Decremental PEEP titration: a step away from the table.

The setting of PEEP in patients with ARDS has become a standard of practice for nearly 46 years.1 One of the more widely used methods in current practice for PEEP selection is the ARDS Network PEEP/FIO2 table. 2 This table guides the clinician to increase or decrease PEEP and FIO2 based on oxygenation. The low-to-modest levels of PEEP utilized throughout the table have been challenged in 2 studies that randomized patients to receive mechanical ventilation with 6 mL/kg of tidal volume (VT) with the traditional PEEP table or a higher PEEP table.3,4 These studies failed to demonstrate an improvement in clinical outcomes. A systematic review and meta-analysis of high PEEP in ARDS published in RESPIRATORY CARE found no improvement in 28 day mortality.5 The meta-analysis raised some interesting points related to PEEP selection methods used in the included studies; most intriguing is that perhaps using a table to set PEEP has the potential to worsen ventilator-induced lung injury in some patients, rather than provide benefit. Currently, the appropriate level and best methods to select PEEP for ARDS remain unclear. This uncertainty should not discourage PEEP studies, rather it should encourage clinicians to study methods of selecting PEEP based on variables other than oxygenation guided by a table.