Positive end-expiratory pressure as a potential modulator of patient-ventilator interaction: A physiological perspective

Adrian Gallardo

Abstract

Background

Patient–ventilator dyssynchrony is a frequent and clinically relevant phenomenon during mechanical ventilation and has been associated with increased work of breathing, longer duration of ventilation, and worse outcomes. Although positive end-expiratory pressure (PEEP) is a cornerstone of ventilatory management to improve oxygenation and alveolar stability, its potential role in modulating of patient–ventilator interaction patterns and dyssynchrony has received comparatively little attention.

Objective

To provide a narrative review of the physiological mechanisms by which PEEP may influence patient–ventilator interaction patterns and dyssynchronies, integrating the available clinical and experimental evidence, including indirect data derived from studies on respiratory mechanics, auto-PEEP, and ventilatory interaction.

Methods

A non-systematic narrative review of the literature was conducted, focusing on studies addressing patient–ventilator interaction, auto-PEEP, respiratory mechanics, and the clinical consequences of dyssynchrony. When direct evidence linking PEEP to specific patterns of dyssynchrony was lacking, physiological inferences were drawn from related studies, and the rationale for these extrapolations is explicitly discussed.

Results

PEEP influences key determinants of patient–ventilator interaction, including end-expiratory lung volume, transpulmonary pressure, inspiratory threshold load, and expiratory time. Appropriately titrated PEEP may reduce ineffective efforts by partially counterbalancing intrinsic PEEP, stabilizing alveolar units, and attenuating excessive inspiratory effort. Conversely, excessive or insufficient PEEP may exacerbate dyssynchrony by promoting air trapping, flow limitation, or premature cycling. Although most of the available evidence is indirect, consistent physiological principles support a significant modulatory role of PEEP in the development and resolution of various patient-ventilator interaction patterns and dyssynchronies.

Conclusion

PEEP should be considered not only as a tool for oxygenation and respiratory mechanics, but also as a potential modulator that should be personalized to improve patient-ventilator interaction. Prospective studies specifically designed to evaluate the impact of PEEP on dyssynchrony are needed to guide more individualized ventilatory strategies. Keywords: PEEP, Dyssynchronies, Patient-Ventilator Interactions

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