• Christoph Boesing, Laura Schaefer, Jochen Johannes Schoettler, Alena Quentin, Grietje Beck, Manfred Thiel, Patrick Honeck, Karl-Friedrich Kowalewski, Paolo Pelosi, RoccoPatricia R MPRM, Thomas Luecke, and Joerg Krebs.
• From the Department of Anaesthesiology and Critical Care Medicine (CB, LS, JJS, AQ, GB, MT, TL, JK), Department of Urology and Urosurgery, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany (PH, KFK), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Department of Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP) and Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil (PRMR).
• Eur J Anaesthesiol. 2023 Nov 1; 40 (11): 817825817-825.

BackgroundThe Trendelenburg position with pneumoperitoneum during surgery promotes dorsobasal atelectasis formation, which impairs respiratory mechanics and increases lung stress and strain. Positive end-expiratory pressure (PEEP) can reduce pulmonary inhomogeneities and preserve end-expiratory lung volume (EELV), resulting in decreased inspiratory strain and improved gas-exchange. The optimal intraoperative PEEP strategy is unclear.ObjectivesTo compare the effects of individualised PEEP titration strategies on set PEEP levels and resulting transpulmonary pressures, respiratory mechanics, gas-exchange and haemodynamics during Trendelenburg position with pneumoperitoneum.DesignProspective, randomised, crossover single-centre physiologic trial.SettingUniversity hospital.PatientsThirty-six patients receiving robot-assisted laparoscopic radical prostatectomy.InterventionsRandomised sequence of three different PEEP strategies: standard PEEP level of 5 cmH 2 O (PEEP 5 ), PEEP titration targeting a minimal driving pressure (PEEP ΔP ) and oesophageal pressure-guided PEEP titration (PEEP Poeso ) targeting an end-expiratory transpulmonary pressure ( PTP ) of 0 cmH 2 O.Main Outcome MeasuresThe primary endpoint was the PEEP level when set according to PEEP ΔP and PEEP Poeso compared with PEEP of 5 cmH 2 O. Secondary endpoints were respiratory mechanics, lung volumes, gas-exchange and haemodynamic parameters.ResultsPEEP levels differed between PEEP ΔP , PEEP Poeso and PEEP5 (18.0 [16.0 to 18.0] vs. 20.0 [18.0 to 24.0]vs. 5.0 [5.0 to 5.0] cmH 2 O; P  < 0.001 each). End-expiratory PTP and lung volume were lower in PEEP ΔP compared with PEEP Poeso ( P  = 0.014 and P  < 0.001, respectively), but driving pressure, lung stress, as well as respiratory system and dynamic elastic power were minimised using PEEP ΔP ( P  < 0.001 each). PEEP ΔP and PEEP Poeso improved gas-exchange, but PEEP Poeso resulted in lower cardiac output compared with PEEP 5 and PEEP ΔP .ConclusionPEEP ΔP ameliorated the effects of Trendelenburg position with pneumoperitoneum during surgery on end-expiratory PTP and lung volume, decreased driving pressure and dynamic elastic power, as well as improved gas-exchange while preserving cardiac output.Trial RegistrationGerman Clinical Trials Register (DRKS00028559, date of registration 2022/04/27). https://drks.de/search/en/trial/DRKS00028559.Copyright © 2023 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.

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