Perioperative Medicine

ABSTRACT
Background: Individualized positive end-expiratory pressure (PEEP) guided
by dynamic compliance improves oxygenation and reduces postoperative atel-

Individualized Positive ectasis in nonobese patients. The authors hypothesized that dynamic com-
pliance–guided PEEP could also reduce postoperative atelectasis in patients

End-expiratory Pressure
undergoing bariatric surgery.
Methods: Patients scheduled to undergo laparoscopic bariatric surgery
on Postoperative were eligible. Dynamic compliance–guided PEEP titration was conducted in all
patients using a downward approach. A recruitment maneuver (PEEP from 10

Atelectasis in Patients to 25 cm H2O at 5–cm H2O step every 30 s, with 15–cm H2O driving pressure)

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

was conducted both before and after the titration. Patients were then random-

with Obesity: A ized (1:1) to undergo surgery under dynamic compliance–guided PEEP (PEEP
with highest dynamic compliance plus 2 cm H2O) or PEEP of 8 cm H2O. The

Randomized Controlled primary outcome was postoperative atelectasis, as assessed with computed
tomography at 60 to 90 min after extubation, and expressed as percentage

Clinical Trial
to total lung tissue volume. Secondary outcomes included Pao2/inspiratory
oxygen fraction (Fio2) and postoperative pulmonary complications.

Xiang Li, M.D., He Liu, M.D., Ph.D., Jun Wang, M.D., Results: Forty patients (mean ± SD; 28 ± 7 yr of age; 25 females; average
body mass index, 41.0 ± 4.7 kg/m2) were enrolled. Median PEEP with highest
Zhi-Lin Ni, M.D., Zhong-Xiao Liu, M.D., Jia-Li Jiao, M.S.,
dynamic compliance during titration was 15 cm H2O (interquartile range, 13
Yuan Han, M.D., Ph.D., Jun-Li Cao, M.D., Ph.D.
to 17; range, 8 to 19) in the entire sample of 40 patients. The primary out-
Anesthesiology 2023; 139:262–73 come of postoperative atelectasis (available in 19 patients in each group) was
13.1 ± 5.3% and 9.5 ± 4.3% in the PEEP of 8 cm H2O and dynamic compliance–
guided PEEP groups, respectively (intergroup difference, 3.7%; 95% CI, 0.5
EDITOR’S PERSPECTIVE to 6.8%; P = 0.025). Pao2/Fio2 at 1 h after pneumoperitoneum was higher in
the dynamic compliance–guided PEEP group (397 vs. 337 mmHg; group dif-
What We Already Know about This Topic ference, 60; 95% CI, 9 to 111; P = 0.017) but did not differ between the two
• Atelectasis is common after bariatric surgery and may predispose groups 30 min after extubation (359 vs. 375 mmHg; group difference, –17;
the patient to postoperative pulmonary complications. 95% CI, –53 to 21; P = 0.183). The incidence of postoperative pulmonary
• Optimal methods for reducing atelectasis using varying levels of complications was 4 of 20 in both groups.
positive end-expiratory pressure (PEEP) or recruitment maneuvers Conclusions: Postoperative atelectasis was lower in patients undergoing
are controversial.
laparoscopic bariatric surgery under dynamic compliance–guided PEEP ver-
What This Article Tells Us That Is New sus PEEP of 8 cm H2O. Postoperative Pao2/Fio2 did not differ between the two
groups.
• The authors randomized patients undergoing bariatric surgery to
undergo surgery with an optimal dynamic compliance–determined (ANESTHESIOLOGY 2023; 139:262–73)
level of PEEP or a fixed PEEP level of 8 cm H2O (following a stan-
dardized recruitment maneuver). Computed tomography was per-
formed in the early postoperative period to quantitate the degree
• The median PEEP level determined by optimal dynamic compliance
of atelectasis (primary outcome). Secondary outcomes included
was nearly double that of the control group (15 cm H2O).
Pao2/inspiratory oxygen fraction ratio and postoperative pulmonary
• The primary outcome was significantly reduced, although no signif-
complications.
icant differences were noted in postoperative secondary outcomes.

This article is featured in “This Month in Anesthesiology,” page A1. This article is accompanied by an editorial on p. 239. This article has a related Infographic on p. A17.
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links
to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). This article has a visual abstract available in the online version.
X.L. and H.L. contributed equally to this article.
Submitted for publication July 9, 2022. Accepted for publication April 27, 2023. Published online first on July 13, 2023.
Xiang Li, M.D.: Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou
Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
He Liu, M.D., Ph.D.: Department of Anesthesiology, Huzhou Central Hospital, Huzhou, China.
Jun Wang, M.D.: Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical
University, Xuzhou, China.
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Anesthesiology 2023; 139:262–73. DOI: 10.1097/ALN.0000000000004603

262 September 2023 ANESTHESIOLOGY, V 139 • NO 3

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Individual PEEP in Obesity

A telectasis is a common complication in patients under-

going surgery under general anesthesia, particularly in
obese patients.1 Postoperative atelectasis could last for more
Materials and Methods
This is a single-center, randomized controlled trial in
patients undergoing laparoscopic bariatric surgery. The trial
than 24 h and contribute to a variety of other complica-
was registered before patient enrollment at clinicaltrials.gov
tions, including hypoxemia and pneumonia.2
(NCT04169607; uniform resource locator: https://clini-
Positive end-expiratory pressure (PEEP) is a strat-
caltrials.gov/ct2/show/NCT04169607; accessed May 20,
egy that helps to keep alveoli open during surgery and
2023; principal investigator: Yuan Han; date of registration:
to prevent postoperative atelectasis. A fixed PEEP with-
November 20, 2019). The trial was approved by the Ethics
out considering the respiratory mechanics in individual
Committee of the Affiliated Hospital of Xuzhou Medical
patients, however, is not optimal. Individualized PEEP
University (Xuzhou, China; ID: XYFY2019-KL168-01).
therefore has been increasingly studied,3–8 and has been
All participants signed informed consent before enrollment.

