Intraoperative driving pressure–guided high PEEP vs standard low PEEP for postoperative pulmonary complications

Citation:

Dorland G, Gama de Abreu M, Hemmes SNT, Hol L, Hollmann MW, van Meenen DMP, Nijbroek SGLH, et al. Intraoperative driving pressure–guided high PEEP vs standard low PEEP for postoperative pulmonary complications. JAMA. 2025;[published online December 3]. doi:10.1001/jama.2025.23373.

Study at a glance

- Design and setting: International, multicentre, assessor-blinded parallel-group RCT in adults at intermediate/high risk of postoperative pulmonary complications undergoing open abdominal surgery (29 hospitals in 5 European countries; N=1435 analysed).

- Interventions: Individualized driving pressure–guided high PEEP with repeated recruitment maneuvers vs standard low PEEP (5 cm H2O) without recruitment; both groups received low tidal volume volume-controlled ventilation and contemporary perioperative care.

- Primary outcome (composite postoperative pulmonary complications ≤5 days): 19.8% with high PEEP vs 17.4% with low PEEP; absolute risk difference 2.5 percentage points (95% CI −1.5 to 6.4; p=0.23) — no clear reduction in pulmonary complications; low-certainty evidence.

- Key secondary: Intraoperative complications were more frequent with high PEEP, mainly hypotension (54.0% vs 45.0%) and vasoactive drug use (32.0% vs 18.8%), while desaturation was less common (0.8% vs 2.8%); postoperative extrapulmonary complications, ICU/hospital length of stay, and in-hospital mortality (3.6% vs 3.3%) were similar between groups.

- Safety: High PEEP increased intraoperative hemodynamic instability without demonstrable benefit on postoperative pulmonary outcomes or mortality; overall evidence suggests avoiding routine driving pressure–guided high PEEP for this population (moderate certainty for intraoperative harms, low to very low for most other clinical endpoints).