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| PEEP | |
|---|---|
| Name | PEEP |
| Caption | Positive end-expiratory pressure setup on a mechanical ventilator |
| Specialty | Pulmonology; Critical care medicine |
| Introduced | 1960s |
PEEP
Positive end-expiratory pressure (PEEP) is a ventilatory parameter used in invasive and noninvasive respiratory support that maintains airway pressure above atmospheric pressure at end expiration. In acute respiratory failure, acute respiratory distress syndrome (ARDS), and perioperative care, PEEP is adjusted to improve oxygenation, prevent alveolar collapse, and modify lung mechanics. Clinicians apply PEEP in settings involving mechanical ventilators from manufacturers such as Maquet, Drägerwerk, and GE Healthcare and consider evidence from trials conducted by groups including the ARDS Network, EuroELSO, and investigators publishing in The New England Journal of Medicine.
PEEP is defined as the positive pressure maintained in the airways at the end of passive expiration while a patient is connected to a ventilator such as models by Philips Respironics or Hamilton Medical. It differs from inspiratory pressure modes like pressure-controlled ventilation used in protocols endorsed by societies such as the American Thoracic Society, European Respiratory Society, and Society of Critical Care Medicine. Commonly reported values range from minimal levels (e.g., 2–5 cmH2O) used in postoperative care after procedures at centers like Mayo Clinic to higher levels (≥10 cmH2O) used in severe hypoxemia managed at institutions like Massachusetts General Hospital. PEEP interfaces with adjuncts including recruitment maneuvers popularized in studies from Johns Hopkins Medicine and adjunct therapies such as prone positioning implemented following trials from King's College Hospital.
PEEP is applied in invasive ventilation modes delivered via endotracheal tubes placed using techniques standardized by American Academy of Otolaryngology–Head and Neck Surgery and in noninvasive interfaces like masks produced by ResMed and Respironics. In ARDS, multicenter trials from the ARDS Network and investigators at Guy's and St Thomas' NHS Foundation Trust examined higher versus lower PEEP strategies. In cardiothoracic surgery at Cleveland Clinic, PEEP is used to prevent atelectasis after procedures such as coronary artery bypass grafting reported in cohorts from Mount Sinai Hospital. Neonatal intensive care units at Boston Children's Hospital and Royal Women's Hospital use PEEP (often termed CPAP in neonates) to manage respiratory distress syndrome described in guidelines from American Academy of Pediatrics.
PEEP increases functional residual capacity by recruiting collapsed alveoli, shifting pressure–volume relationships first characterized in classic physiologic work by Alfred F. Cohn and later expanded in reviews in Lancet Respiratory Medicine. By modifying transpulmonary pressure, PEEP influences lung strain and stress studied in animal models at Institut Pasteur and Max Planck Institute for Heart and Lung Research. PEEP also alters hemodynamics through effects on venous return and right ventricular afterload highlighted in investigations at Cleveland Clinic Foundation and summarized in guidelines from European Society of Cardiology when discussing interactions with cardiopulmonary physiology during ventilatory support.
Clinicians monitor PEEP directly on ventilator displays and indirectly via parameters such as plateau pressure and driving pressure; these techniques are discussed in methodology papers from Harvard Medical School and Imperial College London. Esophageal manometry, popularized in studies from Sorbonne University and University of California, San Francisco, provides estimates of pleural pressure to derive transpulmonary pressure and guide individualized PEEP. Imaging modalities including computed tomography used at Johns Hopkins Hospital and bedside lung ultrasound techniques developed at University of Barcelona help assess recruitability. Quality metrics from multicenter registries such as International Severe Acute Respiratory and Emerging Infection Consortium inform monitoring practices.
PEEP titration strategies include fixed PEEP–FiO2 tables used in ARDSNet protocols, decremental recruitment maneuvers evaluated in trials from University of Toronto, and personalized approaches using driving pressure minimization advocated by researchers at University College London. Tools for optimization include electrical impedance tomography employed in studies at Aalborg University Hospital and computer models developed by groups at MIT and ETH Zurich. Protocols combining PEEP with adjuncts such as low tidal volume strategies from the ARDS Network and prone positioning protocols from Royal Brompton Hospital form integrated care bundles used in ICUs worldwide.
Excessive PEEP can cause barotrauma (e.g., pneumothorax), hemodynamic compromise from decreased venous return, and overdistension leading to ventilator-induced lung injury—risks quantified in randomized trials at Vanderbilt University Medical Center and observational cohorts from Stanford Health Care. Contraindications or cautions include untreated tension pneumothorax and certain neurosurgical situations described in practice statements from American Association of Neurological Surgeons. Monitoring for complications employs chest radiography protocols standardized at Royal Infirmary of Edinburgh and hemodynamic assessment techniques taught in courses by European Society of Intensive Care Medicine.
PEEP concepts emerged from mid-20th-century work on oxygen therapy and mechanical ventilation, with early clinical adoption following reports from centers such as Beth Israel Deaconess Medical Center and historical summaries in archives at Wellcome Trust. Landmark randomized controlled trials and meta-analyses published in outlets like The Lancet, Critical Care Medicine, and Journal of the American Medical Association shaped practice, including pivotal contributions by the ARDS Network and international collaborations at World Health Organization–affiliated studies. Ongoing research continues across academic hubs including Yale School of Medicine, University of Sydney, and Peking University Health Science Center.