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

shown to improve oxygenation in both nonobese and
The study was conducted following the Declaration of
obese patients.3,8
Helsinki. Trial reporting complied with the CONsolidated
Optimal PEEP in individual patients could be titrated
Standards of Reporting Trials guidelines.
using several methods, including electrical impedance
tomography, transpulmonary pressure, and respiratory com-
pliance.3–11 Among these methods, only respiratory compli- Patients
ance could be determined without additional equipment Adult inpatients scheduled to undergo laparoscopic bariat-
other than the ventilator. Under zero-flow conditions, static ric surgery were eligible. Recruitment was conducted by
compliance is accurate in reflecting the consequences of the site investigator on the day of admission. Subjects with
PEEP changes on the elastic properties of the respiratory one of more of the following conditions were excluded:
system. However, measuring static compliance requires American Society of Anesthesiologists (Schaumburg,
holding the breath for a few seconds at the end of inspira- Illinois) physical status IV or greater, lung bullae, continuing
tion to allow gas redistribution in the distal lungs, which is smoking within 1 week before surgery, chronic obstructive
not pragmatic for daily practice in our opinion. Dynamic pulmonary disease requiring oxygen, congestive heart fail-
compliance thus represents a viable alternative in titrating ure (New York Heart Association [New York, New York]
optimal PEEP.7,10,12–14 classification III or greater), thoracic surgery history, and
Postoperative atelectasis could be estimated directly using planned transfer to intensive care unit after surgery. Enrolled
computed tomography or indirectly using measures that patients were randomized at a 1:1 ratio to undergo surgery
reflect the level of oxygenation.6,11,15 Computed tomogra- using either dynamic compliance–guided PEEP (2 cm H2O
phy is the only accepted standard method for quantifying above the PEEP with the highest dynamic compliance) or
the exact degree of atelectasis.16 Previous studies using com- a fixed PEEP at 8 cm H2O.
puted tomography to quantify atelectasis have demonstrated
reduced postoperative atelectasis with individualized PEEP Randomization, Concealment, and Blinding
in nonobese patients.6 In contrast, reduced oxygenation with
individualized PEEP has been established but only within a The randomization sequence was generated using SPSS 23
narrow time window after surgery in studies using arterial for Windows (SPSS Inc., USA) by a staff member who was
blood gas and electrical impedance tomography.3,8 not involved in this trial otherwise. Concealment was con-
We conducted a single-center, randomized controlled ducted using sealed, opaque envelopes. The envelope with
trial in patients undergoing laparoscopic bariatric surgery the group allocation for each patient was opened at the
to test the hypothesis that dynamic compliance–guided completion of PEEP titration. The patients, the radiologist,
PEEP could reduce the postoperative atelectasis. and the investigators who assessed the outcomes (except the
intraoperative oxygen saturation measured by pulse oxim-
Zhi-Lin Ni, M.D.: Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical etry (Spo2), respiratory mechanical parameters, and hemo-
University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou dynamic parameters) were blinded to group allocation; all
Medical University, Xuzhou, China.
other personnel were aware of the grouping.
Zhong-Xiao Liu, M.D.: Department of Radiology, Affiliated Hospital of Xuzhou Medical
University, Xuzhou, China.
Jia-Li Jiao, M.S.: Institute of Translational Medicine, Shanghai Jiao Tong University, Standard Procedure
Shanghai, China.
Patients received routine IV rapid sequence anesthesia
Yuan Han, M.D., Ph.D.: Department of Anesthesiology, Eye & Ear, Nose, and Throat induction using sufentanil (0.5 μg/kg lean weight) and
Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of
etomidate (0.3 mg/kg total body weight). Cis-atracurium
Anesthesiology, Xuzhou Medical University, Xuzhou, China.
(0.2 mg/kg total body weight) is given to facilitate tra-
Jun-Li Cao, M.D., Ph.D.: Jiangsu Province Key Laboratory of Anesthesiology,
Xuzhou Medical University, Xuzhou, China.; NMPA Key Laboratory for Research
cheal intubation. After intubation, transversus abdominis
and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, plane block was performed under ultrasound guidance.
Xuzhou, China. Combined IV and inhaled anesthesia was maintained with

Li et al. Anesthesiology 2023; 139:262–73 263

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Perioperative Medicine

propofol, remifentanil, sevoflurane, and cis-atracurium until until the final step of 25 cm H2O PEEP and 40 cm H2O
the end of surgery. Routine intraoperative monitoring inspiratory pressure. The driving pressure was maintained
included Spo2, electrocardiogram, invasive arterial blood at 15 cm H2O throughout the increase. Then the titration
pressure, nasopharyngeal temperature, and muscle relaxant of dynamic compliance–guided PEEP was performed by
monitoring (train-of-four). decreasing the PEEP in steps of 2 cm H2O every 30 s until
the final step of 5 cm H2O in volume-controlled ventila-
tion mode, with the same ventilatory parameters except
Dynamic Compliance Titration
PEEP as those at the beginning of mechanical ventilation.
Mechanical ventilation was conducted in the volume-­ The dynamic compliance was calculated using tidal volume
controlled ventilation mode with a tidal volume of 8 ml/ (VT)/(peak pressure - PEEP). To avoid potential underesti-
kg predicted body weight (male 50 + 0.91 × [height (cm) mation of optimal PEEP value due to pneumoperitoneum,

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

– 152.4], female 45.5 + 0.91 × [height (cm)– 152.4]) using dynamic compliance–guided PEEP was set as 2 cm H2O
an A7 anesthesia machine (Mindray Biomedical Electronics, above the PEEP with the maximum dynamic compliance.
China). Other parameters included PEEP of 8 cm H2O, After the titration trial, Fio2 was lowered to 0.5 to miti-
inspiratory oxygen fraction (Fio2) of 1.0, inspiratory-to-­ gate absorptive atelectasis. A second recruitment maneuver
expiratory ratio of 1:2, 20% inspiratory pause, and respi- was performed using the same protocol as the first recruit-
ratory rate of 12 breaths/min. After randomization, the ment maneuver. All patients received 250 ml IV fluid and
respiratory rate was adjusted to maintain end-tidal carbon 40 μg phenylephrine in a bolus before the first recruitment
dioxide partial pressure at 35 to 45 mmHg. maneuver to prevent hypotension (mean arterial pressure
All patients, regardless of the group assignment, received less than 65 mmHg). If hypotension still occurred, an addi-
a titration trial immediately after intubation. An example of tional bolus of phenylephrine (40 μg) was used.
the titration trial and results (inverted U-shaped relation-
ship between dynamic compliance and PEEP) is shown in
figure 1. Before the start of the titration trial, patients were
Intervention and Control
switched to a 20° to 25° reverse Trendelenburg and 20° to Upon completion of the titration trial, all patients (regardless
25° right-leaning supine position (identical to the position of the group assignment) received dynamic compliance–
during surgery).The titration trial was initiated by a recruit- guided PEEP for 1 min for respiratory mechanical and
ment maneuver, with the following ventilator setting: pres- hemodynamic parameters recording. Then investigators
sure-controlled ventilation mode, 10 cm H2O PEEP, 25 cm opened the envelopes containing the group assignment
H2O inspiratory pressure, 6 breaths/min respiratory rate, 1:2 information. Surgical incision and pneumoperitoneum
inspiratory-to-expiratory ratio. The PEEP and inspiratory insufflation proceeded under dynamic compliance–guided
pressure were then increased in steps of 5 cm H2O per 30 s PEEP for patients in the dynamic compliance–guided

