Positive end-expiratory pressure in pediatric acute respiratory distress syndrome: a narrative review.

BACKGROUND AND

OBJECTIVE

Pediatric acute respiratory distress syndrome (PARDS) is associated with substantial morbidity and mortality. Positive end-expiratory pressure (PEEP) can support alveolar recruitment, improve oxygenation, and mitigate ventilator-induced lung injury (VILI). Despite its central role in lung-protective ventilation, evidence to guide PEEP titration in PARDS remains limited. This review summarizes physiologic principles, existing evidence, and bedside strategies for PEEP management in children.

METHODS

We performed a narrative review using PubMed from 1967 to 2025, limited to English-language studies. Search terms included "pediatric acute respiratory distress syndrome", "positive end-expiratory pressure", "PEEP", "positive-pressure respiration", "mechanical ventilation", "pressure-volume curves", "electrical impedance tomography", "esophageal manometry", "stress index", and "ventilator-induced lung injury". Reference lists from key publications and guidelines were also screened.

KEY CONTENT AND FINDINGS: Among available strategies, utilization of the low PEEP:FiO2 table from the ARDSnet study has the strongest evidence and is simple to apply at the bedside. Other approaches, such as compliance-based maneuvers, oxygenation-guided incremental-decremental maneuvers, stress index, pressure-volume curves, chest imaging, esophageal manometry, and electrical impedance tomography (EIT) lack robust pediatric outcome data. Of these methods for PEEP titration, esophageal manometry and EIT hold significant promise.

CONCLUSIONS

Evidence supports maintaining PEEP at or above ARDSNet lower-table recommendations with close attention to physiologic response. Adjunctive monitoring with esophageal manometry or EIT may help balance recruitment and overdistension, but pediatric-specific trials are needed to define best practice. Standardized multicenter studies will be essential to establish evidence-based PEEP strategies in PARDS.