• Yoon Jung Kim, Bo Rim Kim, Hee Won Kim, Ji-Yoon Jung, Hye-Yeon Cho, Jeoung-Hwa Seo, Won Ho Kim, Hee-Soo Kim, Suhyun Hwangbo, and Hyun-Kyu Yoon.
• Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
• Br J Anaesth. 2023 Nov 1; 131 (5): 955965955-965.

BackgroundIndividualised positive end-expiratory pressure (PEEP) improves respiratory mechanics. However, whether PEEP reduces postoperative pulmonary complications (PPCs) remains unclear. We investigated whether driving pressure-guided PEEP reduces PPCs after laparoscopic/robotic abdominal surgery.MethodsThis single-centre, randomised controlled trial enrolled patients at risk for PPCs undergoing laparoscopic or robotic lower abdominal surgery. The individualised group received driving pressure-guided PEEP, whereas the comparator group received 5 cm H2O fixed PEEP during surgery. Both groups received a tidal volume of 8 ml kg-1 ideal body weight. The primary outcome analysed per protocol was a composite of pulmonary complications (defined by pre-specified clinical and radiological criteria) within 7 postoperative days after surgery.ResultsSome 384 patients (median age: 67 yr [inter-quartile range: 61-73]; 66 [18%] female) were randomised. Mean (standard deviation) PEEP in patients randomised to individualised PEEP (n=178) was 13.6 cm H2O (2.1). Individualised PEEP resulted in lower mean driving pressures (14.7 cm H2O [2.6]), compared with 185 patients randomised to standard PEEP (18.4 cm H2O [3.2]; mean difference: -3.7 cm H2O [95% confidence interval (CI): -4.3 to -3.1 cm H2O]; P<0.001). There was no difference in the incidence of pulmonary complications between individualised (25/178 [14.0%]) vs standard PEEP (36/185 [19.5%]; risk ratio [95% CI], 0.72 [0.45-1.15]; P=0.215). Pulmonary complications as a result of desaturation were less frequent in patients randomised to individualised PEEP (8/178 [4.5%], compared with standard PEEP (30/185 [16.2%], risk ratio [95% CI], 0.28 [0.13-0.59]; P=0.001).ConclusionsDriving pressure-guided PEEP did not decrease the incidence of pulmonary complications within 7 days of laparoscopic or robotic lower abdominal surgery, although uncertainty remains given the lower than anticipated event rate for the primary outcome.Clinical Trial RegistrationKCT0004888 (http://cris.nih.go.kr, registration date: April 6, 2020).Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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