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Duan et al recently published in Intensive Care Medicine the results of a trial looking at a PEEP of 5 cm H2O vs 10 cm H2O and impact on failure rate (progression to intubation) when using non-invasive ventilation (NIV). In their trial, the high PEEP group had a lower rate of intubation (32% vs 43%), and this was statistically significant. It is important to note that they excluded patients whose indication for NIV was heart failure, asthma, or COPD exacerbation.
Ultimately, how to choose the right PEEP is a very complex question and requires tailoring to your patient's physiology and clinical circumstances. For example, hypercarbic patients may benefit more from a maximization of their driving pressure (Pplat - PEEP), which can involve lowering their PEEPs, especially when trying to avoid gastric insufflation (remember, pressures of 30 cm of H2O or higher are very likely to open the LES).
Bottom Line: PEEP and other vent settings should be tailored to the patient's pathophysiology, but this trial suggests that in hypoxemic patients not getting NIV for heart failure, asthma, or COPD exacerbation, a higher PEEP (10 vs 5) may reduce the risk of intubation.
References
Duan, J., Liu, X., Shu, W. et al. Low versus high positive end expiratory pressure in noninvasive ventilation for hypoxemic respiratory failure: a multicenter randomized controlled trial. Intensive Care Med (2025). https://doi-org.proxy-hs.researchport.umd.edu/10.1007/s00134-025-07902-4