Protective Ventilation With Higher Versus Lower PEEP During General Anesthesia for Surgery in Obese Patients

Conditions

General Anesthesia, Morbid Obesity, Surgery

Brief summary

Postoperative respiratory failure, particularly after surgery under general anesthesia, adds to the morbidity and mortality of surgical patients. Anesthesiologists inconsistently use positive end-expiratory pressure (PEEP) and recruitment maneuvers in the hope that this may improve oxygenation and protect against postoperative pulmonary complications (PPCs), especially in obese patients. While anesthesiologists tend to use PEEP higher than in non-obese patients. While it is uncertain whether a strategy that uses higher levels of PEEP with recruitment maneuvers truly prevents PPCs in these patients, use of higher levels of PEEP with recruitment maneuvers could compromise intra-operative hemodynamics. The investigators aim to compare a ventilation strategy using higher levels of PEEP with recruitment maneuvers with one using lower levels of PEEP without recruitment maneuvers in obese patients at an intermediate-to-high risk for PPCs. We hypothesize that an intra-operative ventilation strategy using higher levels of PEEP and recruitment maneuvers, as compared to ventilation with lower levels of PEEP without recruitment maneuvers, prevents PPCs in obese patients at an intermediate-to-high risk for PPC.

Nasa P, van Meenen DMP, Paulus F, Ferrando C, Bluth T, Gama de Abreu M, Ball L, Bossers SM, Schober P, Schultz MJ, Serpa Neto A, Hemmes SNT, REPEAT, PROVHILO, PROBESE, investigators of the PROVE network, ESAIC CTN.

2025-09-101 citations

10.1016/j.bja.2025.07.076

Association of plasma biomarkers of lung injury with positive end expiratory pressure and postoperative pulmonary complications in obese surgical patients

Thomas Bluth, Eva Rivas, Manuel López-Baamonde, Josep Sanahuja, Antonio López-Hernández et al. (25 authors)

European Journal of Anaesthesiology2025-06-20

10.1097/eja.0000000000002221

Respiratory mechanics and mechanical power during low vs. high positive end-expiratory pressure in obese surgical patients - A sub-study of the PROBESE randomized controlled trial.

Scharffenberg M, Mandelli M, Bluth T, Simonassi F, Wittenstein J, Teichmann R, Birr K, Kiss T, Ball L, Pelosi P, Schultz MJ, Gama de Abreu M, Huhle R, PROBESE-investigators, Protective Ventilation Network, Clinical Trials Network of the European Society of Anaesthesiology and Intensive Care.

2023-10-125 citations

10.1016/j.jclinane.2023.111242

Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure

Christoph Ellenberger, Paolo Pelosi, Marcelo Gama de Abreu, Hermann Wrigge, John Diaper et al. (9 authors)

European Journal of Anaesthesiology2022-09-1211 citations

10.1097/eja.0000000000001741

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

Schuijt MTU, Hol L, Nijbroek SG, Ahuja S, van Meenen D, Mazzinari G, Hemmes S, Bluth T, Ball L, Gama-de Abreu M, Pelosi P, Schultz MJ, Serpa Neto A.

2022-04-1638 citations

10.1016/j.eclinm.2022.101397

Intraoperative ventilation management differs between genders – insights from a worldwide prospective cohort study

Sunny G. L. H. Nijbroek, Ary Serpa Neto, Sabrine N.T. Hemmes, Marcus J. Schultz

Epidemiology2020-09-071 citations

10.1183/13993003.congress-2020.2598

Geo–economic variations in intraoperative ventilation management – insights from a worldwide prospective cohort study

Liselotte Hol, Sabrine N.T. Hemmes, Ary Serpa Neto, Marcus J. Schultz

Epidemiology2020-09-07

10.1183/13993003.congress-2020.1426

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

Thomas Bluth, Ary Serpa Neto, Marcus J. Schultz, Paolo Pelosi, Marcelo Gama de Abreu

JAMA2019-06-03360 citations

10.1001/jama.2019.7505

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications

The LAS VEGAS investigators

European Journal of Anaesthesiology2017-06-14317 citations

10.1097/eja.0000000000000646

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial.

