preload)
            • Lung compliance
            1. ●
              Action

              Optimize Driving Pressure

              Target ΔP <15 cmH2O

              • Driving Pressure = Pplat - PEEP
              • Lower driving pressure associated with survival
              • If ↑PEEP increases driving pressure, lung not recruitable
              • Balance oxygenation vs driving pressure
              1. ◆
                Decision

                Recruitment Maneuver?

                Consider if P/F not improving

                • ATS 2017: Conditional recommendation against routine RM
                • May try in select cases
                • Risk of barotrauma, hemodynamic collapse
                1. ●
                  Action

                  Recruitment Maneuver (If Done)

                  Use with caution

                  • Sustained inflation: 30-40 cmH2O x 30-40 sec
                  • Or incremental PEEP (staircase)
                  • Monitor for hemodynamic compromise
                  • Have vasopressors ready
                  • Not routinely recommended
                  1. ✓
                    Outcome

                    PEEP Optimized

                    Continue lung protective ventilation

                2. ●
                  Action

                  Continue PEEP/FiO2 Titration

                  Use table-based approach

                  • Adjust per ARDSNet tables
                  • Daily reassessment
                  • Wean PEEP as FiO2 requirements decrease
                  1. ✓
                    Outcome

                    Consider Rescue Therapies

                    If P/F remains <100 despite optimization

        2. ●
          Action

          ARDSNet High PEEP/FiO2 Table

          For moderate-severe ARDS if recruitable

          • FiO2 0.3 → PEEP 12-14
          • FiO2 0.4 → PEEP 14-16
          • FiO2 0.5 → PEEP 16-18
          • FiO2 0.6 → PEEP 18-20
          • FiO2 0.7 → PEEP 20
          • FiO2 0.8 → PEEP 20-22
          • FiO2 0.9 → PEEP 22
          • FiO2 1.0 → PEEP 22-24

Guideline Source

An Official ATS/ESICM/SCCM Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with ARDS

DOI: 10.1164/rccm.201703-0548STView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • ARDSNet tables are empiric, not individualized
  • High PEEP vs low PEEP depends on recruitability
  • Does not address PEEP with prone positioning
  • Esophageal manometry available at limited centers
  • Driving pressure optimization may be superior but not standardized

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

Global: ARDSNet PEEP tables most widely used

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the PEEP Titration in ARDS?

The PEEP Titration in ARDS is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on An Official ATS/ESICM/SCCM Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with ARDS.

What guideline is the PEEP Titration in ARDS based on?

This algorithm is based on An Official ATS/ESICM/SCCM Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with ARDS (DOI: 10.1164/rccm.201703-0548ST).

What are the limitations of the PEEP Titration in ARDS?

Known limitations include: ARDSNet tables are empiric, not individualized; High PEEP vs low PEEP depends on recruitability; Does not address PEEP with prone positioning; Esophageal manometry available at limited centers; Driving pressure optimization may be superior but not standardized. Individual patient factors may require deviation from these recommendations.

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