Adult ARDS on invasive ventilation: set PEEP
Adults only. Severity by PaO2/FiO2 (P/F) on PEEP 5 cmH2O or more: mild >200-300 mmHg, moderate >100-200 mmHg, severe 100 mmHg or less.
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PEEP Titration in ARDS
PEEP Titration in ARDS: Adult ARDS on invasive ventilation: set PEEP → Brain injury or pregnancy: use different gas targets → Lung-protective ventilatio...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Brain injury or pregnancy: use different gas targets
The SpO2 88-95% and pH 7.30 targets below are not safe for these patients.
- Acute brain injury or raised ICP: PaO2 80-120 mmHg and PaCO2 35-45 mmHg; no permissive hypercapnia; neurocritical care input (ESICM 2020)
- Pregnancy: PaO2 70 mmHg or more (SpO2 about 95% or more); avoid permissive hypercapnia; obstetric team and fetal monitoring
- Keep Vt, plateau and PEEP limits; senior ICU decision on the balance
03Action Lung-protective ventilation for all
Adults only. Set this before PEEP titration (ARDSNet protocol).
- Vt 6 mL/kg predicted body weight (PBW); range 4-8 mL/kg PBW
- Plateau pressure 30 cmH2O or less: 0.5 s inspiratory hold, check at least 4-hourly and after each PEEP or Vt change
- PEEP 5 cmH2O minimum. Target SpO2 88-95% or PaO2 55-80 mmHg (not in brain injury or pregnancy)
- RR up to 35/min for pH 7.30-7.45
- PBW: male 50 + 0.91 x (height cm - 152.4); female 45.5 + 0.91 x (height cm - 152.4)
04Warning No prolonged recruitment maneuvers
Give higher PEEP without recruitment maneuvers (ATS 2024).
- Never hold 35 cmH2O or more for 60 s or more, and no staircase or incremental-PEEP maneuvers: higher mortality (ATS 2024, strong recommendation against)
- Brief maneuvers (under 60 s): not routine (ESICM 2023 suggests against)
- Brief maneuver after disconnection or suction: senior clinician only; stop if BP, SpO2 or heart rate falls
05Decision Moderate or severe ARDS (P/F 200 mmHg or less)?
P/F on PEEP 5 cmH2O or more, after the baseline settings.
- If Yes
- Moderate-severe
06Warning Moderate-severe ARDS: check before higher PEEP
Higher PEEP can drop BP and cause barotrauma. Lower PEEP if BP falls, SpO2 falls or plateau goes above 30 cmH2O.
- Shock, hypotension or hypovolaemia: resuscitate first; raise PEEP in steps with continuous arterial BP monitoring
- RV failure or acute cor pulmonale: get an echo; higher PEEP can worsen RV failure; senior decision
- Pneumothorax, bronchopleural fistula, raised ICP, unilateral lung disease or severe airflow obstruction: senior decision
07Action Moderate-severe ARDS: higher PEEP/FiO2 table
ARDSNet higher PEEP table. ATS 2024 suggests higher PEEP without recruitment maneuvers (conditional). Use the lowest step that reaches SpO2 88-95%.
- FiO2 0.3: PEEP 5-14 cmH2O (steps 5, 8, 10, 12, 14)
- FiO2 0.4: PEEP 14-16 cmH2O
- FiO2 0.5: PEEP 16-18 cmH2O
- FiO2 0.5-0.8: PEEP 20 cmH2O
- FiO2 0.8: PEEP 22 cmH2O
- FiO2 0.9: PEEP 22 cmH2O
- FiO2 1.0: PEEP 22-24 cmH2O
- Other trial methods (experienced units): PEEP to the highest safe plateau pressure, or PEEP at best compliance; no recruitment maneuver
08Action After each PEEP change: check the response
Check mechanics, BP and oxygenation.
- Plateau 30 cmH2O or less. If higher: lower Vt in 1 mL/kg steps (minimum 4 mL/kg PBW)
- Driving pressure (plateau minus PEEP): aim 15 cmH2O or less (observational data). A rise after a PEEP increase suggests overdistension
- BP, heart rate and lactate; echo if BP falls
- SpO2 88-95%, P/F and compliance
09Decision Harm after the PEEP change?
MAP below 65 mmHg or new vasopressor need, SpO2 falls, new pneumothorax, driving pressure rises, or plateau above 30 cmH2O despite Vt 4 mL/kg PBW.
- If Yes
- Harm
10Action Harm: go back to the last safe PEEP
Lower PEEP step by step, treat the cause, then check the response again. Get senior ICU review.
- Hypotension: lower PEEP; fluid or vasopressor as indicated; echo for RV failure
- Pneumothorax: drain; then use the lowest effective pressures
- Driving pressure rose with PEEP: lung is not recruiting; use lower PEEP
- Path rejoins step 08Shared downstream outcome
If No- No harm
11Decision P/F below 150 mmHg after stabilisation?
On PEEP 5 cmH2O or more, after a period of lung-protective ventilation and PEEP adjustment (ESICM 2023).
