Driving Pressure–Guided Individualized Positive End-Expiratory Pressure in Abdominal Surgery: A Randomized Controlled Trial

Abstract

BACKGROUND: The optimal positive end-expiratory pressure (PEEP) to prevent postoperative pulmonary complications (PPCs) remains unclear. Recent evidence showed that driving pressure was closely related to PPCs. In this study, we tested the hypothesis that an individualized PEEP guided by minimum driving pressure during abdominal surgery would reduce the incidence of PPCs. METHODS: This single-centered, randomized controlled trial included a total of 148 patients scheduled for open upper abdominal surgery. Patients were randomly assigned to receive an individualized PEEP guided by minimum driving pressure or an empiric fixed PEEP of 6 cm H2O. The primary outcome was the incidence of clinically significant PPCs within the first 7 days after surgery, using a χ2 test. Secondary outcomes were the severity of PPCs, the area of atelectasis, and pleural effusion. Other outcomes, such as the incidence of different types of PPCs (including hypoxemia, atelectasis, pleural effusion, dyspnea, pneumonia, pneumothorax, and acute respiratory distress syndrome), intensive care unit (ICU) admission rate, length of hospital stay, and 30-day mortality were also explored. RESULTS: The median value of PEEP in the individualized group was 10 cm H2O. The incidence of clinically significant PPCs was significantly lower in the individualized PEEP group compared with that in the fixed PEEP group (26 of 67 [38.8%] vs 42 of 67 [62.7%], relative risk = 0.619, 95% confidence intervals, 0.435–0.881; P = .006). The overall severity of PPCs and the area of atelectasis were also significantly diminished in the individualized PEEP group. Higher respiratory compliance during surgery and improved intra- and postoperative oxygenation was observed in the individualized group. No significant differences were found in other outcomes between the 2 groups, such as ICU admission rate or 30-day mortality. CONCLUSIONS: The application of individualized PEEP based on minimum driving pressure may effectively decrease the severity of atelectasis, improve oxygenation, and reduce the incidence of clinically significant PPCs after open upper abdominal surgery.

Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications–posthoc analysis of two randomised clinical trials in open abdominal surgery

“… 15 , 21 Recently, a single–centre randomised clinical trial showed that using driving pressure–guided individualized PEEP levels resulted in less clinically significant postoperative pulmonary complications compared to using a fixed PEEP in patients undergoing open upper abdominal surgery. 27 These findings should be verified in future randomised clinical trials. The absence of an association between driving pressure and the occurrence of postoperative pulmonary complications in our study could be due to a lack of statistical power.…”

Effect of Driving Pressure-Oriented Ventilation on Patients Undergoing One-Lung Ventilation During Thoracic Surgery: A Systematic Review and Meta-Analysis

“…Our findings suggest that driving pressure-oriented ventilation reduces the incidence of PPC S in patients undergoing thoracic surgery, which is consistent with previous findings ( 1 ). Despite some heterogeneity in the type of surgery, the results of previous studies have demonstrated that driving pressure-oriented ventilation can reduce the incidence of PPC S and improve patient prognosis ( 1 , 34 ). Since driving pressure is a new concept, this strategy is more widely used in patients with ARDS, and the number of RCTs that have focused on this aspect of thoracic surgery is limited.…”

ΔP-Guided PEEP in the Operating Room––Do We Need More Guidance?

“…One interesting finding in the study by Zhang et al 2 was that mechanical power (MP) of ventilation was higher in the ΔP-guided PEEP group. MP can be seen as the amount of energy transferred from the ventilator to the lung, and has been proposed, alongside ΔP, as an additional biomarker to guide ventilation.…”

“…In their study, Zhang et al 2 used the first approach, ie, they used incremental PEEP trials. The “Driving PrESsure DurIng GeNeral AnesThesIa for Open AbdOmiNal Surgery” (DESIGNATION) study is an international multicenter ongoing randomized clinical trial in which a decremental PEEP trial is used to select the best PEEP, after an initial incremental PEEP trial to 20 cm H 2 O as a recruitment maneuver.…”

“…A “personalized” PEEP approach may be more appropriate, as the balance between prevention of atelectasis and induction of overdistension probably differs between patients. Since ΔP is a “digital” biomarker for both atelectasis and overdistension, a ΔP-guided PEEP strategy has been proposed before, 1 and recently in your journal, Zhang et al 2 presented the findings of a randomized clinical trial confirming benefit of a ΔP-guided PEEP strategy in patients undergoing open abdominal surgery.…”