Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients A Randomized Clinical Trial

The objective of this randomized trial was to determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with lower levels of PEEP. A total of 2013 adults with a BMI of 35 or higher undergoing non-cardiac, non-neurological surgery under GA from 77 sites in 23 countries were included. Patients were randomized to a high level of PEEP of 12 cm H2O with alveolar recruitment maneuvers or to a low level of PEEP of 4 cm H2O. All patients received a tidal volume of 7ml/kg tidal volume. The primary outcome was a composite of pulmonary complications within the first 5 postoperative days including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Secondary outcomes included intraoperative hypoxemia. There was no difference in the primary outcome 21.3% vs. 23.6% in the high PEEP vs. low PEEP group. Fewer patients had hypoxemia in the high vs. low PEEP group 5.0 vs. 13.6%, P<0.001). The authors concluded that an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers did not reduce postoperative pulmonary complications.