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.

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
than 24 h and contribute to a variety of other complica-
tions, including hypoxemia and pneumonia.2
Positive end-expiratory pressure (PEEP) is a strat-
egy that helps to keep alveoli open during surgery and
to prevent postoperative atelectasis. A fixed PEEP with-
out considering the respiratory mechanics in individual
patients, however, is not optimal. Individualized PEEP
therefore has been increasingly studied,3–8 and has been
shown to improve oxygenation in both nonobese and
obese patients.3,8
Optimal PEEP in individual patients could be titrated
using several methods, including electrical impedance
tomography, transpulmonary pressure, and respiratory com-
pliance.3–11 Among these methods, only respiratory compli-
ance could be determined without additional equipment
other than the ventilator. Under zero-flow conditions, static
compliance is accurate in reflecting the consequences of
PEEP changes on the elastic properties of the respiratory
system. However, measuring static compliance requires
holding the breath for a few seconds at the end of inspira-
tion to allow gas redistribution in the distal lungs, which is
not pragmatic for daily practice in our opinion. Dynamic
compliance thus represents a viable alternative in titrating
optimal PEEP.7,10,12–14
Postoperative atelectasis could be estimated directly using
computed tomography or indirectly using measures that
reflect the level of oxygenation.6,11,15 Computed tomogra-
phy is the only accepted standard method for quantifying
the exact degree of atelectasis.16 Previous studies using com-
puted tomography to quantify atelectasis have demonstrated
reduced postoperative atelectasis with individualized PEEP
in nonobese patients.6 In contrast, reduced oxygenation with
individualized PEEP has been established but only within a
narrow time window after surgery in studies using arterial
blood gas and electrical impedance tomography.3,8
We conducted a single-center, randomized controlled
trial in patients undergoing laparoscopic bariatric surgery
to test the hypothesis that dynamic compliance–guided
PEEP could reduce the postoperative atelectasis.
Zhi-Lin Ni, M.D.: Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical
University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou
Medical University, Xuzhou, China.
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,
Shanghai, China.
Yuan Han, M.D., Ph.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.
Jun-Li Cao, M.D., Ph.D.: Jiangsu Province Key Laboratory of Anesthesiology,
Xuzhou Medical University, Xuzhou, China.; NMPA Key Laboratory for Research
and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University,
Xuzhou, China.
Li et al. Anesthesiology 2023; 139:262–73
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
Individual PEEP in Obesity
Materials and Methods
This is a single-center, randomized controlled trial in
patients undergoing laparoscopic bariatric surgery. The trial
was registered before patient enrollment at clinicaltrials.gov
(NCT04169607; uniform resource locator: https://clini-
caltrials.gov/ct2/show/NCT04169607; accessed May 20,
2023; principal investigator: Yuan Han; date of registration:
November 20, 2019). The trial was approved by the Ethics
Committee of the Affiliated Hospital of Xuzhou Medical
University (Xuzhou, China; ID: XYFY2019-KL168-01).
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
The study was conducted following the Declaration of
Helsinki. Trial reporting complied with the CONsolidated
Standards of Reporting Trials guidelines.
Patients
Adult inpatients scheduled to undergo laparoscopic bariat-
ric surgery were eligible. Recruitment was conducted by
the site investigator on the day of admission. Subjects with
one of more of the following conditions were excluded:
American Society of Anesthesiologists (Schaumburg,
Illinois) physical status IV or greater, lung bullae, continuing
smoking within 1 week before surgery, chronic obstructive
pulmonary disease requiring oxygen, congestive heart fail-
ure (New York Heart Association [New York, New York]
classification III or greater), thoracic surgery history, and
planned transfer to intensive care unit after surgery. Enrolled
patients were randomized at a 1:1 ratio to undergo surgery
using either dynamic compliance–guided PEEP (2 cm H2O
above the PEEP with the highest dynamic compliance) or
a fixed PEEP at 8 cm H2O.
