Individualized Perioperative PEEP in Older Surgical Patients: A Three-Dimensional Titration Framework

Postoperative pulmonary complications (PPCs) remain a major determinant of morbidity, delayed functional recovery, and long-term outcomes in older surgical patients. While positive end-expiratory pressure (PEEP) is a cornerstone of lung-protective ventilation, fixed or uniformly high PEEP strategies have yielded inconsistent benefits in the elderly and are frequently limited by hemodynamic intolerance. Accumulating evidence suggests that the optimal PEEP in older patients lies within a narrow therapeutic window defined by competing risks of atelectasis, overdistension, and circulatory compromise. This narrative review synthesizes current evidence linking individualized perioperative PEEP to PPCs and functional recovery in older adults, with a particular focus on the limitations of one-size-fits-all approaches. We propose a pragmatic three-dimensional titration framework that integrates respiratory mechanics (driving pressure and compliance), regional lung imaging (lung ultrasound and electrical impedance tomography), and hemodynamic tolerance to guide PEEP selection. By mapping physiological endpoints to clinical and functional outcomes, we highlight how individualized PEEP strategies may improve perioperative safety and recovery trajectories in the aging population. Finally, we discuss translational pathways, implementation challenges, and key research gaps to inform future trials and clinical adoption.