Fig. 1. Titration protocol and results from a representative patient. The patient received a recruitment maneuver before and after the
titration trial. The recruitment maneuver was performed under pressure-controlled ventilation mode, with a stepwise increase in positive
end-expiratory pressure (PEEP) from 10 to 25 by 5 cm H2O every 30 s and a driving pressure of 15 cm H2O. The decremental titration trial was
performed under volume-controlled ventilation mode, with a stepwise decrease in PEEP from 25 to 5 by 2 cm H2O every 40 s. In this patient,
the PEEP that corresponded to the highest dynamic compliance was 17 cm H2O.

264 Anesthesiology 2023; 139:262–73 Li et al.

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Individual PEEP in Obesity

PEEP group, and under 8 cm H2O for patients in the PEEP in between) were used to calculate the amount of atel-
of 8 cm H2O group. PEEP value was maintained through- ectasis for each patient. The validity of this method has
out the surgery after randomization using the volume-­ been established based on good agreement of differently
controlled ventilation mode. Intra-abdominal pressure was aerated compartments between the extrapolated results
maintained at 14 mmHg during surgery. from 10 sections and those from all computed tomog-
After exsufflation of pneumoperitoneum, the ventilation raphy sections by a previous study.18 The lung area was
mode was switched to pressure control, and the patients delineated, and major pulmonary vessels (short diameter
were switched to a supine position. VT was maintained by 3 mm or greater) were excluded manually. Lung aeration
adjusting inspiratory pressure. Extubation was performed in compartments were calculated as a percentage of the
the operating room, and then patients were transferred to total lung tissue volume using the following Hounsfield
postanesthesia care unit. After returning to the ward, sup- unit thresholds: nonaerated (–100 to + 100 Hounsfield

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

plemental oxygen was provided through a venturi mask at a units), poorly aerated (−500 to −101 Hounsfield units),
flow rate of 3 l/min until 8 am next day. normally aerated (−900 to −501 Hounsfield units), and
hyperaerated (−1,000 to −901 Hounsfield units).19 Total
Measurements and Timepoints lung volume (V Lung; including gas and tissue volume)
was calculated used the formula20
The timepoints of measurements are shown in Table E1 in X1  Vi + Vi+1

+ V1 +2 V
N

the Supplemental Digital Content (https://links.lww.com/ V Lung = f

2
t
N

ALN/D153). Arterial blood gas analysis was conducted i=1

before preoxygenation, after intubation, 1 h after insufflation where N is the number of slices, t is the slice thickness, f
of pneumoperitoneum, before extubation, and 30 min after is the distance between slices (feed), and Vi is the lung total
extubation. Respiratory mechanical parameters and hemo- volume in the ith slice. The following formula was used to
dynamic parameters were measured after intubation, titra- calculate the tissue volume of each lung aeration category21:
tion, and randomization, 10 min and 1 h after insufflation Tissue voulume = (1 CT number= 1000 )  total volume
of pneumoperitoneum. Respiratory mechanical parameters
consisted of peak pressure, plateau pressure, driving pressure
(plateau pressure - PEEP), dynamic compliance [VT / (peak Outcomes
pressure – PEEP)], and static compliance [VT / (plateau
Initially, the primary outcome was the difference of atel-
pressure – PEEP)]. Hemodynamic parameters included
ectasis between two chest computed tomography scans
heart rate and mean arterial pressure.
performed preoperatively and at 30 to 60 min after extu-
Spo2 was monitored continuously until 8 am the next
bation. Due to the COVID-19 outbreak soon after the
day using a B650 monitor (GE Healthcare, Finland) in the
trial commencement, preoperative computed tomography
operating room and a portable pulse oximeter in the ward.
was no longer possible due to a strict mandate from the
Postoperative hypoxemia was assessed based on the percent-
government to minimize preoperative stay and the risk of
age of time with a Spo2 less than 92%.12
COVID-19 transmission within hospitals.The change from
Incidence and severity of postoperative pulmonary
30 to 60 min to 60 to 90 min after extubation was due to
complications were collected on postoperative days 0, 1, 2,
staff shortage and work overload during the COVID-19
and 7, as previously described (Table E2 in Supplemental
pandemic. At this point, the primary outcome was changed
Digital Content, https://links.lww.com/ALN/D153).17
to the amount of postoperative atelectasis in postoperative
The mechanical ventilation duration, intraoperative vaso-
computed tomography images, expressed as the percentage
pressor dosage, and IV fluids were also recorded.
of nonaerated tissue in total lung tissue volume (amount
of atelectasis = nonaerated tissue volume/total lung tissue
Chest Computed Tomography volume * 100%).
Chest computed tomography scans were conducted at 60 Secondary outcomes included PEEP value, the ratio
to 90 min after extubation and completed at end-­expiration of Pao2 to Fio2, Spo2, respiratory mechanical parameters,
by instructing patients to exhale normally and hold their hemodynamic parameters, intraoperative vasopressor dos-
breath at functional residual capacity.The computed tomog- age, fluids volume, and postoperative pulmonary complica-
raphy scan was set with a scan quality reference of 120 kVp tions. Postoperative pulmonary complications are defined
and 100 mAs by Somatom Definition (Siemens Medical in detail in Table E2 in Supplemental Digital Content
Systems, Germany). Image reconstruction was performed (https://links.lww.com/ALN/D153).
using a slice thickness of 5 mm. The Digital Imaging and
Communications in Medicine images were analyzed using
Sample Size Calculations
Advantage Workstation 4.6 (GE Healthcare, USA). The sample size was calculated based on the assumption of
Ten computed tomography sections (the most cra- 3% group difference in the amount of postoperative atel-
nial and caudal ones, and eight evenly spaced sections ectasis, with a SD of 3% in both groups. The 3% margin

