Overall, we suggest targeting gas exchange when titrating ventilation settings, as most obese patients can safely maintain PaO
2 55–80 mmHg and SatO
2 88–94% and carbon dioxide levels resulting in pHa > 7.25, also tolerating mild hypercapnia, especially in ARDS patients. We suggest changing FiO
2 and respiratory rate as first methods to achieve these goals, respectively. However, using elevated respiratory rates may lead to increase intrinsic PEEP (PEEPi) due to airway closure and expiratory flow limitation. We strongly recommend to inspect visually the expiratory flow-time curve and to perform an expiratory hold when the presence of PEEPi is suspected. Driving pressure (∆P), i.e., the difference between plateau pressure (
Pplat)—PEEP, was not associated with mortality in obese ARDS patients [
7]; however, this parameter has an important role in VILI and should be ideally limited to a maximum value of 17 cmH
2O in ARDS and 15 cmH
2O in non-ARDS obese patients. Titration of PEEP levels is controversial. Hemodynamic is more frequent than respiratory impairment in obese patients without ARDS [
4]. We prefer prioritizing FiO
2 increase over PEEP increase in patients with ARDS. Increases in PEEP should never result in an increase of ∆P, as it suggests hyperinflation and could result in worse clinical outcome [
8]. However, a low-PEEP strategy might not ensure acceptable oxygenation in all patients. In patients with persistent hypoxemia, we consider using higher PEEP levels titrated on the lowest ∆P in a decremental PEEP trial [
9,
10] or based on transpulmonary pressure [
11]. In an observational study, higher PEEP was associated with better survival in ARDS obese patients [
12], but definitive evidence is lacking, and we recommend balancing the negative effects of PEEP, especially on hemodynamics.