Individualized PEEP titration by lung compliance during one-lung ventilation: a meta-analysis.

Summary

Across 10 RCTs (n=3426), individualized PEEP titration by lung compliance during OLV reduced postoperative pulmonary complications versus fixed PEEP (RR 0.55). Benefits were strongest with dynamic compliance-based, decremental strategies, with improved mechanics/oxygenation and no hemodynamic penalty.

Key Findings

• Meta-analysis of 10 RCTs (n=3426) showed reduced composite postoperative pulmonary complications with individualized PEEP (RR 0.55, 95% CI 0.38–0.78).
• Risk of pneumonia (RR 0.71) and atelectasis (RR 0.63) decreased; respiratory mechanics and oxygenation improved without hemodynamic differences.
• Benefits concentrated in dynamic compliance-based titration and stepwise decremental strategies rather than driving pressure/static compliance or incremental strategies.

Clinical Implications

In thoracic anesthesia, consider dynamic compliance-guided, decremental PEEP titration rather than fixed PEEP during OLV to reduce pneumonia/atelectasis and improve oxygenation.

Limitations

• Heterogeneity in PEEP titration methods and definitions of postoperative pulmonary complications
• Potential publication bias and limited blinding feasibility in ventilation strategy trials

Future Directions

Standardize dynamic compliance measurement and decremental protocols; test implementation strategies and patient-centered outcomes in pragmatic trials.