Li et al. Anesthesiology 2023; 139:262–73 265

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Perioperative Medicine

was arbitrarily set following previously used criteria.6 The compliance–guided PEEP group had higher mean dynamic
3% SD was based on the results of a previous study.3 Other compliance, static compliance, peak pressure, plateau pres-
assumptions included α = 0.05, power = 0.85, and dropout sure, and driving pressure throughout the anesthesia than the
rate = 10%. The calculation using a two-tailed Student’s t PEEP of 8 cm H2O group (e.g., after randomization, 10 min
test yielded 40 patients (20 in each group). after pneumoperitoneum, 1 h after pneumoperitoneum, and
immediately before extubation; all P < 0.001).
Statistical Analysis
Normality of continuous variables was examined using the
Postoperative Atelectasis
Shapiro–Wilk test. Normally distributed variables, includ- The analysis of the primary outcome was conducted using
ing the primary outcome of atelectasis, were analyzed using the data of 38 patients (19 in each group) who completed
a Student’s t test and presented as mean ± SD. Variables the postoperative computed tomography scan. The post-

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

not following normal distribution were analyzed using a operative atelectasis was 13.1 ± 5.3% in the PEEP of 8 cm
Mann–Whitney U test and presented as the median (inter- H2O group versus 9.5 ± 4.3% in the dynamic compliance–
quartile range). Categorical variables were analyzed using guided PEEP group (difference, 3.7%; 95% CI, 0.5 to 6.8%;
the chi-square test or Fisher exact test, as appropriate. For P = 0.025; table 2; fig. 5). The group difference was 4.5%
correlation between two variables, the Spearman rank cor- (95% CI, 0.9 to 8.0%; P = 0.015) in the right lung, and
relation test was used. 3.6% (95% CI, –0.3 to 7.5%; P = 0.069) in the left lung.The
To analyze repeated measure outcomes, including respi- amount of poorly aerated, normally aerated, and hyperaer-
ratory mechanics, hemodynamic parameters, Pao2/Fio2, ated tissue in postoperative computed tomography did not
and Spo2, a linear mixed model with fixed effects for group, differ significantly between the two groups (table 2).
timepoint and interaction of timepoint and group, random
intercept at the level of participants, and an unstructured Oxygenation and Hemodynamics
covariance matrix was used for calculation of significant
Arterial blood analysis was not available in two patients
differences between groups. Pairwise comparisons were
(one in each group) before extubation and one patient in
run at each timepoint if statistically significant interaction
the dynamic compliance–guided PEEP group at 30 min
existed. No correction was applied for multiple compari-
after extubation. Pao2/Fio2 did not differ between the two
sons of secondary outcomes. All statistical tests were two-
groups either before intubation (P = 0.536) or after intu-
sided and conducted using SPSS 23 for Windows (SPSS
bation (P = 0.211). Pao2/Fio2 was significantly higher in
Inc., USA). Statistical significance was set at P < 0.05. No
the dynamic compliance–guided PEEP group at 1 h after
imputation of missing values was performed due to the
pneumoperitoneum (P = 0.001) and before extubation
small amount of missing data.
(P = 0.017; fig. 5). Pao2/Fio2 at 30 min after extubation did
not differ between the two groups (P = 0.183). Percentage
Results of the time with hypoxemia (Spo2 less than 92%) until 8
This trial was conducted during a period from December am the day after surgery was 1.1% (interquartile range, 0.1
16, 2019, to September 30, 2020. Patient flow through the to 8.2%) in the PEEP of 8 cm H2O group and 0.6% (inter-
trial is shown in figure 2. A total of 40 patients (28 ± 7 yr quartile range, 0.1 to 3.0%) in the dynamic compliance–
of age; 25 females) were randomized (20 in each group). guided PEEP group (difference, 0.20%; 95% CI, –0.3 to 4.1;
In the analysis of the titration data in the entire sample of P = 0.407).The rate of hypotension during the recruitment
40 patients, the PEEP with maximum dynamic compliance maneuver and the dosage of phenylephrine throughout the
was 15 cm H2O (interquartile range, 13 to 17; range, 8 to surgery did not differ between the two groups (table 1).
19). The observation suggested a weak positive correlation Persistent hypotension was not observed in either group.
between body mass index and individualized PEEP with
maximum dynamic compliance (Spearman correlation Postoperative Pulmonary Complications
coefficient, r = 0.36), and the scatterplot showing their rela- Four patients in each group (20% for both) developed
tionship is presented in figure 3. Baseline and intraoperative postoperative pulmonary complications within 7 days after
characteristics were generally comparable between the two surgery. No grade 3 or higher postoperative pulmonary
groups (table 1). complications were observed.
As the linear mixed model exhibited statistical significance
for group by time interaction in most of the repeatedly mea-
sured respiratory mechanics, we reported the results of group Discussion
comparisons of these variables at each timepoint (fig. 4 and The results from this trial demonstrated that in patients
table E3 in the Supplemental Digital Content, https://links. undergoing laparoscopic bariatric surgery, postopera-
lww.com/ALN/D153). Respiratory mechanics were simi- tive atelectasis was lower under dynamic compliance–
lar between the two groups during titration. The dynamic guided PEEP versus PEEP of 8 cm H2O. The dynamic

266 Anesthesiology 2023; 139:262–73 Li et al.

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Individual PEEP in Obesity

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

Fig. 2. CONsolidated Standards of Reporting Trials flow diagram. ICU, intensive care unit.

compliance–guided PEEP group had higher Pao2/Fio2 differed between the two groups by only 3.6%. However,
during but not after surgery. the similar discrepancy between the reduced postoperative
The analysis of computed tomography revealed that atelectasis and no improvement in postoperative oxygen-
patients in the dynamic compliance–guided PEEP group ation has also been reported in several previous studies,6,8
developed atelectasis accounting for 9.5% of the total lung suggesting the existence of other underlying mechanisms.
tissue volume, less than the 13.1% in the PEEP of 8 cm H2O One potential mechanism is that morphological appear-
group at 60 to 90 min after extubation. However, the two ances of atelectasis (such as computed tomography) occur
groups did not differ in Pao2/Fio2 at 30 min after extubation. later than physiologic changes (such as Pao2/Fio2). Small
Such a discrepancy indicates intraoperative lung recruit- airways tend to close in the early period after extubation
ment may not necessarily translate into high postoperative and impair gas exchange in distal alveoli in the absence
lung aeration, as previously suggested by Lagier et al.23 The of postoperative lung stabilization strategies. However, the
lack of improvement in postoperative oxygenation in our morphological performance of collapsed alveoli as revealed
trial could be due to the fact that postoperative atelectasis by computed tomography requires complete absorption of