Randomization, Concealment, and Blinding
The randomization sequence was generated using SPSS 23
for Windows (SPSS Inc., USA) by a staff member who was
not involved in this trial otherwise. Concealment was con-
ducted using sealed, opaque envelopes. The envelope with
the group allocation for each patient was opened at the
completion of PEEP titration. The patients, the radiologist,
and the investigators who assessed the outcomes (except the
intraoperative oxygen saturation measured by pulse oxim-
etry (Spo2), respiratory mechanical parameters, and hemo-
dynamic parameters) were blinded to group allocation; all
other personnel were aware of the grouping.
Standard Procedure
Patients received routine IV rapid sequence anesthesia
induction using sufentanil (0.5 μg/kg lean weight) and
etomidate (0.3 mg/kg total body weight). Cis-atracurium
(0.2 mg/kg total body weight) is given to facilitate tra-
cheal intubation. After intubation, transversus abdominis
plane block was performed under ultrasound guidance.
Combined IV and inhaled anesthesia was maintained with
263
 Perioperative Medicine

propofol, remifentanil, sevoflurane, and cis-atracurium until
the end of surgery. Routine intraoperative monitoring
included Spo2, electrocardiogram, invasive arterial blood
pressure, nasopharyngeal temperature, and muscle relaxant
monitoring (train-of-four).
Dynamic Compliance Titration
Mechanical ventilation was conducted in the volume-­
controlled ventilation mode with a tidal volume of 8 ml/
kg predicted body weight (male 50 + 0.91 × [height (cm)
until the final step of 25 cm H2O PEEP and 40 cm H2O
inspiratory pressure. The driving pressure was maintained
at 15 cm H2O throughout the increase. Then the titration
of dynamic compliance–guided PEEP was performed by
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
PEEP as those at the beginning of mechanical ventilation.
The dynamic compliance was calculated using tidal volume
(VT)/(peak pressure - PEEP). To avoid potential underesti-
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
an A7 anesthesia machine (Mindray Biomedical Electronics,
China). Other parameters included PEEP of 8 cm H2O,
inspiratory oxygen fraction (Fio2) of 1.0, inspiratory-to-­
expiratory ratio of 1:2, 20% inspiratory pause, and respi-
ratory rate of 12 breaths/min. After randomization, the
respiratory rate was adjusted to maintain end-tidal carbon
dioxide partial pressure at 35 to 45 mmHg.
All patients, regardless of the group assignment, received
a titration trial immediately after intubation. An example of
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
switched to a 20° to 25° reverse Trendelenburg and 20° to
25° right-leaning supine position (identical to the position
during surgery).The titration trial was initiated by a recruit-
ment maneuver, with the following ventilator setting: pres-
sure-controlled ventilation mode, 10 cm H2O PEEP, 25 cm
H2O inspiratory pressure, 6 breaths/min respiratory rate, 1:2
inspiratory-to-expiratory ratio. The PEEP and inspiratory
pressure were then increased in steps of 5 cm H2O per 30 s
dynamic compliance–guided PEEP was set as 2 cm H2O
above the PEEP with the maximum dynamic compliance.
After the titration trial, Fio2 was lowered to 0.5 to miti-
gate absorptive atelectasis. A second recruitment maneuver
was performed using the same protocol as the first recruit-
ment maneuver. All patients received 250 ml IV fluid and
40 μg phenylephrine in a bolus before the first recruitment
maneuver to prevent hypotension (mean arterial pressure
less than 65 mmHg). If hypotension still occurred, an addi-
tional bolus of phenylephrine (40 μg) was used.
Intervention and Control
Upon completion of the titration trial, all patients (regardless
of the group assignment) received dynamic compliance–
guided PEEP for 1 min for respiratory mechanical and
hemodynamic parameters recording. Then investigators
opened the envelopes containing the group assignment
information. Surgical incision and pneumoperitoneum
insufflation proceeded under dynamic compliance–guided
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.

