PEEP and alveolar recruitment after 60 years of acute respiratory distress syndrome.

Authors

Domenico Luca Grieco, Remì Coudroy, Annemijn H Jonkman, Ling Liu, Francesca Collino, Luca S Menga, Tommaso Rosà, Glasiele Alcala, Katerina Vaporidi, Irene Telias, Luigi Camporota, V Marco Ranieri, Massimo Antonelli, Laurent Brochard, Salvatore M Maggiore

Published in

Intensive care medicine. Jun 22, 2026. Epub Jun 22, 2026.

Abstract

Positive end-expiratory pressure (PEEP) remains a cornerstone of acute respiratory distress syndrome management. However, randomized trials of PEEP strategies have yielded conflicting results, reflecting inter-individual heterogeneity. PEEP-induced alveolar recruitment enhances lung protection by redistributing tidal volume over a larger functional lung and reducing atelectrauma and bronchiolotrauma. Conversely, in poorly recruitable lungs, PEEP predominantly increases stress in already aerated regions, potentially exacerbating ventilator-induced lung injury and cardiovascular compromise. The net effect of PEEP reflects a patient-specific balance between recruitment and overdistension, shaped by hemodynamic tolerance. Clinical markers traditionally used for assessing PEEP response (gas exchange, compliance, and driving pressure), while informative at a population level, remain unreliable for clinical decision-making at the individual level. With the exception of specific subgroups (e.g., obesity), patients with PaO₂/FiO₂ > 200 mmHg are unlikely to have substantial alveolar collapse amenable to recruitment and can be managed with lower PEEP (e.g., 5-8 cmH₂O) facilitating transition to assisted ventilation. In contrast, higher PEEP is more likely to benefit patients with PaO₂/FiO₂ ≤ 200 mmHg, in whom a physiologically grounded framework should begin with assessment of lung recruitability (e.g., computed tomography, gas recruitment indices). This should account for airway closure, since PEEP below the airway opening pressure does not modify lung volume and may confound respiratory mechanics interpretation. In patients with significant recruitability, PEEP titration should integrate global measures (plateau pressure, stress index) with regional monitoring (electrical impedance tomography, transpulmonary pressure) when available. Conversely, poorly recruitable patients are unlikely to benefit from higher PEEP and can be managed with lower levels.

PMID:
42329250
Bibliographic data and abstract were imported from PubMed on 22 Jun 2026.

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