Li et al. Anesthesiology 2023; 139:262–73 267

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Perioperative Medicine

the trapped air, which is a slow process at low inspiratory studies of intrapulmonary gas distribution of individual
oxygen fraction.24 Accordingly, the open lung effects of lungs,25 this finding is not surprising since surgery was con-
individualized PEEP may partly remain in the early extu- ducted in a partial right-leaning lateral decubitus position
bation period. in all patients in this trial. Since the effects of individualized
We observed a reduced amount of postoperative atel- PEEP on lung ventilation in the lateral decubitus position
ectasis in the dynamic compliance–guided PEEP group in has not been explored in other studies, this finding cannot
the right but not in the left lung. In reference to previous be taken as a definitive conclusion. It is important to note,
however, that since the lateral decubitus angle was small
in our trial, this conclusion cannot be extended to a com-
pletely lateral decubitus position.
The median optimal PEEP in this trial was 15 cm H2O

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

with a range of 8 to 19 cm H2O in patients with an average
body mass index of approximately 40 kg/m2. Such a rela-
tively high PEEP may raise concerns about adverse events
and reduce the enthusiasm to use individualized PEEP in
routine practice.26–28 Several previous studies have indi-
cated that high levels of PEEP (10 cm H2O or greater) are
necessary to improve pulmonary function in patients with
morbid obesity, pneumoperitoneum, and Trendelenburg
position.6,29,30 A study by Spadaro et al. showed that in
patients with a body mass index around 25 kg/m2, 5 cm H2O
PEEP was required in nonpneumoperitoneum state in the
supine position to significantly reduce the intrapulmonary
shunt rate, whereas 10 cm H2O PEEP was required with
pneumoperitoneum.29 A study by Tharp et al. calculated
Fig. 3. Scatter plot of optimal positive end-expiratory pressure optimal PEEP as the originally set PEEP minus transpul-
(PEEP) and body mass index in individual patients. All 40 partic- monary pressure, and showed that in patients with a BMI
ipants received the titration trial and obtained their PEEP value greater than 40 kg/m2, optimal PEEP was 16.8 and 21.5 cm
with maximum dynamic compliance. The Spearman correlation
coefficient between body mass index and titrated PEEP was
H2O before and after insufflation of pneumoperitoneum,
0.361 (P = 0.022). respectively.30 Considering the mean body mass index of
40 kg/m2 in our study, dynamic compliance–guided PEEP

Table 1. Baseline Characteristics of Patients

Characteristics PEEP of 8 cm H2O (n = 20) Dynamic Compliance–guided PEEP (n = 20)

Baseline characteristics
 Age, yr 27 ± 7 28 ± 7
 Female, n (%) 15 (75) 10 (50)
 ASA Physical Status
  II, n (%) 14 (70) 15 (75)
  III, n (%) 6 (30) 5 (25)
 Body mass index, kg/m2 40.1 ± 3.5 41.9 ± 5.6
 Predicted body weight, kg* 60.1 ± 8.2 64.5 ± 10.5
 Waist-to-hip ratio 0.99 ± 0.060 0.99 ± 0.065
 Current and former smoker, n (%) 6 (30) 11 (55)
 Hypertension, n (%) 2 (10) 7 (35)
 Diabetes, n (%) 5 (25) 3 (15)
Intraoperative characteristics
 Duration of mechanical ventilation (min) 152 ± 34 142 ± 32
 Intravenous fluids (ml) 1,303 ± 243 1,360 ± 300
 Hypotension during recruitment maneuver [n (%)]† 8 (40) 6 (30)
 Vasopressor (phenylephrine) dosage (μg) 335 ± 325 280 ± 251

Data are presented as mean ± SD or median (interquartile range) for continuous variables, and n (%) for categorical variables.
*Predicted body weight (kg) is calculated as [50 + 0.91 × (height – 152.4)] for males and [45.5 + 0.91 × (height – 152.4)] for females. †Hypotension is defined as a mean arterial
pressure less than 65 mmHg.
ASA, American Society of Anesthesiologists; PEEP, positive end-expiratory pressure.

268 Anesthesiology 2023; 139:262–73 Li et al.

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Individual PEEP in Obesity

A B

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

C D

E F

Fig. 4. Time course of repeated measure outcomes. Repeated measure outcomes include peak pressure (A), plateau pressure (B), driving
pressure (C), dynamic compliance (D), static compliance (E), heart rate (F), and mean arterial pressure (G). Filled circles represent means, and
vertical lines identify 95% CI of the data at the given timepoint.

Li et al. Anesthesiology 2023; 139:262–73 269

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Perioperative Medicine

Table 2. Lung Aeration Compartments of Total, Right, and Left Lung

PEEP of 8 cm H2O (n = 20) Dynamic Compliance–guided PEEP (n = 20) P Value

Total lung (%)

 Nonaerated (atelectasis) 13.1 ± 5.3 9.5 ± 4.3 0.025*
 Poorly aerated 28.8 ± 11.5 29.9 ± 15.1 0.813
 Normally aerated 56.8 ± 15.0 60.4 ± 17.4 0.492
 Hyperaerated 0.1 (0–0.4) 0.1 (0–0.3) 0.351
Right lung (%)
 Nonaerated (atelectasis) 13.1 ± 6.4 8.7 ± 4.3 0.015*
 Poorly aerated 33.9 ± 15.3 33.2 ± 16.7 0.397

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

 Normally aerated 52.9 ± 20.0 57.9 ± 18.9 0.427
 Hyperaerated 0 (0–0.1) 0 (0–0.2) 0.401
Left lung (%)
 Nonaerated (atelectasis) 13.7 ± 6.3 10.1 ± 5.5 0.069
 Poorly aerated 25.4 ± 9.6 27.1 ± 14.4 0.662
 Normally aerated 60.7 ± 13.7 62.4 ± 17.1 0.735
 Hyperaerated 0.1 (0–0.3) 0.1 (0.1–0.4) 0.223

Data are presented as mean ± SD or median (interquartile range).

*P values < 0.05.
PEEP, positive end-expiratory pressure.

