Increases in positive end-expiratory pressure (PEEP) improve arterial oxygenation in preterm infants, but the effects on cardiopulmonary hemodynamics are understood poorly. We aimed to determine the effect of increased PEEP on cardiopulmonary hemodynamics and to compare measurements from indwelling flow probes with Doppler echocardiography. Preterm lambs (129 +/- 1 days) were ventilated initially with a tidal volume of 7 ml/kg and 4 cmH(2)O of PEEP. In ramp lambs (n = 7), PEEP was increased by 2-cmH(2)O increments to 10 cmH(2)O and then in decrements back to 4 cmH(2)O. PEEP was unchanged in controls (n = 6). Doppler echocardiographic flow measurements in the left pulmonary artery (LPA) and ductus arteriosus (DA) were correlated with flow probe measurements. Compared with controls, high PEEP reduced LPA flow from baseline (10-cmH(2)O PEEP: 43 +/- 8% vs. control: 83 +/- 21%; P = 0.029). High PEEP increased the proportion of right-to-left (R-L) shunting through the DA, with a trend to an increased oxygenation index compared with controls (oxygenation index: 44.5 +/- 13.5 at 10-cmH(2)O PEEP vs. 19.4 +/- 4.5 in controls; P = 0.07). Increasing PEEP decreased heart rate (17 beats/min; P = 0.03) and tended to lower systolic arterial pressure (5.0 mmHg; P = 0.052) compared with controls. Doppler echocardiography measurement of LPA flows correlated strongly with indwelling flow probe (r(2) = 0.73, P < 0.001), except during highly turbulent flows. Increases in PEEP have significant cardiopulmonary consequences in preterm lambs, including reduced LPA flow and increased R-L shunt through the DA. These changes are likely due to the concomitant increase in downstream pulmonary vascular resistance and increased cardiovascular constraint induced by PEEP.