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👉🏼 From Chongqing Medical University, Chongqing, China, comes the study by Duan J. et al., published on the last day of April 2025 in Intensive Care Medicine.

👉🏼 This is the first randomized controlled trial, conducted across seven ICUs, to compare the effects of applying high PEEP (10 cmH₂O) versus low PEEP (5 cmH₂O), both with the addition of pressure support in patients with acute hypoxemic respiratory failure receiving noninvasive ventilation (NIV) via oronasal or nasal masks.

👉🏼 Inclusion criteria were: age between 16 and 85 years, use of a dedicated noninvasive ventilator, PaCO₂ ≤ 50 mmHg, PaO₂/FiO₂ ≤ 300 mmHg, anticipated NIV duration >12 hours, and preserved consciousness (Kelly score ≤ 3 or Glasgow Coma Scale [GCS] ≥ 13).

👉🏼 The primary outcome was the rate of NIV failure, defined as intubation, death, or therapy withdrawal (i.e., refusal of intubation despite clinical indication).

👉🏼 Between January 2022 and August 2024, 380 patients (190 per group) were enrolled in an intention-to-treat analysis. Most patients had pneumonia or ARDS.

🧐 NIV failure occurred in 43% (82/190) of patients in the low PEEP group and 32% (61/190) in the high PEEP group (absolute difference: 11.1%, 95% CI: 1.3–20.5%, p = 0.034).

🧐 Within the first 72 hours after randomization, the low PEEP group exhibited lower PaO₂/FiO₂ ratios (mean difference: −31 mmHg, 95% CI: −38 to −24). A slightly higher tidal volume (VT) was also observed in the low PEEP group compared to the high PEEP group (+0.8 mL/kg).

🧐 In a mediation analysis, the authors found that 77% of the total effect of PEEP on NIV failure was mediated through PaO₂/FiO₂, while 14% was mediated through VT. However, this effect should be interpreted with caution, as the study lacked sufficient statistical power to detect a significant difference in the effect of VT.

😎 Want to read the full article? Click the link below:

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/10.1007/s00134-025-07902-4