A B

Fig. 5. Postoperative atelectasis and perioperative Pao2/inspiratory oxygen fraction (Fio2). (A) Box plot of postoperative atelectasis in total,
left, and right lung measured by computer tomography at 60 to 90 min after extubation. Magenta boxes represent the positive end-expiratory
pressure (PEEP) of 8 cm H2O group, and blue boxes represent the dynamic compliance–guided PEEP group. The ends of boxes represent the
25th and 75th percentiles, and the middle lines represent medians. The upper and lower whiskers represent 95% CI. Compared with the PEEP
of 8 cm H2O group, the dynamic compliance–guided PEEP group developed less atelectasis in total and right (relative lower) lung, but not left
lung. P values < 0.05 are indicated in bold. (B) Line graph of perioperative Pao2/Fio2 measured by arterial blood gas analysis. Magenta circles
and dotted lines represent the PEEP of 8 cm H2O group. Blue circles and solid lines represent the dynamic compliance–guided PEEP group.
The upper and lower whiskers represent the SD. The data were missing in two patients (one in each group) before extubation and one patient
in the dynamic compliance–guided PEEP group at 30 min after extubation. Compared with the PEEP of 8 cm H2O group, Pao2/Fio2 was higher
in the dynamic compliance–guided PEEP group at 1 h after pneumoperitoneum and before extubation, but not at 30 min after extubation.

with a median of 17 cm H2O is within the reasonable range, resistance. Therefore, during the stepwise decrease of PEEP
in our opinion. from 25 to 5 cm H2O in this trial, the relationship between
As mentioned in the introduction, the goal of optimal dynamic compliance and PEEP followed an inverted
PEEP is to produce the best compromise of atelectasis and U-shaped pattern (initial increase and then decrease). The
alveolar hyperdistention.6 Excessive PEEP leads to alveolar PEEP value with maximum dynamic compliance was
hyperdistension and increased elastic resistance, which in selected as the optimal PEEP to balance small airway clo-
turn counteracts or even exceeds the reduction in airway sure versus alveolar hyperdistension. Pneumoperitoneum

270 Anesthesiology 2023; 139:262–73 Li et al.

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Individual PEEP in Obesity

may impact optimal PEEP value,30 but repeating the titra- insufflation.30 Adding 2 cm H2O to the PEEP with max-
tion procedure after insufflation/exsufflation of pneumo- imum dynamic compliance may not be sufficient to bal-
peritoneum is not pragmatic. Considering increased need ance the impact of pneumoperitoneum. Last, a fixed PEEP
for higher PEEP with pneumoperitoneum, 2 cm H2O was rather than static compliance-guided PEEP was used as the
added to the final dynamic compliance–guided PEEP for control. Accordingly, whether static compliance-guided
use during the entire surgery. Another consideration is the individualized PEEP is superior to dynamic compliance–
change of body position from a reverse Trendelenburg to guided PEEP remains unknown.
supine position upon exsufflation of pneumoperitoneum,
which in turn tends to cancel out the effects of exsufflation. Conclusions
Thus, we did not remove the additional PEEP value of 2 cm
H2O after exsufflation of pneumoperitoneum. Postoperative atelectasis was lower in patients undergoing
laparoscopic bariatric surgery under dynamic compliance–

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

Although fluids and vasopressor were given in advance
and the maximum plateau pressure was at a relatively low guided PEEP versus PEEP of 8 cm H2O. Postoperative Pao2/
level (40 cm H2O), hypotension was common during the Fio2 did not differ between the two groups.
recruitment maneuver. No refractory hemodynamic insta-
bility was observed in this trial, perhaps due to the exclusion Acknowledgments
criterion of severe cardiopulmonary diseases.31 The safety The authors thank Kehong Zhang, M.D., Ph.D., from
of individualized PEEP in patients with compromised car- Ivy Medical Editing (Shanghai, China) for revising the
diopulmonary function needs further evaluation in future final manuscript. The authors thank the surgical team of
studies. Consistent with previous trials of individualized Xiaocheng Zhu, M.D., Ph.D., from the Department of
PEEP in both nonobese and obese patients,3,4,6 the dosage Gastroenterological Surgery, Affiliated Hospital of Xuzhou
of phenylephrine and fluid volume during anesthesia were Medical University (Xuzhou, China) for excellent surgery.
comparable between the two groups, adding support to the
hemodynamic safety of individualized PEEP.9 The poten-
Research Support
tial reasons of good hemodynamic stability lie in adequate
fluid and vasoactive drugs infusion before maneuver,32 and This work was supported by the National Natural Science
preserved right ventricular function due to low pulmonary Foundation of China (Beijing, China; #82293641, and
vascular resistance caused by individualized PEEP.33 82130033, to Jun-Li Cao), the Jiangsu Provincial Special
This trial has several limitations. First, recruitment Program of Medical Science (Nanjing, China; #BL2014029,
maneuver with a plateau pressure of 40 cm H2O may be to Jun-Li Cao), the National Natural Science Foundation
insufficient for optimal alveolar recruitment in obese of China (#82271295, to Yuan Han), the Natural Science
patients. A previous study suggested that a plateau pressure Foundation of Shanghai (Shanghai, China; #21ZR1411300,
as high as 55 cm H2O may not be suffiicient.22 This relatively to Yuan Han), and the Shenkang Clinical Study Foundation
low level was chosen to minimize the impact on hemo- of Shanghai (Shanghai, China; #SHDC2020CR4061, to
dynamic stability. Second, atelectasis was assessed using 10 Yuan Han).The funders have no involvement in study design,
slices instead of the whole lung, and therefore was subject data collection and interpretation, writing of the manuscript,
to bias. Having said that, good agreement of differently aer- and the decision to submit the manuscript for publication.
ated compartments between the extrapolated results based
on 10 sections and those from all computed tomography Competing Interests
sections has been established.18 Accordingly, this method
The authors declare no competing interests.
has been widely used in studies of atelectasis.6,11,18,20 Third,
this trial was not sufficiently powered to detect a change
in more clinically relevant outcomes, such as postoperative Reproducible Science
pulmonary complications or Pao2/Fio2. Fourth, the fixed Full protocol available at: [email protected]. Raw data
PEEP value was 8 instead of 5 cm H2O in our trial, which available at: [email protected].
was different from previous studies in daily clinical prac-
tice.3,6–8 A higher fixed PEEP in the PEEP of 8 cm H2O
group would tend to decrease the group difference. Under Correspondence
such a condition (favors the PEEP of 8 cm H2O group), the Address correspondence to Dr. Cao: Jiangsu Province
results (reduced atelectasis) are more solid. Fifth, the aver- Key Laboratory of Anesthesia and Analgesia Application
age body mass index in this trial (40 kg/m2) is considerably Technology, Xuzhou Medical University, Xuzhou,
lower than in the obese patients undergoing bariatric sur- 221004, Jiangsu, China. [email protected] or junli-
gery in Western countries. Sixth, based on previous find- [email protected] article may be accessed for personal
ings, optimal PEEP in morbidly obese patients was elevated use at no charge through the Journal Web site, www.anes-
by approximately 5 cm H2O after pneumoperitoneum thesiology.org.

