- Design
- Single-centre parallel-group randomised controlled trial
- Population
- 117 adults with ARISCAT ≥26 having laparoscopic colorectal surgery
- Primary outcome
- Postoperative pulmonary complications within 30 days
- Effect
- 49.2% vs 72.4%, HR 0.53 (95% CI 0.33 to 0.85)
Pneumoperitoneum and steep head-down positioning promote atelectasis. A single-centre randomised trial in BJA enrolled 117 adults with an ARISCAT score of 26 or more having laparoscopic colorectal surgery and allocated them to PEEP titrated with electrical impedance tomography or a fixed PEEP of 5 cmH2O.
Individualised PEEP lowered driving pressure (median 16 against 19 cmH2O). Pulmonary complications within 30 days, adjudicated by a multidisciplinary team, occurred in 49.2% with EIT-guided PEEP against 72.4% with fixed PEEP (HR 0.53, 95% CI 0.33 to 0.85), with less atelectasis and pneumonia.
The effect is large for a small single-centre trial, and complication rates in both arms were high, which may reflect a sensitive definition. Larger multicentre trials of individualised PEEP have given mixed results, so this is supportive rather than settling. EIT is also not widely available.
- Individualised PEEP reduced pulmonary complications in a single-centre trial of high-risk laparoscopic colorectal surgery.
- A fixed PEEP of 5 cmH2O may be too low under pneumoperitoneum and steep Trendelenburg positioning.
- Where EIT is unavailable, consider titrating PEEP to the lowest driving pressure.
- Calculate an ARISCAT score pre-operatively to identify patients at intermediate or high pulmonary risk.
Why it matters
A setting most anaesthetists leave at a default may be contributing to avoidable pulmonary complications.
Don't overread it
This was a single-centre trial of 117 patients; larger trials of individualised PEEP have not consistently shown benefit.
The statistics, in plain English
A hazard ratio of 0.53 means complications occurred at about half the rate. The absolute difference, 49.2% against 72.4%, is about 23 percentage points, which is unusually large and deserves confirmation.
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