# Setting PEEP in patients with COVID-19-related ARDS: a physiological comparison between methods

## TL;DR

This study compares different methods for setting PEEP in patients with ARDS caused by COVID-19, finding that one method reduces lung collapse better than others.

## Contribution

The study introduces a novel comparison of PEEP-setting methods using EIT data in patients with COVID-19-related ARDS.

## Key findings

- Targeting EITCP resulted in higher PEEP levels and less lung collapse compared to other methods.
- EIT-based methods better protect against high overdistension or collapse compared to targeting PL,EE.

## Abstract

Several approaches for setting PEEP in patients with (COVID-19-related) ARDS have been proposed. It is unclear whether a best approach exist, and how the recommended PEEP and resulting transpulmonary pressure, overdistension and collapse relate.

To compare approaches based on electrical impedance tomography (EIT) (including targeting the crossing point of overdistension/collapse curves, EITCP) with targeting positive end-expiratory transpulmonary pressure (PL,EE) and targeting highest respiratory system compliance (CRS).

Post-hoc analysis of 29 patients with COVID-19-related ARDS from cohorts of two Dutch hospitals. Patients underwent a decremental PEEP trial, while EIT data and esophageal pressure data were recorded. We compared the recommended PEEP, as well as resulting PL,EE and amounts of overdistension and collapse at the suggested PEEP.

Targeting EITCP resulted in higher recommended PEEP (14 [12–16] cmH2O) compared to a positive PL,EE (12 [8–14] cmH2O), while highest CRS resulted in intermediate PEEP levels. Individually, the difference between the highest and lowest recommended PEEP level were 6 [4–8] cmH2O. PL,EE at the recommended PEEP was generally higher when targeting EITCP compared to and positive PL,EE (1.4 [0.6–2.1] cmH2O). The amount of collapse was lowest with EITCP (3.0 [2.0–4.0]%) and highest when targeting PL,EE (5.4 [2.0–12.0]%). No significant differences in the amount of overdistension were found. Targeting positive PL,EE resulted in 51% patients with high (> 10%) values for either overdistension or collapse, more than any other method.

Targeting EITCP results in slightly higher recommended PEEP and PL,EE levels compared to positive PL,EE, leading to less collapse, but not more overdistension. EIT-based methods protect better against high values of either overdistension or collapse.

The online version contains supplementary material available at 10.1186/s40635-026-00885-6.