What is your approach to PEEP titration in the management of a morbidly obese patient with ARDS?

Unfortunately, there is no definitive evidence on how to best adjust positive end-expiratory pressure (PEEP) in morbidly obese patients with acute respiratory distress syndrome (ARDS) as patients with a body mass index (BMI) of greater than 35 kg/m² were excluded from most of the large clinical trials of different PEEP strategies in ARDS. However, there are certain physiologic considerations and practice patterns for this patient population that are worth considering at the bedside.

Patients with obesity are prone to have atelectasis from the increased weight of the chest wall and abdominal pressure and may need more PEEP to overcome this atelectasis. A secondary analysis of the AVEOLI trial did find that in patients with a BMI of 30 to 35 ...