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Background <p>Despite the physiological advantages of positive end-expiratory pressure (PEEP), its optimal utilization during one-lung ventilation (OLV) remains uncertain. We aimed to investigate whether individualized PEEP titration by lung compliance is associated with a reduced risk of postoperative pulmonary complications during OLV.</p> Methods <p>We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials until April 1, 2024, to identify published randomized controlled trials that compared individualized PEEP titration by lung compliance with fixed PEEP during OLV. The primary outcome was a composite of postoperative pulmonary complications. Secondary outcomes included clinical outcomes (pneumonia, atelectasis, ARDS, cardiovascular complications, mortality), respiratory mechanics, gas exchanges, and hemodynamic variables. Subgroup analyses were conducted for the primary outcome according to the PEEP titration method (dynamic compliance <i>vs.</i> driving pressure/static compliance, stepwise decremental <i>vs.</i> incremental strategy).</p> Results <p>Ten trials involving 3426 patients were included. Compared with fixed PEEP, individualized PEEP titration by lung compliance was associated with reduced risk of a composite of postoperative pulmonary complications (eight trials, 3351 patients, risk ratio [RR] 0.55, 95% CI 0.38–0.78). Subgroup analyses suggested the association was evident in the subgroup with titration by dynamic compliance rather than driving pressure/static compliance and in the subgroup with PEEP titration by stepwise decremental but not stepwise incremental strategy. Individualized PEEP titration by lung compliance was also associated with a reduced risk of pneumonia (RR 0.71, 95% CI 0.52–0.96) and atelectasis (RR 0.63, 95% CI 0.45–0.88), higher dynamic compliance, PaO<sub>2</sub>, PaO<sub>2</sub>/FiO<sub>2</sub>, and lower driving pressure. The individualized and fixed PEEP groups did not differ in ARDS, cardiovascular complications, mortality, peak pressure, plateau pressure, PaCO<sub>2</sub>, heart rate, and mean arterial pressure.</p> Conclusions <p>Compared with fixed PEEP, individualized PEEP titration by lung compliance is associated with a reduced risk of postoperative pulmonary complications during OLV, especially in PEEP titration by dynamic compliance or stepwise decremental strategy. It improves respiratory mechanics and oxygenation with no difference in hemodynamic variables.</p> <p><i>Trial registration number</i> ClinicalTrials.gov (PROSPERO No. CRD42024529980).</p>

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Individualized PEEP titration by lung compliance during one-lung ventilation: a meta-analysis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年1月15日

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  • Wan-Jie Gu,
  • Feng-Zhi Zhao,
  • Federico Piccioni,
  • Rui Shi,
  • Xiang Si,
  • Shuo Chen,
  • Maurizio Cecconi,
  • Hai-Yan Yin

摘要

Background

Despite the physiological advantages of positive end-expiratory pressure (PEEP), its optimal utilization during one-lung ventilation (OLV) remains uncertain. We aimed to investigate whether individualized PEEP titration by lung compliance is associated with a reduced risk of postoperative pulmonary complications during OLV.

Methods

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials until April 1, 2024, to identify published randomized controlled trials that compared individualized PEEP titration by lung compliance with fixed PEEP during OLV. The primary outcome was a composite of postoperative pulmonary complications. Secondary outcomes included clinical outcomes (pneumonia, atelectasis, ARDS, cardiovascular complications, mortality), respiratory mechanics, gas exchanges, and hemodynamic variables. Subgroup analyses were conducted for the primary outcome according to the PEEP titration method (dynamic compliance vs. driving pressure/static compliance, stepwise decremental vs. incremental strategy).

Results

Ten trials involving 3426 patients were included. Compared with fixed PEEP, individualized PEEP titration by lung compliance was associated with reduced risk of a composite of postoperative pulmonary complications (eight trials, 3351 patients, risk ratio [RR] 0.55, 95% CI 0.38–0.78). Subgroup analyses suggested the association was evident in the subgroup with titration by dynamic compliance rather than driving pressure/static compliance and in the subgroup with PEEP titration by stepwise decremental but not stepwise incremental strategy. Individualized PEEP titration by lung compliance was also associated with a reduced risk of pneumonia (RR 0.71, 95% CI 0.52–0.96) and atelectasis (RR 0.63, 95% CI 0.45–0.88), higher dynamic compliance, PaO2, PaO2/FiO2, and lower driving pressure. The individualized and fixed PEEP groups did not differ in ARDS, cardiovascular complications, mortality, peak pressure, plateau pressure, PaCO2, heart rate, and mean arterial pressure.

Conclusions

Compared with fixed PEEP, individualized PEEP titration by lung compliance is associated with a reduced risk of postoperative pulmonary complications during OLV, especially in PEEP titration by dynamic compliance or stepwise decremental strategy. It improves respiratory mechanics and oxygenation with no difference in hemodynamic variables.

Trial registration number ClinicalTrials.gov (PROSPERO No. CRD42024529980).