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PEEP Valves

Question# 810

Does RPPEO support adding a PEEP device to airway management tools?


PEEP (Positive End and Expiratory Pressure) valves can be valuable tools when managing a patient’s airway and maintaining their ventilations. They are known to be used as a non-invasive way of increasing oxygenation in patients who are in significant respiratory distress or respiratory arrest where assisted ventilations are not suitably maintaining oxygen saturations. It maintains air pressure in the alveoli, “splinting” them open to increase the surface area involved in gas exchange. There are several situations where PEEP would greatly benefit a patient such as those who remain hypoxemic (SpO2 < 90%) despite good bag-valve mask ventilations; the patients with fluid overload and COPD in severe respiratory distress. There are however some contraindications to using PEEP as well, such as, known, or suspected pneumothorax, traumatic cause of respiratory arrest, and hypotensive patients. PEEP valves have the potential to decrease venous return to the heart when utilizing higher pressures as well as potentially increasing intracranial pressure, more than normal ventilations would.

With all of the above considered, one study by Dai et al. outlines that a PEEP device attached to a BVM has the potential to increase the efficacy of BVM ventilations. Furthermore, Butcher et al. mention that a PEEP valve attached and titrated from 5 to 15cm H20 on a BVM can improve oxygenation prior to intubation in patients who are unable to be appropriately pre-oxygenated with standard therapy. Both studies do also highlight the risks surrounding the use of PEEP valves. “A high concentration of inhaled oxygen may also cause absorption atelectasis” (Dai, et al., 2021). It is also important “not to exceed 20cm H2O on a BVM as this pressure can open the lower esophageal sphincter and cause gastric insufflation and vomiting. Low pressure, low volume insufflation can help prevent gastric distention” (Butcher, Vashisht, Ladd, & Cooper, 2023).

In conclusion, while PEEP valve devices can be a great tool, they need to be utilized in the right cases for the right patients. This additional education is important prior to adding them to every resuscitation bag. The RPPEO can help provide evidence-based best practices, but they are unable to change equipment of the various services. We recommend that you reach out to your manager regarding a review or change to your equipment if you believe a change is necessary.


Butcher, J. T., Vashisht, R., Ladd, M., & Cooper, J. S. (2023). Bag-Valve-Mask Ventilation. STATPEARLS. Retrieved from

Dai, Y., Dai, J., Walline, J. H., Fu, Y., Zhu, H., Xu, J., & Yu, X. (2021). Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A prospective, randomized, double-blind trial. doi:10.1186/s13063-021-05413-3


31 May 2024

ALSPCS Version




Please reference the MOST RECENT ALS PCS for updates and changes to these directives.