ORIGINAL RESEARCH article
Front. Med.
Sec. Intensive Care Medicine and Anesthesiology
Volume 12 - 2025 | doi: 10.3389/fmed.2025.1642064
This article is part of the Research TopicAdvanced Monitoring in ARDS: Enhancing Mechanical Ventilation through Innovative TechniquesView all 3 articles
The potential risk of ventilator-induced lung injury from five different PEEP titration techniques in ARDS
Provisionally accepted
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
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The optimal positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) remains uncertain. This study compared the PEEP levels using five distinct titration methods to assess potential ventilator-induced lung injury (VILI).Methods: This study included twenty-one patients with moderate to severe ARDS who were monitored using esophageal balloon manometry and electrical impedance tomography (EIT). A recruitment maneuver followed by decremental PEEP titration was performed. Optimal PEEP(OP) was assessed using five criteria: highest respiratory system compliance (CRS), highest lung compliance (CL), end-expiratory transpulmonary pressure (Ptp_ee_direct ) ≥ 0 cm H2O, elastance-derived end-inspiratory transpulmonary pressure (Ptp_ei_derived) ≤ 25 cm H2O, and EIT-based analysis balancing the degree of overdistention and lung collapse.Results: Significant differences in OP were observed across the methods (p=0.001): CRS 8.0 cmH₂O (8.0,13.9); CL 9.8 cmH₂O (8.0,14.0); Ptp_ee_direct ≥ 0 cmH₂O 14.0 cmH₂O (11.9,17.9); Ptp_ei_derived ≤ 25 cmH₂O 12.0 cmH₂O (10.0,13.9); EIT balancing the degree of overdistention and lung collapse 13.01 cmH₂O (9.88,14.78). The OP guided by Ptp_ee_direct of ≥ 0 cmH2O is significantly higher than OP by the highest CRS(p=0.001) and the highest CL (p=0.002), and met the overdistension criteria, namely plateau pressure > 30 cmH2O and the highest percentage of overdistension by EIT. The PEEP guided by CRS had a higher potential risk of lung collapse, reflected by the negative value of Ptp_ee_direct and a higher percentage of lung collapse by EIT.Transpulmonary pressure-guided PEEP titration yielded higher PEEP levels, while CRSguided PEEP was lower and associated with a higher risk of collapse. Overdistension and collapse varied with the chosen PEEP method. In patients with moderate to severe ARDS, OP can vary depending on the method of assessment.
Keywords: Acute Respiratory Distress Syndrome, Ventilator-Induced Lung Injury, transpulmonary pressure, Electrical impedance tomography, PEEP titration
Received: 05 Jun 2025; Accepted: 13 Aug 2025.
Copyright: © 2025 Sutherasan, Songsomboon, Kulapa, Junhasavasdikul and Theerawit. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Pongdhep Theerawit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
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