What PEEP level, set above a patient's plateau pressure, is appropriate for initial settings during alveolar recruitment maneuvers?

Setting an appropriate level of positive end-expiratory pressure (PEEP) during alveolar recruitment maneuvers is crucial for optimizing lung mechanics and improving oxygenation. The primary goal of these maneuvers is to open collapsed alveoli and enhance ventilation-perfusion matching.

A PEEP level of 10 cm H2O is often recommended because it strikes a balance between improving lung recruitment and minimizing potential hemodynamic compromise. It is generally considered safe and effective in avoiding excessive airway pressures, while still being high enough to help recruit collapsed lung units.

In contrast, higher PEEP levels, such as 20 cm H2O, 30 cm H2O, or 40 cm H2O, may lead to over-distention of healthy alveoli and could cause barotrauma or hemodynamic instability, especially if they significantly exceed the patient's plateau pressure. Such high levels of PEEP could also impede circulation by decreasing venous return due to increased intrathoracic pressure.

Therefore, starting with 10 cm H2O is a clinically appropriate approach for initial settings during alveolar recruitment maneuvers, focusing on enhancing oxygenation while maintaining safety in terms of lung protection.