Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial

Ana Fernandez-Bustamante, Juraj Sprung, Robert A. Parker, Karsten Bartels, Toby N. Weingarten, Carolina Kosour, B. Taylor Thompson, Marcos F. Vidal Melo

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Background: Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. Methods: In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). Results: Thirty-seven patients (48.6% female; age range: 47–73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7–10]), compared with the control group (12 cm H2O [10–15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2–68.8] vs controls: 39.0 ml cm H2O [32.9–43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14–0.35]), both between, and within, subjects throughout surgery. Conclusions: This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. Clinical trial registration: NCT02671721.

Original languageEnglish (US)
Pages (from-to)383-392
Number of pages10
JournalBritish Journal of Anaesthesia
Issue number3
StatePublished - Sep 2020
Externally publishedYes


  • lung compliance
  • mechanical ventilation
  • positive end-expiratory pressure
  • postoperative pulmonary complications
  • respiratory mechanics
  • ventilator-induced lung injury

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine


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