Key result
Respiratory therapists set initial PEEP ~1.1 cmH2O higher than specialized nurses in acute cardiogenic pulmonary edema.
Why the study?
There is limited data regarding optimal ventilatory settings, including PEEP and pressure support strategies, in patients with acute cardiogenic pulmonary oedema treated with non-invasive ventilation.
Cross-Sectional (n=337)
Yes
Mean Difference: 1.05
p-value: p=0.003
There is significant inter-professional variability in the clinical practice of setting PEEP during non-invasive ventilation for acute cardiogenic pulmonary edema.
Background Acute cardiogenic pulmonary oedema (ACPO) is a life-threatening clinical condition requiring acute care hospitalization and associated increased mortality. The use of non-invasive ventilation (NIV) has a class IIa indication in patients with acute heart failure with respiratory insufficiency. NIV improves vital parameters and dyspnea more rapidly than conventional oxygen therapy for patients with ACPO. However, there is limited data regarding optimal ventilatory settings, including positive end-expiratory pressure (PEEP) and pressure support strategies in patients with ACPO. Purpose The aim of this study is to assess the knowledge, experience, and decision-making of specialized nurses and respiratory therapists regarding the use of NIV in patients with ACPO. Methods This multicenter, cross-sectional study utilized an open, voluntary and anonymous survey among specialized nurses and respiratory therapists working in the Emergency Departments (ED), Coronary Care Unit (CCU), and Intensive Care Unit (ICU) across 49 hospitals in the Netherlands, Belgium, Germany, Saudi Arabia, Qatar, and the United States, conducted between August and October 2025. Data were collected using 28-item questionnaire focusing on NIV practices, with an emphasis on PEEP selection, institutional protocol adherence, and self-reported competence in initiating and adjusting NIV settings. The mentioned responses were measured on a Likert scale from 1 (Strongly disagree) to 5 (Strongly agree). Results A total of 337 specialized nurses and respiratory therapists participated in this voluntary survey. The largest group of respondents were ICU nurses (32%), followed by respiratory therapists (30.6%), CCU nurses (22%), and ED nurses (15.4%). The majority of respondents reported initiating NIV in patients with ACPO (mean 3.50 ± 1.03). Regarding PEEP settings, the overall mean was 6.2 cmH2O (6.2 ± 1.80), with respiratory therapists starting on average 1.05 cmH2O higher than specialized nurses (p= 0.003). When increasing PEEP, ED nurses reported often titrating PEEP higher than the other groups (8.97 ± 1.14) (p = 0.013). We observe that respiratory therapists, compared with ICU, CCU, and ED nurses, are willing to further increase PEEP when necessary (8.64 ± 2.04) (p = 0.013). Self-reported expertise in setting PEEP was highest among respiratory therapists (4.28 ± 0.65), followed by CCU nurses (3.74 ± 0.89), ICU nurses (3.65 ± 0.85), and ED nurses (3.59 ± 0.75) (p < 0.001). Conclusion This study demonstrates significant variability in the clinical practice of setting PEEP in patients with ACPE. Respiratory therapists start with higher PEEP levels and titrate them higher compared to ICU, ED, and CCU nurses. Prospective studies are needed to evaluate the real world PEEP application and to determine optimal PEEP strategies for patients with ACPO.
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Troost et al. (2026) conducted a cross-sectional in Acute cardiogenic pulmonary edema (n=337). Respiratory therapist profession vs. Specialized nurses (ICU, CCU, ED) was evaluated on Initial PEEP setting (MD 1.05, p=0.003). Respiratory therapists initiated non-invasive ventilation with PEEP levels 1.05 cmH2O higher on average compared to specialized nurses for acute cardiogenic pulmonary edema (p=0.003).
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