Setting positive end-expiratory pressure: Role in diaphragm-protective ventilation

Myrte Wennen, Wout Claassen, Leo Heunks*

*Corresponding author for this work

Research output: Contribution to journalReview articlePopular


Purpose of review:

With mechanical ventilation, positive end-expiratory pressure (PEEP) is applied to improve oxygenation and lung homogeneity. However, PEEP setting has been hypothesized to contribute to critical illness associated diaphragm dysfunction via several mechanisms. Here, we discuss the impact of PEEP on diaphragm function, activity and geometry.

Recent findings:

PEEP affects diaphragm geometry: it induces a caudal movement of the diaphragm dome and shortening of the zone of apposition. This results in reduced diaphragm neuromechanical efficiency. After prolonged PEEP application, the zone of apposition adapts by reducing muscle fiber length, so-called longitudinal muscle atrophy. When PEEP is withdrawn, for instance during a spontaneous breathing trial, the shortened diaphragm muscle fibers may over-stretch which may lead to (additional) diaphragm myotrauma. Furthermore, PEEP may either increase or decrease respiratory drive and resulting respiratory effort, probably depending on lung recruitability. Finally, the level of PEEP can also influence diaphragm activity in the expiratory phase, which may be an additional mechanism for diaphragm myotrauma.


Setting PEEP could play an important role in both lung and diaphragm protective ventilation. Both high and low PEEP levels could potentially introduce or exacerbate diaphragm myotrauma. Today, the impact of PEEP setting on diaphragm structure and function is in its infancy, and clinical implications are largely unknown.

Original languageEnglish
Pages (from-to)61-68
Number of pages8
JournalCurrent Opinion in Critical Care
Issue number1
Publication statusPublished - 1 Feb 2024

Bibliographical note

Publisher Copyright:
© 2024 Lippincott Williams and Wilkins. All rights reserved.


Dive into the research topics of 'Setting positive end-expiratory pressure: Role in diaphragm-protective ventilation'. Together they form a unique fingerprint.

Cite this