• Niklas S Campos, Thomas Bluth, HemmesSabrine N TSNTDepartment of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam University Medical Centers, location 'AMC', Amsterdam, the Netherlands., Julian Librero, Natividad Pozo, Carlos Ferrando, Lorenzo Ball, Guido Mazzinari, Paolo Pelosi, Gama de AbreuMarceloMPulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany., Marcus J Schultz, A Serpa Neto, REPEAT, investigators for the PROVHILO study, iPROVE study, PROBESE study investigators, and PROVE Network.
• Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Cardio-Pulmonary Department, Pulmonary Division, Faculdade de Medicina, Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.
• Br J Anaesth. 2022 Jun 1; 128 (6): 104010511040-1051.

BackgroundHigh intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery.MethodsThe three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed.ResultsComplete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17).ConclusionsHigh PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications.Clinical Trial RegistrationNCT03937375 (Clinicaltrials.gov).Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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