PEEP group, and under 8 cm H2O for patients in the PEEP
of 8 cm H2O group. PEEP value was maintained through-
out the surgery after randomization using the volume-­
controlled ventilation mode. Intra-abdominal pressure was
maintained at 14 mmHg during surgery.
After exsufflation of pneumoperitoneum, the ventilation
mode was switched to pressure control, and the patients
were switched to a supine position. VT was maintained by
adjusting inspiratory pressure. Extubation was performed in
the operating room, and then patients were transferred to
postanesthesia care unit. After returning to the ward, sup-
plemental oxygen was provided through a venturi mask at a
flow rate of 3 l/min until 8 am next day.
Measurements and Timepoints
The timepoints of measurements are shown in Table E1 in
the Supplemental Digital Content (https://links.lww.com/
ALN/D153). Arterial blood gas analysis was conducted
before preoxygenation, after intubation, 1 h after insufflation
of pneumoperitoneum, before extubation, and 30 min after
extubation. Respiratory mechanical parameters and hemo-
dynamic parameters were measured after intubation, titra-
tion, and randomization, 10 min and 1 h after insufflation
of pneumoperitoneum. Respiratory mechanical parameters
consisted of peak pressure, plateau pressure, driving pressure
(plateau pressure - PEEP), dynamic compliance [VT / (peak
pressure – PEEP)], and static compliance [VT / (plateau
pressure – PEEP)]. Hemodynamic parameters included
heart rate and mean arterial pressure.
Spo2 was monitored continuously until 8 am the next
day using a B650 monitor (GE Healthcare, Finland) in the
operating room and a portable pulse oximeter in the ward.
Postoperative hypoxemia was assessed based on the percent-
age of time with a Spo2 less than 92%.12
Incidence and severity of postoperative pulmonary
complications were collected on postoperative days 0, 1, 2,
and 7, as previously described (Table E2 in Supplemental
Digital Content, https://links.lww.com/ALN/D153).17
The mechanical ventilation duration, intraoperative vaso-
pressor dosage, and IV fluids were also recorded.
Chest Computed Tomography
Chest computed tomography scans were conducted at 60
to 90 min after extubation and completed at end-­expiration
by instructing patients to exhale normally and hold their
breath at functional residual capacity.The computed tomog-
raphy scan was set with a scan quality reference of 120 kVp
and 100 mAs by Somatom Definition (Siemens Medical
Systems, Germany). Image reconstruction was performed
using a slice thickness of 5 mm. The Digital Imaging and
Communications in Medicine images were analyzed using
Advantage Workstation 4.6 (GE Healthcare, USA).
Ten computed tomography sections (the most cra-
nial and caudal ones, and eight evenly spaced sections
Li et al. Anesthesiology 2023; 139:262–73
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
Individual PEEP in Obesity
in between) were used to calculate the amount of atel-
ectasis for each patient. The validity of this method has
been established based on good agreement of differently
aerated compartments between the extrapolated results
from 10 sections and those from all computed tomog-
raphy sections by a previous study.18 The lung area was
delineated, and major pulmonary vessels (short diameter
3 mm or greater) were excluded manually. Lung aeration
compartments were calculated as a percentage of the
total lung tissue volume using the following Hounsfield
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
units), poorly aerated (−500 to −101 Hounsfield units),
normally aerated (−900 to −501 Hounsfield units), and
hyperaerated (−1,000 to −901 Hounsfield units).19 Total
lung volume (V Lung; including gas and tissue volume)
was calculated used the formula20
X1  Vi + Vi+1

+ V1 +2 V
N
V Lung = f

2
t
N
i=1
where N is the number of slices, t is the slice thickness, f
is the distance between slices (feed), and Vi is the lung total
volume in the ith slice. The following formula was used to
calculate the tissue volume of each lung aeration category21:
Tissue voulume = (1 CT number= 1000 )  total volume
Outcomes
Initially, the primary outcome was the difference of atel-
ectasis between two chest computed tomography scans
performed preoperatively and at 30 to 60 min after extu-
bation. Due to the COVID-19 outbreak soon after the
trial commencement, preoperative computed tomography
was no longer possible due to a strict mandate from the
government to minimize preoperative stay and the risk of
COVID-19 transmission within hospitals.The change from
30 to 60 min to 60 to 90 min after extubation was due to
staff shortage and work overload during the COVID-19
pandemic. At this point, the primary outcome was changed
to the amount of postoperative atelectasis in postoperative
computed tomography images, expressed as the percentage
of nonaerated tissue in total lung tissue volume (amount
of atelectasis = nonaerated tissue volume/total lung tissue
volume * 100%).
