Recruitment and titrated positive end-expiratory pressure in acute respiratory distress—have we reached the ceiling?

Acute respiratory distress (ARDS) is a serious medical condition having significant mortality, the management of which hinges primarily on appropriate ventilator management. The different aspects of management have been a matter of intense research over the last several decades which have led to better understanding of the disease process as well as periodic modifications in ventilator strategies. Over the years, the two aspects of ventilator strategies that have been accepted as standard-of-care are low tidal volume (LTV) strategy and suitable high positive end expiratory pressure (PEEP) ventilation. However, the exact “quantum” of PEEP has been ardently debated and has not been yet determined even after scores of trials. The evidence in favour of either an arbitrary “higher” or “lower” PEEP has been largely equivocal.