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Purpose <p>Airway driving pressure has garnered considerable attention for lung-protective ventilation. We evaluated the clinical effectiveness of airway driving pressure as a target to individualize positive-end-expiratory pressure (PEEP) setting in mechanically ventilated patients at risk for postoperative respiratory failure.</p> Methods <p>We conducted a multicenter, pragmatic, assessor-masked, randomized trial among adult patients undergoing emergency abdominal surgery in 22 hospitals in France. Patients were assigned 1:1 to receive individually adjusted highest PEEP targeting a driving pressure &lt; 13 cmH<sub>2</sub>O after an initial recruitment maneuver (intervention group) or to a fixed PEEP level of 5 cmH<sub>2</sub>O (control group). The primary outcome was a composite of postoperative respiratory failure (failure to wean from the ventilator or the composite of reintubation or curative non-invasive ventilation) or all-cause mortality at 30&#xa0;days. Secondary outcomes included components of the composite primary outcome.</p> Results <p>The primary outcome occurred in 87 out of 338 (25.7%) intervention patients and in 69 out of 341 (20.2%) control patients (difference, 5.5%; 95% confidence interval [CI] − 0.8 to 11.8; relative risk, 1.27; 95%CI 0.96–1.68; <i>p</i> = 0.08). The difference was primarily due to an increased incidence of reintubation or need for curative non-invasive ventilation among intervention patients (difference, 7.1%; 95% CI 2.5–11.9; relative risk, 1.97; 95% CI 1.24–3.11; <i>p</i> = 0.004). Other secondary outcomes did not differ.</p> Conclusion <p>Among patients at risk for postoperative respiratory failure after emergency abdominal surgery, a strategy of individually adjusted highest PEEP in targeting driving pressure lower than 13 cmH<sub>2</sub>O did not reduce postoperative respiratory failure or death.</p> Trial registration <p>ClinicalTrials.gov Identifier: NCT03987789.</p>

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Personalized driving pressure-guided positive end-expiratory pressure in patients at risk of postoperative respiratory failure (IMPROVE-2): a multicenter, pragmatic, randomized clinical trial

  • 期刊论文

  • 发表日期：

    2025年8月21日

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  • Emmanuel Futier,
  • Audrey De Jong,
  • Cédric Cirenei,
  • Thomas Godet,
  • Matthieu Jabaudon,
  • Jean-Michel Constantin,
  • Nicolas Grillot,
  • Pierre Bouzat,
  • Lois Henry,
  • Dimitri Margetis,
  • Gilles Lebuffe,
  • Marc Garnier,
  • Céline Lambert,
  • Bruno Pereira,
  • Samir Jaber,
  • Thomas Godet,
  • Ugo Schiff,
  • Benoît Baietto,
  • Bertille Paquette,
  • Oana Cherbis,
  • Jean–Etienne Bazin,
  • Samir Jaber,
  • Audrey De Jong,
  • Gilles Lebuffe,
  • Cédric Cirenei,
  • Lois Henry,
  • Nicolas Grillot,
  • Pierre Bouzat,
  • Jean-Michel Constantin,
  • Dimitri Margetis,
  • Marc Garnier,
  • Hélène Beloeil,
  • Serge Molliex,
  • Julien Pottecher,
  • Philippe Cuvillon,
  • Sigismond Lasocki,
  • Marion Faucher,
  • Djamel Mokart,
  • Emmanuel Samain,
  • Jean Stéphane David,
  • Vincent Minville,
  • Marc Leone

摘要

Purpose

Airway driving pressure has garnered considerable attention for lung-protective ventilation. We evaluated the clinical effectiveness of airway driving pressure as a target to individualize positive-end-expiratory pressure (PEEP) setting in mechanically ventilated patients at risk for postoperative respiratory failure.

Methods

We conducted a multicenter, pragmatic, assessor-masked, randomized trial among adult patients undergoing emergency abdominal surgery in 22 hospitals in France. Patients were assigned 1:1 to receive individually adjusted highest PEEP targeting a driving pressure < 13 cmH2O after an initial recruitment maneuver (intervention group) or to a fixed PEEP level of 5 cmH2O (control group). The primary outcome was a composite of postoperative respiratory failure (failure to wean from the ventilator or the composite of reintubation or curative non-invasive ventilation) or all-cause mortality at 30 days. Secondary outcomes included components of the composite primary outcome.

Results

The primary outcome occurred in 87 out of 338 (25.7%) intervention patients and in 69 out of 341 (20.2%) control patients (difference, 5.5%; 95% confidence interval [CI] − 0.8 to 11.8; relative risk, 1.27; 95%CI 0.96–1.68; p = 0.08). The difference was primarily due to an increased incidence of reintubation or need for curative non-invasive ventilation among intervention patients (difference, 7.1%; 95% CI 2.5–11.9; relative risk, 1.97; 95% CI 1.24–3.11; p = 0.004). Other secondary outcomes did not differ.

Conclusion

Among patients at risk for postoperative respiratory failure after emergency abdominal surgery, a strategy of individually adjusted highest PEEP in targeting driving pressure lower than 13 cmH2O did not reduce postoperative respiratory failure or death.

Trial registration

ClinicalTrials.gov Identifier: NCT03987789.