Optimal intraoperative PEEP varies among patients. Individualizing PEEP reduces post-operative atelectasis.

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• Sérgio M Pereira, Mauro R Tucci, Morais Caio C A CCA, Claudia M Simões, Bruno F F Tonelotto, Michel S Pompeo, Fernando U Kay, Paolo Pelosi, Joaquim E Vieira, and Amato Marcelo B P MBP.
• From Divisao de Anestesia, Terapia Intensiva e Dor (S.M.P., C.M.S., B.F.F.T., M.S.P., J.E.V.) Divisao de Pneumologia, Instituto do Coracao (S.M.P., M.R.T., C.C.A.M., M.B.P.A.), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil Anesthesia Department, Hospital Sírio-Libanes, Sao Paulo, Brazil (C.M.S., B.F.F.T, ) UT Southwestern Medical Center - Radiology Department, Dallas, Texas (F.U.K.) Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino Policlinico Hospital, University of Genoa, Italy (P.P.).
• Anesthesiology. 2018 Dec 1; 129 (6): 1070-1081.

What We Already Know About This TopicWHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been established, the added protection afforded by positive end-expiratory pressure (PEEP) remains uncertain. The authors hypothesized that a low fixed PEEP might not fit all patients and that an individually titrated PEEP during anesthesia might improve lung function during and after surgery.MethodsForty patients were studied in the operating room (20 laparoscopic and 20 open-abdominal). They underwent elective abdominal surgery and were randomized to institutional PEEP (4 cm H2O) or electrical impedance tomography-guided PEEP (applied after recruitment maneuvers and targeted at minimizing lung collapse and hyperdistension, simultaneously). Patients were extubated without changing selected PEEP or fractional inspired oxygen tension while under anesthesia and submitted to chest computed tomography after extubation. Our primary goal was to individually identify the electrical impedance tomography-guided PEEP value producing the best compromise of lung collapse and hyperdistention.ResultsElectrical impedance tomography-guided PEEP varied markedly across individuals (median, 12 cm H2O; range, 6 to 16 cm H2O; 95% CI, 10-14). Compared with PEEP of 4 cm H2O, patients randomized to the electrical impedance tomography-guided strategy had less postoperative atelectasis (6.2 ± 4.1 vs. 10.8 ± 7.1% of lung tissue mass; P = 0.017) and lower intraoperative driving pressures (mean values during surgery of 8.0 ± 1.7 vs. 11.6 ± 3.8 cm H2O; P < 0.001). The electrical impedance tomography-guided PEEP arm had higher intraoperative oxygenation (435 ± 62 vs. 266 ± 76 mmHg for laparoscopic group; P < 0.001), while presenting equivalent hemodynamics (mean arterial pressure during surgery of 80 ± 14 vs. 78 ± 15 mmHg; P = 0.821).ConclusionsPEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery. Individualized PEEP settings could reduce postoperative atelectasis (measured by computed tomography) while improving intraoperative oxygenation and driving pressures, causing minimum side effects.

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