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

Summary

In 1435 high-risk adults undergoing open abdominal surgery, a strategy of driving pressure–guided high PEEP with recruitment maneuvers did not lower the incidence of postoperative pulmonary complications compared with standard low PEEP. High PEEP increased intraoperative hypotension and vasoactive use, while low PEEP had more transient desaturation events.

Key Findings

• Primary outcome (postoperative pulmonary complication composite) was similar: 19.8% (high PEEP) vs 17.4% (low PEEP), P=0.23.
• High PEEP increased intraoperative hypotension (54.0% vs 45.0%) and vasoactive agent use (32.0% vs 18.8%).
• Low PEEP group had more intraoperative desaturation events (2.8% vs 0.8%).

Clinical Implications

Standard low tidal volume ventilation with low PEEP remains appropriate for open abdominal surgery; routine use of high PEEP titrated to driving pressure with recruitment maneuvers should be reconsidered given lack of benefit and higher hypotension.

Limitations

• Composite outcome may dilute effects on individual complications.
• Open-label intraoperative strategies could not be blinded; applicability to laparoscopic surgery is uncertain.

Future Directions

Identify subgroups (e.g., severe obesity, baseline atelectasis risk) that may benefit from higher PEEP, and refine individualized ventilation beyond PEEP titration (e.g., recruitment timing, monitoring).