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Driving pressure guided ventilation in robot-assisted laparoscopic surgery with steep Trendelenburg position: a
Sooah Cho1, Bo Rim Kim2, Sang-Youn Park1
1Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.
Anesthesia and Pain Medicine
|May 14, 2026
Summary
Driving pressure (DP)-guided positive end-expiratory pressure (PEEP) titration during robot-assisted laparoscopic prostatectomy (RALP) reduced lung de-aeration. However, this approach did not decrease postoperative pulmonary complications.
Area of Science:
- Anesthesiology
- Critical Care Medicine
- Pulmonary Medicine
Background:
- Robot-assisted laparoscopic prostatectomy (RALP) involves pneumoperitoneum and steep Trendelenburg positioning, which can impair ventilation and increase postoperative pulmonary complications (PPCs).
- Positive end-expiratory pressure (PEEP) may mitigate atelectasis, but optimal levels for RALP are not well-defined.
- Driving pressure (DP)-guided PEEP titration is a potential strategy to optimize ventilation during RALP.
Purpose of the Study:
- To evaluate the efficacy of driving pressure (DP)-guided positive end-expiratory pressure (PEEP) titration in reducing lung de-aeration during robot-assisted laparoscopic prostatectomy (RALP).
- To compare individualized PEEP guided by DP minimization versus fixed PEEP in patients undergoing RALP.
- To assess the impact of DP-guided PEEP on lung ultrasound (LUS) scores, oxygenation, and postoperative pulmonary complications (PPCs).
Main Methods:
- A single-center, randomized controlled trial included adult patients undergoing RALP without pulmonary disease.
- Patients were randomized to either DP minimization-guided individualized PEEP (DP group) or fixed 5 cmH2O PEEP (control group).
- Driving pressure was calculated as plateau pressure minus PEEP. Lung atelectasis was quantified using a modified lung ultrasound (LUS) score.
Main Results:
- The DP group received higher individualized PEEP (median 8.0 cmH2O) compared to the control group (5.0 cmH2O).
- The DP group exhibited significantly lower LUS scores at the end of Trendelenburg positioning and during recovery, indicating reduced atelectasis.
- Intraoperative oxygenation (PaO2) was higher in the DP group during Trendelenburg positioning.
Conclusions:
- DP-guided PEEP titration effectively reduced lung de-aeration, as assessed by modified LUS scores, during RALP.
- Despite improved lung aeration, the DP-guided PEEP strategy did not lead to a significant reduction in postoperative pulmonary complications (PPCs) or hospital stay.
- Further research may be needed to explore strategies that translate improved lung aeration into reduced PPCs in the context of RALP.
