Intraoperative Driving Pressure-Guided High PEEP vs Standard Low PEEP for Postoperative Pulmonary Complications.

Summary

In adults at risk undergoing open abdominal surgery, a driving pressure–guided high PEEP strategy with recruitment maneuvers did not reduce postoperative pulmonary complications versus standard low PEEP. The high PEEP strategy increased intraoperative hypotension and vasoactive use, while low PEEP had more brief desaturation events. All patients received low tidal volume ventilation.

Key Findings

• Primary composite pulmonary complications: 19.8% (high PEEP) vs 17.4% (low PEEP); absolute difference 2.5% (95% CI −1.5% to 6.4%), P=0.23
• Higher intraoperative hypotension and vasoactive use with high PEEP; more desaturation events in the low PEEP group
• All patients received low tidal volume ventilation; 29 sites across 5 European countries; n=1435 completed

Clinical Implications

Avoid routine high PEEP with recruitment maneuvers to prevent postoperative pulmonary complications in open abdominal surgery; prioritize low tidal volumes and consider hemodynamic tolerance. Tailored PEEP strategies should be reserved for selected physiologic indications.

Limitations

• Composite primary outcome may dilute specific effect signals
• Potential lack of blinding to intraoperative strategy; generalizability primarily to open abdominal surgery

Future Directions

Identify physiologic subgroups that may benefit from higher PEEP or recruitment, refine driving pressure targets, and evaluate hemodynamic-optimized ventilation protocols.