Li et al. Anesthesiology 2023; 139:262–73 271

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Perioperative Medicine

Supplemental Digital Content Carvalho AR, Giannella-Neto A, Reske AW, Wrigge

H: Individualized positive end-expiratory pressure in
Table E1, E2, E3, https://links.lww.com/ALN/D153
obese patients during general anaesthesia: A random-
ized controlled clinical trial using electrical impedance
References tomography. Br J Anaesth 2017; 119:1194–205
9. Simon P, Girrbach F, Petroff D, Schliewe N, Hempel
1. Hedenstierna G, Rothen HU: Respiratory function G, Lange M, Bluth T, Gama de Abreu M, Beda A,
during anesthesia: Effects on gas exchange. Compr Schultz MJ, Pelosi P, Reske AW, Wrigge H; PROBESE
Physiol 2012; 2:69–96 Investigators of the Protective Ventilation Network*
2. Eichenberger A, Proietti S, Wicky S, Frascarolo P, Suter and the Clinical Trial Network of the European Society
M, Spahn DR, Magnusson L: Morbid obesity and post- of Anesthesiology: Individualized versus fixed positive

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

operative pulmonary atelectasis: An underestimated end-expiratory pressure for intraoperative mechani-
problem. Anesth Analg 2002; 95:1788–92, table of cal ventilation in obese patients: A secondary analysis.
contents Anesthesiology 2021; 134:887–900
3. Girrbach F, Petroff D, Schulz S, Hempel G, Lange 10. Xu D, Wei W, Chen L, Li S, Lian M: Effects of different
M, Klotz C, Scherz S, Giannella-Neto A, Beda A, positive end-expiratory pressure titrating strategies on
Jardim-Neto A, Stolzenburg JU, Reske AW, Wrigge H, oxygenation and respiratory mechanics during one-
Simon P: Individualised positive end-expiratory pres- lung ventilation: A randomized controlled trial. Ann
sure guided by electrical impedance tomography for Palliat Med 2021; 10:1133–44
robot-assisted laparoscopic radical prostatectomy: A 11. Ball L, Braune A, Corradi F, Brusasco C, Garlaschi A,
prospective, randomised controlled clinical trial. Br J Kiss T, Bluth T, Simonassi F, Bergamaschi A, Kotzerke
Anaesth 2020; 125:373–82 J, Schultz MJ, de Abreu MG, Pelosi P: Ultra-low-dose
4. Fernandez-Bustamante A, Sprung J, Parker RA, sequential computed tomography for quantitative lung
Bartels K, Weingarten TN, Kosour C, Thompson BT, aeration assessment-a translational study. Intensive Care
Vidal Melo MF: Individualized peep to optimise Med Exp 2017; 5:19
respiratory mechanics during abdominal surgery: A 12. Van Hecke D, Bidgoli JS,Van der Linden P: Does lung
pilot randomised controlled trial. Br J Anaesth 2020; compliance optimization through peep manipulations
125:383–92 reduce the incidence of postoperative hypoxemia in
5. Park M, Ahn HJ, Kim JA, Yang M, Heo BY, Choi JW, laparoscopic bariatric surgery? A randomized trial.
Kim YR, Lee SH, Jeong H, Choi SJ, Song IS: Driving Obes Surg 2019; 29:1268–75
pressure during thoracic surgery: A randomized clinical 13. Ferrando C, Mugarra A, Gutierrez A, Carbonell JA,
trial. Anesthesiology 2019; 130:385–93 Garcia M, Soro M, Tusman G, Belda FJ: Setting indi-
6. Pereira SM, Tucci MR, Morais CCA, Simões CM, vidualized positive end-expiratory pressure level with a
Tonelotto BFF, Pompeo MS, Kay FU, Pelosi P, Vieira positive end-expiratory pressure decrement trial after a
JE, Amato MBP: Individual positive end-expiratory recruitment maneuver improves oxygenation and lung
pressure settings optimize intraoperative mechani- mechanics during one-lung ventilation. Anesth Analg
cal ventilation and reduce postoperative atelectasis. 2014; 118:657–65
Anesthesiology 2018; 129:1070–81 14. Pintado MC, de Pablo R, Trascasa M, Milicua JM,
7. Ferrando C, Soro M, Unzueta C, Suarez-Sipmann F, Sanchez-Garcia M: Compliance-guided versus fio2-
Canet J, Librero J, Pozo N, Peiró S, Llombart A, León driven positive-end expiratory pressure in patients with
I, India I, Aldecoa C, Díaz-Cambronero O, Pestaña D, moderate or severe acute respiratory distress syndrome
Redondo FJ, Garutti I, Balust J, García JI, Ibáñez M, according to the berlin definition. Med Intensiva 2017;
Granell M, Rodríguez A, Gallego L, de la Matta M, 41:277–84
Gonzalez R, Brunelli A, García J, Rovira L, Barrios F, 15. Jeong H, Tanatporn P, Ahn HJ, Yang M, Kim JA, Yeo
Torres V, Hernández S, Gracia E, Giné M, García M, H, Kim W: Pressure support versus spontaneous ven-
García N, Miguel L, Sánchez S, Piñeiro P, Pujol R, tilation during anesthetic emergence-effect on post-
García-Del-Valle S, Valdivia J, Hernández MJ, Padrón operative atelectasis: A randomized controlled trial.
O, Colás A, Puig J, Azparren G,Tusman G,Villar J, Belda Anesthesiology 2021; 135:1004–14
J; Individualized PeRioperative Open-lung VEntilation 16. Lundquist H, Hedenstierna G, Strandberg A, Tokics L,
(iPROVE) Network: Individualised perioperative Brismar B: Ct-assessment of dependent lung densities
open-lung approach versus standard protective venti- in man during general anaesthesia. Acta Radiol 1995;
lation in abdominal surgery (iPROVE): A randomised 36:626–32
controlled trial. Lancet Respir Med 2018; 6:193–203 17. Kroenke K, Lawrence VA, Theroux JF, Tuley MR:
8. Nestler C, Simon P, Petroff D, Hammermüller S, Operative risk in patients with severe obstructive pul-
Kamrath D, Wolf S, Dietrich A, Camilo LM, Beda A, monary disease. Arch Intern Med 1992; 152:967–71

