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The objective of this study was to determine the effect of maximum PEEP levels at birth on the physiological and injury response in preterm lambs. Steroid-exposed preterm lambs (124\u2013127 days gestation; n = 65) were randomly assigned from birth to either 1) positive pressure ventilation (PPV) at 8 cmH<jats:sub>2<\/jats:sub>O PEEP or 3-min dynamic stepwise PEEP strategy (DynPEEP), with either 2) 20 cmH<jats:sub>2<\/jats:sub>O maximum PEEP (10 PEEP second steps) or 3) 14 cmH<jats:sub>2<\/jats:sub>O maximum PEEP (20-s steps), all followed by standardized PPV for 90 min. Lung mechanics, gas exchange, regional ventilation and aeration (electrical impedance tomography), and histological and molecular measures of lung injury were compared between groups. Dynamic compliance was greatest using a maximum 20 cmH<jats:sub>2<\/jats:sub>O (DynPEEP). There were no differences in gas exchange, end-expiratory volume, and ventilator requirements. Regional ventilation became more uniform with time following all PEEP strategies. For all groups, gene expression of markers of early lung injury was greater in the gravity nondependent lung, and inversely related to the magnitude of PEEP, being lowest in the 20 cmH<jats:sub>2<\/jats:sub>O DynPEEP group overall. PEEP levels had no impact on lung injury in the dependent lung. Transient high maximum PEEP levels using dynamic PEEP strategies may confer more lung protection at birth. <\/jats:p>","DOI":"10.1152\/ajplung.00047.2022","type":"journal-article","created":{"date-parts":[[2022,8,23]],"date-time":"2022-08-23T12:00:37Z","timestamp":1661256037000},"page":"L464-L472","update-policy":"https:\/\/doi.org\/10.1152\/aps-crossmark-policy","source":"Crossref","is-referenced-by-count":7,"title":["Dynamic positive end-expiratory pressure strategies using time and pressure recruitment at birth reduce early expression of lung injury in preterm lambs"],"prefix":"10.1152","volume":"323","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1522-4691","authenticated-orcid":false,"given":"David G.","family":"Tingay","sequence":"first","affiliation":[{"name":"Neonatology, The Royal Children\u2019s Hospital, Parkville, Victoria, Australia"},{"name":"Neonatal Research, Murdoch Children\u2019s Research Institute, Parkville, Victoria, Australia"},{"name":"Department of 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