Personalized positive-end expiratory pressure using electrical impedance tomography in ARDS patients: a systematic review and meta-analysis

• EIT-guided PEEP titration improves oxygenation in patients with ARDS. • Individualized PEEP adjustment using EIT increases respiratory system compliance. • Electrical impedance tomography allows bedside, real-time assessment of lung mechanics. • EIT-guided ventilation supports physiologically individualized PEEP optimization in ARDS. Personalized mechanical ventilation strategies can improve outcomes in patients with Acute Respiratory Distress Syndrome (ARDS). However, the optimal method for titrating positive end-expiratory pressure (PEEP) remains controversial. Electrical Impedance Tomography (EIT), by enabling real-time, regional assessment of lung regional characteristics, offers potential advantages to guiding PEEP titration as compared to conventional methods. We conducted a systematic review and meta-analysis of randomized clinical trials and observational studies comparing EIT-guided versus conventional PEEP titration in adult ARDS. The review was conducted according to the PRISMA 2020 guidelines. Moreover, the review was conducted in accordance with the MOOSE (Meta-analysis of Observational Studies in Epidemiology) recommendations, where applicable, and with the registered protocol (PROSPERO ID: CRD420251015187). The primary outcomes were the PaO 2 /FiO 2 ratio and respiratory system compliance (Crs). Secondary outcomes included driving pressure (ΔP), mechanical power (MP), and mortality. Random-effects meta-analysis was performed. Risk of bias and GRADE assessments were conducted using the ROB 2.0 and ROBINS-I tools, depending on the study design. Nine studies (n = 356 patients) were included. EIT-guided PEEP titration was associated with an improvement in oxygenation, expressed as PaO 2 /FiO 2 ratio, in the EIT guided PEEP group (MD + 60.81; 95% CI 30.37–91.25), with low heterogeneity. Furthermore, significant improvement in respiratory system compliance was observed in EIT guided PEEP (MD + 6.81 mL/cm H 2 O; 95% CI 3.73–9.89). No statistically significant difference was observed in driving pressure between groups (MD −0.78 cm H 2 O; 95% CI −1.63 to 0.07). Mechanical power showed a non-significant difference across groups (MD −0.76 J/min; 95% CI −2.30 to 0.78). Mortality did not differ between groups (risk ratio 0.88; 95% CI 0.45–1.72). EIT-guided PEEP titration improves oxygenation and respiratory system compliance in patients with ARDS, supporting its role as a physiology-based strategy for ventilatory personalization. Further evidence are needed to determine whether these physiological improvements translate into better clinical outcomes.