Intraoperative lung-protective ventilation rests on three settings. Tidal volume is set at about 6 to 8 mL/kg of predicted body weight, which is calculated from height and sex, not from actual weight — a common error in obese patients. PEEP should be applied rather than zero, and adjusted to the patient and the operation. Driving pressure, plateau pressure minus PEEP, is a useful bedside check: settings that keep it low are generally kinder to the lung. Recruitment manoeuvres can help after pneumoperitoneum or disconnection but should be used with attention to haemodynamics.
- Calculate predicted body weight from height and sex for every ventilated patient.
- Start tidal volume at 6 to 8 mL/kg of predicted body weight.
- Apply PEEP, and reassess it after pneumoperitoneum or position change.
- Watch driving pressure and aim to keep it low.
Why it matters
Using actual weight in obese patients routinely delivers injurious tidal volumes.
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