What if the Intensive Care Unit Abandoned the Physiology Myth—The Case of “Physiological PEEP”

Abstract

There is something deeply appealing about the concept of "physiological positive end-expiratory pressure (PEEP)" because it sounds scientific, natural, and evidence-based. The rationale for physiological PEEP is glottic closure at the end of expiration, which helps in preventing alveolar collapse and optimizing gas exchange. However, the translation of physiological PEEP to a minimum preset PEEP in mechanically ventilated patients is standard practice, though it lacks evidence. Moreover, PEEP is not innocuous in positive-pressure ventilation and can cause harm by altering respiratory and cardiovascular mechanics. We present a viewpoint challenging the dogma of the application of "physiological PEEP" during invasive mechanical ventilation. The PEEP, like any other ventilation setting, should be based on pathology and lung mechanics and needs to be individualized.