PEEP-FiO(2) table versus EIT to titrate PEEP in mechanically ventilated patients with COVID-19-related ARDS

RATIONALE: It is unknown how to titrate positive end-expiratory pressure (PEEP) in patients with COVID-19-related acute respiratory distress syndrome (ARDS). Guidelines recommend the one-size-fits-all PEEP-FiO(2) table. In this retrospective cohort study, an electrical impedance tomography (EIT)-guided PEEP trial was used to titrate PEEP. OBJECTIVES: To compare baseline PEEP according to the high PEEP-FiO(2) table and personalized PEEP following an EIT-guided PEEP trial. METHODS: We performed an EIT-guided decremental PEEP trial in patients with moderate-to-severe COVID-19-related ARDS upon intensive care unit admission. PEEP was set at the lowest PEEP above the intersection of curves representing relative alveolar overdistention and collapse. Baseline PEEP was compared with PEEP set according to EIT. We identified patients in whom the EIT-guided PEEP trial resulted in a decrease or increase in PEEP of ≥ 2 cmH(2)O. MEASUREMENTS AND MAIN RESULTS: We performed a PEEP trial in 75 patients. In 23 (31%) patients, PEEP was decreased ≥ 2 cmH(2)O, and in 24 (32%) patients, PEEP was increased ≥ 2 cmH(2)O. Patients in whom PEEP was decreased had improved respiratory mechanics and more overdistention in the non-dependent lung region at higher PEEP levels. These patients also had a lower BMI, longer time between onset of symptoms and intubation, and higher incidence of pulmonary embolism. Oxygenation improved in patients in whom PEEP was increased. CONCLUSIONS: An EIT-guided PEEP trial resulted in a relevant change in PEEP in 63% of patients. These results support the hypothesis that PEEP should be personalized in patients with ARDS. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-022-04135-5.