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How PEEP Works and Why It Matters: A Comprehensive Guide for Critical Care Nurses


Positive end expiratory pressure, or PEEP, is an important therapy used in mechanically ventilated patients. As critical care nurses, having a strong understanding of PEEP is essential for providing safe, high-quality care.

The Following are guides on How PEEP Works and Why It Matter for Critical Health Workers:

What is PEEP?

PEEP refers to positive pressure applied to the airway at the end of exhalation during mechanical ventilation. It prevents alveolar collapse by keeping airways and alveoli open at end expiration.

In effect, PEEP creates a new functional residual capacity for patients with diseased or unstable lungs.

Purpose of PEEP

The main goals of PEEP are to:

  • Improve oxygenation by recruiting collapsed alveoli
  • Decrease shunting and improve ventilation-perfusion matching
  • Prevent repetitive opening and closing of alveoli to reduce ventilator-induced lung injury

By achieving these effects, PEEP can reduce hypoxemia and provide lung-protective ventilation.

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How Does PEEP Work?

PEEP exerts its effects via increases in functional residual capacity and alveolar recruitment.

The positive pressure keeps alveoli inflated at end expiration when they would normally collapse. This helps prevent atelectasis, improves compliance, and creates more surface area for gas exchange, thereby improving oxygenation.

However, higher levels of PEEP can also lead to over distention of alveoli, barotrauma, reduced venous return, and decreased cardiac output. Finding the optimal, patient-specific PEEP level is therefore crucial.

Indications and Contraindications

PEEP is indicated for conditions causing significant hypoxemia or shunting, including:

  • ARDS
  • Pneumonia
  • Pulmonary edema
  • Atelectasis
  • Chest trauma

There are no absolute contraindications to PEEP. However, use caution in patients with:

  • Hypovolemia: increased intrathoracic pressure can impair venous return
  • Obstructive lung disease: air trapping and hyperinflation can occur
  • Increased intracranial pressure: can further increase ICP

Complications of PEEP

While potentially life-saving, PEEP does carry risks. Nurses must monitor for:

  • Barotrauma and volutrauma
  • Hypotension from decreased venous return
  • Respiratory acidosis from higher CO2 levels
  • Increased peak and plateau pressures
  • Patient-ventilator dyssynchrony

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Setting Optimal PEEP Levels

Determining the optimal PEEP level involves balancing improved oxygenation against potential harms.


  • Start at 5 cm H2O, then increase levels based on continuously monitored oxygenation and plateau pressures
  • Target plateau pressures < 30 cm H2O to avoid barotrauma
  • Check for signs of decreased cardiac output and monitor hemodynamics
  • Assess for patient comfort and dyssynchrony

Additional advanced techniques include electrical impedance tomography, esophageal manometry, and stress index monitoring.

Special Considerations

Certain conditions require special attention regarding PEEP levels:

COPD: Use lower PEEP levels (5 cm H2O or less) to avoid hyperinflation or air trapping.

ARDS: Higher PEEP levels generally indicated but ensure plateau pressures remain < 30 cm

H2O – Obesity: Consider slightly higher PEEP levels compared to normal weight patients.-

Prone Position: Increased PEEP often needed 10-12 cm H2O or higher.

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As a critical therapy for severely ill patients, nurses must have in-depth knowledge of PEEP. Thoughtful application of PEEP with close hemodynamic monitoring can be life-saving, while improper use carries substantial risks.

Determining optimal patient-specific PEEP levels remains complex with many techniques under investigation. Nevertheless, the core principles of balancing improved oxygenation with avoidance of harm can guide nurses in providing the best possible care for ventilated patients.

Also Read:

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Licensure and Credentialing Considerations for International Nurses


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