What auto-PEEP is. Auto-PEEP — also called intrinsic PEEP or breath stacking — occurs when a ventilated patient cannot fully exhale before the next breath is delivered. The residual volume trapped in the lung creates positive end-expiratory pressure that was not set on the ventilator. The ventilator does not display it unless you specifically look for it. Meanwhile, every breath is delivered against a lung that is already under positive pressure, increasing the risk of barotrauma, hemodynamic compromise, and ventilator asynchrony.
Who is at highest risk. COPD and asthma patients on the ventilator — because of prolonged time constants and gas trapping. Patients with tachypnea, high respiratory rates, or inadequate I:E ratios. Any patient where the expiratory flow waveform does not return to zero before the next breath begins. That waveform check takes three seconds and should be part of every ventilator assessment on obstructive lung disease patients.
How to measure it. End-expiratory occlusion pause — press and hold the expiratory pause button for 0.5 to 2 seconds. The displayed pressure at end-expiration minus the set PEEP is the auto-PEEP value. Values above 5 cmH2O are clinically significant. Values above 10 cmH2O are urgent. The maneuver requires the patient to be passive — auto-PEEP measurement in an actively breathing patient is unreliable.
Management actions: Reduce respiratory rate. Extend expiratory time by adjusting I:E ratio toward 1:3 or 1:4 in obstructive patients. Reduce tidal volume if auto-PEEP is causing hyperinflation. Optimize bronchodilator therapy. Many patients labeled as “ventilator asynchrony” have unrecognized auto-PEEP as the driver.
What driving pressure is. Driving pressure is plateau pressure minus total PEEP. It represents the tidal stress delivered to the respiratory system with each breath. In the landmark 2015 Amato et al. analysis of nine ARDS trials, driving pressure was the ventilator variable most strongly associated with survival — outperforming tidal volume and plateau pressure as individual predictors. Driving pressure above 15 cmH2O was associated with significantly increased mortality.
Why tidal volume and Pplat alone are insufficient. A tidal volume of 6 mL/kg IBW in a patient with normal compliance produces very different lung stress than the same volume in a stiff, small recruitable lung. Driving pressure normalizes tidal stress to respiratory system compliance — giving you a measure that better reflects what is actually happening to the lung parenchyma.
What to do with it at the bedside. Calculate driving pressure at every ARDS patient ventilator assessment: inspiratory pause to obtain Pplat, subtract total PEEP. If driving pressure exceeds 15 cmH2O, consider reducing tidal volume — even below 6 mL/kg IBW if tolerated — or increasing PEEP to improve compliance. The goal is driving pressure below 14 cmH2O where achievable.
Why RT departments do not routinely track it: Most ventilator protocols were written before the 2015 Amato analysis. Adding driving pressure to your unit’s ARDS documentation is a practice-level change that does not require a policy rewrite — just a habit change in your assessment workflow.
The pendulum on NMBs. The 2010 ACURASYS trial showed a 90-day mortality benefit with 48-hour cisatracurium infusion in moderate-to-severe ARDS. The 2019 ROSE trial — larger, better controlled — showed no mortality benefit from early NMB compared to a light sedation strategy without routine paralysis. The current consensus: routine early NMB for all moderate-to-severe ARDS is not supported. Selective use for specific indications remains appropriate.
When NMBs are still appropriate in 2026. Life-threatening ventilator dyssynchrony that cannot be managed with optimized sedation. Severe refractory hypoxemia where patient effort contributes to P-SILI. Prone positioning in patients who cannot remain passive with sedation alone. Severe hypercapnia where respiratory rate suppression is necessary. These are patient-specific, time-limited indications — not protocol-driven blanket therapy.
The RT role in NMB management. Train-of-four monitoring guides dosing to maintain adequate but not excessive paralysis, reducing the risk of prolonged weakness from NMB accumulation. RTs managing paralyzed patients must monitor for P-SILI indicators when NMB is being weaned — the rebound of spontaneous effort as paralysis resolves can injure a lung that was protected during paralysis.
Bottom line: NMBs in ARDS are a rescue tool, not a protocol. If your unit is still routinely paralysing all moderate-to-severe ARDS patients in the first 48 hours regardless of sedation adequacy — the evidence says that approach needs review.
The rapid response team in 2026. Most hospitals have a rapid response or medical emergency team responding to deteriorating floor patients before they require ICU transfer. In many facilities, the RT is a standing member of the RRT. In others, RT is called only when a respiratory intervention is already in progress. The difference between those two models is significant — both for patient outcomes and for RT scope visibility.
What the RT brings to the RRT that nobody else does. Rapid assessment of work of breathing that the bedside nurse cannot quantify. Immediate decision between supplemental O2, HFNC, NIV, and invasive airway — and the ability to initiate and manage all of them. Waveform capnography interpretation in non-intubated patients during the response. The RT at an RRT call is the airway and respiratory decision-maker, not support staff waiting to be given a treatment order.
If your RT department is not a standing RRT member. Present your medical director with outcome data from facilities where RT is a standing RRT member — HFNC initiation times, intubation avoidance rates, ICU transfer rates. The evidence for RT involvement in rapid response teams is consistent. The barrier is institutional visibility, not clinical evidence.
One practical step: At your next RRT call, document your specific clinical contribution — the assessment you made, the intervention you initiated, the escalation you prevented or facilitated. That documentation, accumulated over months, builds the outcome case your department needs to argue for standing RRT membership.
Next: RT in the outpatient pulmonary clinic — career path, scope, and what the day actually looks like.
Soon: Chest X-ray interpretation for RTs — what to look for and what it changes about your bedside assessment.
On deck: Asthma biologics — dupilumab and tezepelumab and what RTs need to know for patient education.
Staying at the vent,
15 years across academic medical centers & community hospitals
