Personalized positive-end expiratory pressure using electrical impedance tomography in ARDS patients: a systematic review and meta-analysis - 10/03/26

Doi : 10.1016/j.aicoj.2026.100049

Michela Rauseo ^a,^{^{1
These Authors share equivalent first name.}}, Danila Azzolina ^b,^{^{1
These Authors share equivalent first name.}}, Gaetano Scaramuzzo ^c, Mohd Rashid Khan ^d, Paolo Vetuschi ^e, Francesco Paolo Padovano ^e, Antonello Discenza ^a, Lucia Distaso ^a, Lucia Mirabella ^a, Antonella Cotoia ^a, Savino Spadaro ^c,⁎, ^{^{2
These Authors share equivalent last name.}} , Gilda Cinnella ^a,^{^{2
These Authors share equivalent last name.}}

^a University of Foggia, Department of Medical and Surgical Science, Anesthesia and Intensive Care Medicine, Policlinico Riuniti di Foggia, Italy

^b Biostatistics and Clinical Trial Methodology Unit, Clinical Research Center DEMeTra, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy

^c Department of Translational Medicine, University of Ferrara, Saint' Anna Hospital, Ferrara, Italy

^d Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy

^e Department of Cardiac Anesthesia, Policlinico Riuniti di Foggia, Italy

^⁎ Corresponding author.

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Highlights

•	EIT-guided PEEP titration improves oxygenation in patients with ARDS.
•	Individualized PEEP adjustment using EIT increases respiratory system compliance.
•	Electrical impedance tomography allows bedside, real-time assessment of lung mechanics.
•	EIT-guided ventilation supports physiologically individualized PEEP optimization in ARDS.

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Abstract

Objective

Personalized mechanical ventilation strategies can improve outcomes in patients with Acute Respiratory Distress Syndrome (ARDS). However, the optimal method for titrating positive end-expiratory pressure (PEEP) remains controversial. Electrical Impedance Tomography (EIT), by enabling real-time, regional assessment of lung regional characteristics, offers potential advantages to guiding PEEP titration as compared to conventional methods.

Data sources and study selection

We conducted a systematic review and meta-analysis of randomized clinical trials and observational studies comparing EIT-guided versus conventional PEEP titration in adult ARDS. The review was conducted according to the PRISMA 2020 guidelines. Moreover, the review was conducted in accordance with the MOOSE (Meta-analysis of Observational Studies in Epidemiology) recommendations, where applicable, and with the registered protocol (PROSPERO ID: CRD420251015187). The primary outcomes were the PaO ₂ /FiO ₂ ratio and respiratory system compliance (Crs). Secondary outcomes included driving pressure (ΔP), mechanical power (MP), and mortality. Random-effects meta-analysis was performed. Risk of bias and GRADE assessments were conducted using the ROB 2.0 and ROBINS-I tools, depending on the study design.

Data extraction and data synthesis

Nine studies (n = 356 patients) were included. EIT-guided PEEP titration was associated with an improvement in oxygenation, expressed as PaO ₂ /FiO ₂ ratio, in the EIT guided PEEP group (MD + 60.81; 95% CI 30.37–91.25), with low heterogeneity. Furthermore, significant improvement in respiratory system compliance was observed in EIT guided PEEP (MD + 6.81 mL/cm H ₂ O; 95% CI 3.73–9.89). No statistically significant difference was observed in driving pressure between groups (MD −0.78 cm H ₂ O; 95% CI −1.63 to 0.07). Mechanical power showed a non-significant difference across groups (MD −0.76 J/min; 95% CI −2.30 to 0.78). Mortality did not differ between groups (risk ratio 0.88; 95% CI 0.45–1.72).

Conclusion

EIT-guided PEEP titration improves oxygenation and respiratory system compliance in patients with ARDS, supporting its role as a physiology-based strategy for ventilatory personalization. Further evidence are needed to determine whether these physiological improvements translate into better clinical outcomes.

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Keywords : Electrical impedance tomography, ARDS, PEEP titration, Oxygenation, Respiratory compliance, Lung mechanics, Mechanical ventilation, Driving pressure, Mechanical power.

Abbreviations : ARDS, ATS, BMI, CI, COPD, Crs, D _MP , ΔP (or DP), EELV, EIT, ESICM, FiO ₂ , GI Index, GRADE, ICU, IQR, I², LOA, MD, MP, MPa, OD Index, PaO ₂ , PaCO ₂ , PaO ₂ /FiO ₂ (or P/F Ratio) , PEEP, PGA, Pplat, PRISMA, PROSPERO, PV, RCT, Rec Index, ROB 2.0, ROBINS-I, RR, SD, SEM, VILI, Vt