A seven month old child got admitted with complaints of fever, cough and cold for 4 days and fast breathing for 2 days. He was being treated outside in the form of nebulization and referred here in view of non improvement. There was no significant past history and child was immunized for his age. At the time of presentation to our ER, child was in respiratory failure, in view of which child was intubated and put on mechanical ventilation. Next day child’s clinical condition deteriorated in the form of desaturation, worsening edema and abdominal distension. Intra abdominal pressure was monitored which was high. In order to improve oxygenation, PEEP was increased by conventional methods from 8 to 15 but there was no improvement in oxygenation. Thereafter, PEEP titration was planned by measuring the trans pulmonary pressure by insertion of esophageal catheter. PEEP was titrated and increased from 15(from conventional methods) to 20, keeping the PTPlat between 10 to 15 cm of H2O and PTPeep in range of 0 to 5 cm of H2O, following which the oxygenation improved without any hemodynamic instability. In view of worsening renal functions and increasing fluid overload, renal replacement therapy was started in the form of peritoneal dialysis. PEEP was also titrated according to the intra abdominal pressure during PD cycle in and out targeting the PTPlat and PTPeep. Gradually oxygenation improved. In view of persistent fluid overload and worsening renal functions despite peritoneal dialysis, CRRT was done, following which renal functions became better, fluid overload decreased and child was extubated within next 48 hours.