Background: Acute hypoxemic respiratory failure (AHRF), and acute respiratory distress syndrome (ARDS) managed with mechanical ventilation and positive end-expiratory pressure (PEEP). Conventional PEEP titration methods sometimes fail to account for patient-specific lung recruit ability leading to ventilator induced lung injury (VILI). Electrical impedance tomography (EIT) is a bedside imaging tool that allows individualized PEEP titration based on regional ventilation distribution. We aimed to systematically review the impact of EIT-guided individualized PEEP titration on respiratory mechanics and clinical outcomes in patients with AHRF. Methods: A systematic search was conducted in PubMed, Scopus, and Google Scholar for original studies published between 2020 and 2025. Inclusion criteria were adult patients with ARDS, individualized PEEP titration using EIT or similar methods, and reporting of at least one physiological or clinical outcome. We exclude studies not involving human subjects, review articles, and non-English publications were excluded. Seven studies met the eligibility criteria and were included in the qualitative synthesis. Results: The included studies consisted of four randomized trials, one crossover trial, one prospective cohort, and one retrospective study. Most used EIT-guided decremental PEEP trials to identify optimal PEEP levels. EIT-based titration was associated with improved compliance, reduced mechanical power and driving pressure, and better lung homogeneity. Trends toward reduced 28-day mortality and improved organ function were noted, findings on hard outcomes, ICU stay, and ventilator-free days were inconsistent. Conclusion: EIT-guided individualized PEEP titration improves physiological parameters in patients with AHRF and shows promise in optimizing lung-protective ventilation. Evidence of its impact on clinical outcomes is limited and heterogeneous. Further multicenter randomized trials are needed to confirm its benefits on survival and recovery.