Positive end-expiratory pressure in pediatric acute respiratory distress syndrome: a narrative review.

Background and Objective: Pediatric acute respiratory distress syndrome (PARDS) is associated with substantial morbidity and mortality. Positive end-expiratory pressure (PEEP) can support alveolar recruitment, improve oxygenation, and mitigate ventilator-induced lung injury (VILI). Despite its central role in lung-protective ventilation, evidence to guide PEEP titration in PARDS remains limited. This review summarizes physiologic principles, existing evidence, and bedside strategies for PEEP management in children. Methods: We performed a narrative review using PubMed from 1967 to 2025, limited to English-language studies. Search terms included "pediatric acute respiratory distress syndrome", "positive end-expiratory pressure", "PEEP", "positive-pressure respiration", "mechanical ventilation", "pressure-volume curves", "electrical impedance tomography", "esophageal manometry", "stress index", and "ventilator-induced lung injury". Reference lists from key publications and guidelines were also screened. Key Content and Findings: Among available strategies, utilization of the low PEEP:FiO Conclusions: Evidence supports maintaining PEEP at or above ARDSNet lower-table recommendations with close attention to physiologic response. Adjunctive monitoring with esophageal manometry or EIT may help balance recruitment and overdistension, but pediatric-specific trials are needed to define best practice. Standardized multicenter studies will be essential to establish evidence-based PEEP strategies in PARDS.