Bluth T, Teichmann R, Kiss T, Bobek I, Canet J, Cinnella G, De Baerdemaeker L, Gregoretti C, Hedenstierna G, Hemmes SN, Hiesmayr M, Hollmann MW, Jaber S, Laffey JG, Licker MJ, Markstaller K, Matot I, Müller G, Mills GH, Mulier JP, Putensen C, Rossaint R, Schmitt J, Senturk M, Serpa Neto A, Severgnini P, Sprung J, Vidal Melo MF, Wrigge H, Schultz MJ, Pelosi P, Gama de Abreu M, PROBESE investigators, PROtective VEntilation Network (PROVEnet), Clinical Trial Network of the European Society of Anaesthesiology (ESA).

2017-04-2837 citations

10.1186/s13063-017-1929-0

Interventions

PROCEDUREHigher PEEP

PROCEDURELower PEEP

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

PREVENTION

Masking

DOUBLE (Investigator, Outcomes Assessor)

Eligibility

Sex/Gender

ALL

Age

18 Years to No maximum

Healthy volunteers

No

Inclusion criteria

* Patient scheduled for open or laparoscopic surgery under general anesthesia * Intermediate-to-high risk for PPCs following surgery, according to the ARISCAT risk score (≥ 26) * BMI ≥ 35 kg/m2 * Expected duration of surgery ≥ 2 h

Exclusion criteria

* Age \< 18 years * Previous lung surgery (any) * Persistent hemodynamic instability, intractable shock (considered hemodynamically unsuitable for the study by the patient's managing physician) * History of previous severe chronic obstructive pulmonary disease (COPD) (non-invasive ventilation and/or oxygen therapy at home, repeated systemic corticosteroid therapy for acute exacerbations of COPD) * Recent immunosuppressive medication (patients receiving chemotherapy or radiation therapy up to two months prior to surgery) * Severe cardiac disease (New York Heart Association class III or IV, acute coronary syndrome or persistent ventricular tachyarrhythmias) * Invasive mechanical ventilation longer than 30 minutes (e.g., general anesthesia for surgery) within last 30 days * Pregnancy (excluded by anamneses and/or laboratory analysis) * Prevalent acute respiratory distress syndrome expected to require prolonged postoperative mechanical ventilation * Severe pulmonary arterial hypertension, defined as systolic pulmonary artery pressure \> 40 mmHg * Intracranial injury or tumor * Neuromuscular disease (any) * Need for intraoperative prone or lateral decubitus position * Need for one-lung ventilation * Cardiac surgery * Neurosurgery * Planned reintubation following surgery * Enrolled in other interventional study or refusal of informed consent

Design outcomes

Primary

Measure	Time frame
Postoperative wound healing	Five postoperative days
Postoperative pulmonary complications	Five postoperative days
Hospital-free days at day 90	90 postoperative days
Mortality at day 90	90 postoperative days
Postoperative extra-pulmonary complications	Five postoperative days

Secondary

Measure	Time frame	Description
Need for postoperative ventilatory support	Five postoperative days	invasive or non-invasive ventilation
Unexpected need for ICU admission or ICU readmission within 30 days	Five postoperative days	—
Need for hospital readmission within 30 days	30 postoperative days	—
Intra-operative complications	Surgery period	complications related to the ventilation strategy (for example: de-saturation, defined as SpO2 ≤ 92%, for \> 1 min; hypotension during recruitment maneuvers, as defined by systolic arterial pressure \< 90 mmHg for \> 2 min)

Countries

Austria, Belgium, Brazil, Canada, France, Germany, Hungary, Israel, Italy, Netherlands, Spain, Sweden, Switzerland, Turkey (Türkiye), United Kingdom, United States

Outcome results

None listed