Intraoperative Driving Pressure-Guided High PEEP vs Standard Low PEEP for Postoperative Pulmonary Complications

Area of Science:

• Anesthesiology
• Critical Care Medicine
• Pulmonary Medicine

Background:

• The optimal intraoperative ventilation strategy for patients undergoing open abdominal surgery, particularly concerning positive end-expiratory pressure (PEEP) and recruitment maneuvers, remains uncertain.
• High PEEP and recruitment maneuvers targeting low driving pressure are proposed to improve lung function and reduce postoperative pulmonary complications (PPCs).

Purpose of the Study:

• To compare the efficacy of driving pressure-guided high PEEP with recruitment maneuvers versus standard low PEEP in preventing PPCs in patients undergoing open abdominal surgery.
• To evaluate the impact of these ventilation strategies on intraoperative complications such as hypotension and desaturation.

Main Methods:

• A randomized clinical trial involving 1435 adults at increased risk for PPCs undergoing open abdominal surgery across 29 European sites.
• Patients were randomized to either driving pressure-guided high PEEP with recruitment maneuvers (n=718) or standard low PEEP (n=717) during intraoperative ventilation, with all receiving low tidal volume ventilation.

Main Results:

• The primary outcome, a composite of PPCs within 5 days post-surgery, occurred in 19.8% of the high PEEP group versus 17.4% of the low PEEP group (absolute difference, 2.5%; P=.23), indicating no significant reduction.
• The high PEEP group experienced higher rates of intraoperative hypotension (54.0% vs 45.0%) and increased use of vasoactive agents.
• The low PEEP group had a higher incidence of intraoperative desaturation (2.8% vs 0.8%).

Conclusions:

• Intraoperative ventilation with driving pressure-guided high PEEP and recruitment maneuvers did not significantly reduce postoperative pulmonary complications compared to standard low PEEP in patients undergoing open abdominal surgery.
• The findings suggest that the tested high PEEP strategy does not offer a clinical benefit for preventing PPCs in this patient population.
• Further research may be needed to explore alternative ventilation strategies or patient subgroups that might benefit from high PEEP and recruitment maneuvers.