Management of Auto-PEEP

Immediate Recognition and Emergency Management

The American Heart Association recommends immediate ventilator adjustments, including decreasing respiratory rate, reducing tidal volumes to 6-8 mL/kg, shortening inspiratory time, and prolonging expiratory time to allow complete lung emptying in patients with auto-PEEP 1, 2, 3
If auto-PEEP causes significant hypotension, the American College of Cardiology suggests immediately disconnecting the patient from the ventilator circuit to allow passive exhalation and PEEP dissipation 1
The American Thoracic Society recommends using the DOPE mnemonic (tube Displacement, tube Obstruction, Pneumothorax, Equipment failure) plus auto-PEEP when evaluating any acute deterioration in mechanically ventilated patients 1, 3

The American College of Chest Physicians recommends decreasing minute ventilation by reducing respiratory rate, and using tidal volumes of 6-8 mL/kg to minimize breath stacking and barotrauma risk 1, 2, 3
The Society of Critical Care Medicine suggests setting inspiratory flow rates to 80-100 L/min in adults to shorten inspiratory time and maximize expiratory time, and targeting I:E ratios of 1:4 or 1:5 1, 2, 3
The American Association for Respiratory Care recommends accepting mild hypoventilation and elevated PaCO₂ to reduce barotrauma risk, as hypercapnia is typically well tolerated 1, 2

The American Journal of Respiratory and Critical Care Medicine suggests applying low levels of external PEEP (typically 5 cm H₂O or less) in spontaneously breathing patients to counterbalance intrinsic PEEP and reduce inspiratory threshold load 4
The American Thoracic Society recommends never setting external PEEP levels exceeding the measured intrinsic PEEP, as this worsens hyperinflation and causes hemodynamic compromise 5
The American College of Chest Physicians suggests using flow triggering instead of pressure triggering in patients with auto-PEEP, as flow triggers are more sensitive and reduce patient-ventilator asynchrony 5

The Society of Critical Care Medicine recommends providing adequate sedation to optimize ventilation, decrease ventilator dyssynchrony, and minimize auto-PEEP generation 1, 2
The American College of Cardiology suggests considering paralytic agents only if auto-PEEP persists despite adequate sedation and the patient displays significant ventilator dyssynchrony 1

The American Thoracic Society recommends continuing aggressive bronchodilator therapy (inhaled albuterol) through the endotracheal tube, as airway obstruction is often the primary driver of auto-PEEP 1, 2
The American College of Chest Physicians suggests using the largest endotracheal tube available (8-9 mm) to minimize airway resistance if intubation is required, and checking for and eliminating mucous plugging, tube kinking, or other sources of increased expiratory resistance 1, 2, 3

The American Association for Respiratory Care recommends monitoring pressure-time and flow-time scalars continuously in all mechanically ventilated patients at risk for auto-PEEP, and measuring peak inspiratory pressure, plateau pressure, and mean airway pressure regularly 5
The American College of Cardiology suggests documenting measured auto-PEEP values and correlating with clinical signs of hemodynamic compromise 5
The Society of Critical Care Medicine recommends obtaining expert consultation for optimal ventilator management, as settings require ongoing careful review of ventilation flow and pressure curves 1, 2, 3

The American Journal of Respiratory and Critical Care Medicine warns against hyperventilating patients, as this exacerbates auto-PEEP by not allowing sufficient expiratory time 4
The American College of Cardiology advises against delaying disconnection from the ventilator if severe hypotension occurs—this is a life-saving emergency maneuver 1