Curious to hear everyone’s thoughts on this.

When managing patients on VV ECMO, I’m a firm believer in PEEP titration with the goal of maintaining an open lung strategy. My thought process is that keeping alveoli recruited, while using minimal FiO₂ and ultra protective ventilation, may reduce the repetitive opening and closing that contributes to atelectrauma.

I know others prefer dropping PEEP as low as possible to truly “rest” the lungs and let ECMO do the work.

Personally, I struggle with that concept. In my mind, allowing the lungs to completely derecruit seems like it could create more injury over time, especially if you’re repeatedly trying to recruit a collapsed lung rather than making gradual adjustments to maintain recruitment.

Obviously every patient is different, and compliance, recruitability, hemodynamics, and imaging all play a role. I’m not looking for a right or wrong answer. I’m genuinely interested in hearing how others approach PEEP management on VV ECMO and what evidence or experience has shaped your practice.

What’s your strategy, and why?