- If Yes
- P/F <150
12Warning P/F below 150 mmHg: check before prone position
Proning needs a trained team of 3-5 staff. Prone only after these checks.
- Unstable spine fracture: do not prone (absolute contraindication)
- Raised ICP: prone only if ICP is not significantly raised, with ICP monitoring; neurocritical care decision (ESICM 2020)
- Pregnancy, open chest or abdomen, recent sternotomy, massive haemoptysis or unstable BP: experienced team and senior decision
13Action P/F below 150 mmHg: prone ventilation
If no contraindication. Start early, sessions of 16 h or more each day (ESICM 2023, strong recommendation). Keep lung-protective settings.
- Continue even if oxygenation does not improve at first
- Stop sessions when P/F is 150 mmHg or more with PEEP 10 cmH2O or less and FiO2 0.6 or less, 4 h after return to supine (PROSEVA)
- Early severe ARDS (P/F below 150 mmHg): consider a neuromuscular blocker, only with deep sedation; not routine (ATS 2024, SCCM 2026 conditional; ESICM 2023 strong against routine infusion)
- Talk early to an ECMO centre if oxygenation is getting worse
14Decision Severe despite prone and optimal ventilation (EOLIA criteria)?
P/F below 50 mmHg for more than 3 h, or below 80 mmHg for more than 6 h, or pH below 7.25 with PaCO2 60 mmHg or more for more than 6 h (RR 35/min, plateau 32 cmH2O or less).
- If Yes
- EOLIA criteria met
15Outcome EOLIA criteria met: refer to an ECMO centre now
VV-ECMO for selected severe ARDS in an ECMO centre (ESICM 2023 strong; ATS 2024 conditional). Refer early: more than 7 days of high-pressure ventilation or bleeding risk can rule out ECMO; the ECMO centre decides.
If No- Not met
16Outcome Continue lung-protective ventilation
Reassess PEEP, mechanics and oxygenation at least daily.
If No- P/F >=150
17Action P/F 150 mmHg or more: continue and wean
Reassess PEEP, mechanics and oxygenation at least daily.
- Keep Vt 6 mL/kg PBW and plateau 30 cmH2O or less
- As oxygenation improves, step FiO2 and PEEP down the same table
- Screen daily for a breathing trial when FiO2 0.4 or less and PEEP 8 cmH2O or less
- If P/F falls below 150 mmHg: reassess for prone ventilation
- Path rejoins step 16Shared downstream outcome
If No- Mild
18Action Mild ARDS (P/F >200 mmHg): lower PEEP/FiO2 table
ARDSNet lower PEEP table. No proven benefit of higher PEEP in mild ARDS (ATS 2024). Use the lowest step that reaches SpO2 88-95%. If P/F falls to 200 mmHg or less, change to the higher PEEP table after its cautions.
- FiO2 0.3: PEEP 5 cmH2O
- FiO2 0.4: PEEP 5-8 cmH2O
- FiO2 0.5: PEEP 8-10 cmH2O
- FiO2 0.6: PEEP 10 cmH2O
- FiO2 0.7: PEEP 10-14 cmH2O
- FiO2 0.8: PEEP 14 cmH2O
- FiO2 0.9: PEEP 14-18 cmH2O
- FiO2 1.0: PEEP 18-24 cmH2O
- Path rejoins step 08Shared downstream outcome
Guideline Source
An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline (2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Higher PEEP can harm patients with shock, RV failure, barotrauma, raised ICP, unilateral lung disease or severe airflow obstruction.
- No single best PEEP method: the ATS 2024 higher-PEEP suggestion is conditional, and ESICM 2023 makes no recommendation for either PEEP/FiO2 table.
- Brief recruitment maneuvers, oesophageal pressure and EIT-guided PEEP have uncertain evidence and are not covered.
- Does not cover NIV or high-flow oxygen, corticosteroids, or ECMO management.
Contraindicated Populations
pediatric
Applicable Regions
AUUSEUGlobal
AU: Australian blood gases report PaO2 in mmHg, as used here. For ECMO, contact the regional ECMO referral centre early.
Global: PEEP/FiO2 tables from the NIH NHLBI ARDS Network mechanical ventilation protocol (2008).
Version 2Next review: 2027-09-30
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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 Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline (2024).
What guideline is the PEEP Titration in ARDS based on?
This algorithm is based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline (2024) (DOI: 10.1164/rccm.202311-2011ST).
What are the limitations of the PEEP Titration in ARDS?
Known limitations include: Adults only. Higher PEEP can harm patients with shock, RV failure, barotrauma, raised ICP, unilateral lung disease or severe airflow obstruction.; No single best PEEP method: the ATS 2024 higher-PEEP suggestion is conditional, and ESICM 2023 makes no recommendation for either PEEP/FiO2 table.; Brief recruitment maneuvers, oesophageal pressure and EIT-guided PEEP have uncertain evidence and are not covered.; Does not cover NIV or high-flow oxygen, corticosteroids, or ECMO management.. Individual patient factors may require deviation from these recommendations.
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