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

Summary

In 1,435 high-risk adults undergoing open abdominal surgery, driving pressure–guided high PEEP with recruitment maneuvers did not reduce postoperative pulmonary complications versus standard low PEEP (19.8% vs 17.4%; absolute difference 2.5%, 95% CI -1.5% to 6.4%; P=.23). High PEEP increased intraoperative hypotension and vasoactive use, while desaturation events were fewer with high PEEP.

Key Findings

• Primary composite pulmonary complications within 5 days: 19.8% (high PEEP) vs 17.4% (low PEEP); absolute difference 2.5% (95% CI -1.5% to 6.4%); P=.23
• Intraoperative hypotension and vasoactive agent use were higher with high PEEP (hypotension 54.0% vs 45.0%; vasoactive use 32.0% vs 18.8%)
• Intraoperative desaturation events were fewer in the high PEEP group (0.8% vs 2.8%)

Clinical Implications

Standard low PEEP with low tidal volume should remain the default during open abdominal surgery; avoid routine high PEEP–recruitment strategies targeting lower driving pressure due to lack of benefit and increased hypotension. If high PEEP is considered, ensure vigilant hemodynamic monitoring and individualized risk assessment.

Limitations

• Open-label design and composite primary outcome may dilute specific effects
• Generalizability to laparoscopic or non-abdominal surgeries and long-term pulmonary outcomes is uncertain

Future Directions

Identify subgroups that may benefit or be harmed by higher PEEP and test pragmatic hemodynamic-guided ventilation strategies balancing oxygenation and perfusion.