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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...

Pathway Overview

12 steps

Algorithm Steps

12 total

  1. 01Start

    ARDS - PEEP Titration Needed

    Setting appropriate PEEP based on severity

  2. 02Action

    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
  3. 03Decision

    PEEP Strategy Selection

    Choose based on ARDS severity and recruitability

  4. 04Action

    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
  5. 05Action

    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
  6. 06Action

    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
  7. 07Decision

    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
  8. 08Action

    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
  9. 09Outcome

    PEEP Optimized

    Continue lung protective ventilation

  10. 10Action

    Continue PEEP/FiO2 Titration

    Use table-based approach

    • Adjust per ARDSNet tables
    • Daily reassessment
    • Wean PEEP as FiO2 requirements decrease
  11. Path rejoins step 09Shared downstream outcome
  12. 11Outcome

    Consider Rescue Therapies

    If P/F remains <100 despite optimization

  13. 12Action

    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
  14. Path rejoins step 05Shared downstream outcome

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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