Precise guidelines on PEEP levels in preterm infants are missing. In particular, Cochrane analyses and European consensus guidelines on the management of respiratory distress syndrome do not provide precise information. This is mirrored by studies, showing that the level of applied PEEP is highly variable across neonatal intensive care units. In fact, the center is the most important variable in multivariable models analyzing PEEP levels in ventilated preterm infants.

The optimal applied PEEP is variable and depends among others on postnatal and corrected age as well as type of respiratory disease. As a general principle overdistension and atelectasis should be avoided since they are associated with acute and long-term respiratory morbidity. Applied PEEP levels need to be based on current respiratory situation, including lung physiology and imaging. While lung physiology can be assessed by pressure-volume curves or forced oscillation technique, imaging can include x-ray and electrical impedance tomography.

The UKBB recently started a study to assess whether optimal PEEP in ventilated newborn infants can be determined by a combination of FOT, EIT and oxygenation index. Results of this study will hopefully enable easy identification of optimal PEEP at the bedside.