272 Anesthesiology 2023; 139:262–73 Li et al.

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Individual PEEP in Obesity

18. Reske AW, Reske AP, Gast HA, Seiwerts M, Beda A, Wrigge H; Writing Committee for the PROBESE
Gottschaldt U, Josten C, Schreiter D, Heller N, Wrigge Collaborative Group of the PROtective VEntilation
H, Amato MB: Extrapolation from ten sections can Network (PROVEnet) for the Clinical Trial Network
make ct-based quantification of lung aeration more of the European Society of Anaesthesiology: Effect
practicable. Intensive Care Med 2010; 36:1836–44 of intraoperative high positive end-expiratory pres-
19. Puybasset L, Cluzel P, Gusman P, Grenier P, Preteux F, sure (peep) with recruitment maneuvers vs low peep
Rouby JJ: Regional distribution of gas and tissue in on postoperative pulmonary complications in obese
acute respiratory distress syndrome. I. Consequences patients: A randomized clinical trial. JAMA 2019;
for lung morphology. CT Scan ARDS Study Group. 321:2292–305
Intensive Care Med 2000; 26:857–69 28. Nielsen J, Østergaard M, Kjaergaard J, Tingleff J,
20. Rylander C, Tylén U, Rossi-Norrlund R, Herrmann P, Berthelsen PG, Nygård E, Larsson A: Lung recruitment

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/139/3/262/690692/20230900.0-00010.pdf by guest on 16 September 2023

Quintel M, Bake B: Uneven distribution of ventilation maneuver depresses central hemodynamics in patients
in acute respiratory distress syndrome. Crit Care 2005; following cardiac surgery. Intensive Care Med 2005;
9:R165–71 31:1189–94
21. Cressoni M, Gallazzi E, Chiurazzi C, Marino A, Brioni 29. Spadaro S, Karbing DS, Mauri T, Marangoni E, Mojoli
M, Menga F, Cigada I, Amini M, Lemos A, Lazzerini M, F,Valpiani G, Carrieri C, Ragazzi R,Verri M, Rees SE,
Carlesso E, Cadringher P, Chiumello D, Gattinoni L: Volta CA: Effect of positive end-expiratory pressure
Limits of normality of quantitative thoracic ct analysis. on pulmonary shunt and dynamic compliance during
Crit Care 2013; 17:R93 abdominal surgery. Br J Anaesth 2016; 116:855–61
22. Reinius H, Jonsson L, Gustafsson S, Sundbom M, 30. Tharp WG, Murphy S, Breidenstein MW, Love C,
Duvernoy O, Pelosi P, Hedenstierna G, Fredén F: Booms A, Rafferty MN, Friend AF, Perrapato S, Ahern
Prevention of atelectasis in morbidly obese patients TP, Dixon AE, Bates JHT, Bender SP: Body habitus
during general anesthesia and paralysis:A computerized and dynamic surgical conditions independently impair
tomography study. Anesthesiology 2009; 111:979–87 pulmonary mechanics during robotic-assisted laparo-
23. Lagier D, Zeng C, Fernandez-Bustamante A,Vidal Melo scopic surgery. Anesthesiology 2020; 133:750–63
MF: Perioperative pulmonary atelectasis: Part ii. Clinical 31. Cavalcanti AB, Suzumura A, Laranjeira LN, Paisani
implications. Anesthesiology 2022; 136:206–36 DM, Damiani LP, Guimarães HP, Romano ER,
24. Magnusson L, Spahn DR: New concepts of atelec- Regenga MM, Taniguchi LNT, Teixeira C, Pinheiro
tasis during general anaesthesia. Br J Anaesth 2003; de Oliveira R, Machado FR, Diaz-Quijano FA, Filho
91:61–72 MSA, Maia IS, Caser EB, Filho WO, Borges MC,
25. Rehder K, Hatch DJ, Sessler AD, Fowler WS:The func- Martins PA, Matsui M, Ospina-Tascón GA, Giancursi
tion of each lung of anesthetized and paralyzed man TS, Giraldo-Ramirez ND,Vieira SRR, Assef M, Hasan
during mechanical ventilation. Anesthesiology 1972; MS, Szczeklik W, Rios F, Amato MBP, Berwanger O,
37:16–26 Ribeiro de Carvalho CR: Effect of lung recruitment
26. Hemmes SN, Gama de Abreu M, Pelosi P, Schultz MJ; and titrated positive end-expiratory pressure (PEEP) vs
PROVE Network Investigators for the Clinical Trial low PEEP on mortality in patients with acute respi-
Network of the European Society of Anaesthesiology: ratory distress syndrome: A randomized clinical trial.
High versus low positive end-expiratory pressure JAMA 2017; 318:1335–45
during general anaesthesia for open abdominal surgery 32. Bohm SH, Thamm OC, von Sandersleben A, Bangert
(PROVHILO trial): A multicentre randomised con- K, Langwieler TE, Tusman G, Strate TG, Standl TG:
trolled trial. Lancet 2014; 384:495–503 Alveolar recruitment strategy and high positive
27. Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, Gama end-expiratory pressure levels do not affect hemody-
de Abreu M, Bluth T, Bobek I, Canet JC, Cinnella G, namics in morbidly obese intravascular volume-loaded
de Baerdemaeker L, Gama de Abreu M, Gregoretti patients. Anesth Analg 2009; 109:160–3
C, Hedenstierna G, Hemmes SNT, Hiesmayr M, 33. Gernoth C, Wagner G, Pelosi P, Luecke T: Respiratory
Hollmann MW, Jaber S, Laffey J, Licker MJ, Markstaller and haemodynamic changes during decremental open
K, Matot I, Mills GH, Mulier JP, Pelosi P, Putensen lung positive end-expiratory pressure titration in
C, Rossaint R, Schmitt J, Schultz MJ, Senturk M, patients with acute respiratory distress syndrome. Crit
Serpa Neto A, Severgnini P, Sprung J, Vidal Melo MF, Care 2009; 13:R59

Li et al. Anesthesiology 2023; 139:262–73 273

Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.