The rationale for recruitment maneuvers is to open the atelectatic alveoli, thus increasing end expiratory lung volume, improving gas exchange, and attenuating ventilator induced lung injury. The study aimed to assess the efficacy of titrating positive end expiratory pressure recruitment versus extended sigh recruitment by volumetric capnography in patients with acute respiratory distress syndrome. Methods: Seventy patients were randomly allocated into two equal groups according to plan for

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... ilator management of ARDS by protective lung strategy according to ARDS network. Group I (n= 35) titrating PEEP recruitment, and Group II (n= 35) extended sigh recruitment. The primary outcome measure was mortality in the first 28 days wheras the secondary outcome measures were changes in static compliance, dead space to tidal volume ratio, ventilation / perfusion ratio, duration of mechanical ventilation, weaning outcomes, oxygenation and hemodynamic data. Results: There was no statistically significant difference in 28th day mortality in both groups in group 1, 10 patients were died (28.57%), In group II, 12 patients were died (34.28%) (p value =0.607), wheras there was significant increase regarding static compliance ml/cm H2O, ventilation / perfusion ratio (p value =0.003. 0.001 respectively) and significant decrease regarding dead space to tidal volume ratio in group I compared to group II, 15 minutes after recruitment and significant decrease in duration of mechanical ventilation (days) in group I compared with group II (p value = 0.014, 0.04 respectively). There was a significant difference in weaning categories between both groups with better outcomes in favor of group I (p value = 0.034). The findings of this study presented that there were no significant difference regarding other measurements. Conclusion: Titrating PEEP recruitment was better than extended sigh recruitment as regard weaning outcomes and duration of mechanical ventilation, which may be due to improvement in aerated lung volume, reflected on decreased dead space to tidal volume ratio, better ventilation perfusion ratio and static compliance.