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

Summary

Across 10 RCTs (n=3426), compliance-guided individualized PEEP during one-lung ventilation reduced postoperative pulmonary complications (RR 0.55), with benefits driven by dynamic compliance and decremental titration strategies. Pneumonia and atelectasis were also reduced, with improved respiratory mechanics and oxygenation and no hemodynamic penalty.

Key Findings

• Individualized PEEP by lung compliance reduced composite postoperative pulmonary complications (RR 0.55, 95% CI 0.38–0.78).
• Reductions in pneumonia (RR 0.71) and atelectasis (RR 0.63) with improved dynamic compliance and oxygenation.
• Benefits were most evident with dynamic compliance–guided, stepwise decremental titration; no hemodynamic differences observed.

Clinical Implications

Use dynamic compliance with stepwise decremental PEEP titration during one-lung ventilation to reduce postoperative pulmonary complications, pneumonia, and atelectasis without hemodynamic compromise.

Limitations

• Heterogeneity in titration protocols and outcome definitions across trials
• Incomplete reporting of gas exchange endpoints (truncated in abstract) and limited patient-level data

Future Directions

Conduct patient-level meta-analyses and pragmatic RCTs comparing dynamic compliance vs driving pressure strategies, and validate protocols in diverse thoracic surgical populations.