Secondary outcomes included PEEP value, the ratio
of Pao2 to Fio2, Spo2, respiratory mechanical parameters,
hemodynamic parameters, intraoperative vasopressor dos-
age, fluids volume, and postoperative pulmonary complica-
tions. Postoperative pulmonary complications are defined
in detail in Table E2 in Supplemental Digital Content
(https://links.lww.com/ALN/D153).
Sample Size Calculations
The sample size was calculated based on the assumption of
3% group difference in the amount of postoperative atel-
ectasis, with a SD of 3% in both groups. The 3% margin
265
 Perioperative Medicine
was arbitrarily set following previously used criteria.6 The
3% SD was based on the results of a previous study.3 Other
assumptions included α = 0.05, power = 0.85, and dropout
rate = 10%. The calculation using a two-tailed Student’s t
test yielded 40 patients (20 in each group).
Statistical Analysis
Normality of continuous variables was examined using the
Shapiro–Wilk test. Normally distributed variables, includ-
ing the primary outcome of atelectasis, were analyzed using
a Student’s t test and presented as mean ± SD. Variables
not following normal distribution were analyzed using a
Mann–Whitney U test and presented as the median (inter-
quartile range). Categorical variables were analyzed using
the chi-square test or Fisher exact test, as appropriate. For
correlation between two variables, the Spearman rank cor-
relation test was used.
To analyze repeated measure outcomes, including respi-
ratory mechanics, hemodynamic parameters, Pao2/Fio2,
and Spo2, a linear mixed model with fixed effects for group,
timepoint and interaction of timepoint and group, random
intercept at the level of participants, and an unstructured
covariance matrix was used for calculation of significant
differences between groups. Pairwise comparisons were
run at each timepoint if statistically significant interaction
existed. No correction was applied for multiple compari-
sons of secondary outcomes. All statistical tests were two-
sided and conducted using SPSS 23 for Windows (SPSS
Inc., USA). Statistical significance was set at P < 0.05. No
imputation of missing values was performed due to the
small amount of missing data.
Results
This trial was conducted during a period from December
16, 2019, to September 30, 2020. Patient flow through the
trial is shown in figure 2. A total of 40 patients (28 ± 7 yr
of age; 25 females) were randomized (20 in each group).
In the analysis of the titration data in the entire sample of
40 patients, the PEEP with maximum dynamic compliance
was 15 cm H2O (interquartile range, 13 to 17; range, 8 to
19). The observation suggested a weak positive correlation
between body mass index and individualized PEEP with
maximum dynamic compliance (Spearman correlation
coefficient, r = 0.36), and the scatterplot showing their rela-
tionship is presented in figure 3. Baseline and intraoperative
characteristics were generally comparable between the two
groups (table 1).
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
comparisons of these variables at each timepoint (fig. 4 and
table E3 in the Supplemental Digital Content, https://links.
lww.com/ALN/D153). Respiratory mechanics were simi-
lar between the two groups during titration. The dynamic
266 Anesthesiology 2023; 139:262–73
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
compliance–guided PEEP group had higher mean dynamic
compliance, static compliance, peak pressure, plateau pres-
sure, and driving pressure throughout the anesthesia than the
PEEP of 8 cm H2O group (e.g., after randomization, 10 min
after pneumoperitoneum, 1 h after pneumoperitoneum, and
immediately before extubation; all P < 0.001).
Postoperative Atelectasis
The analysis of the primary outcome was conducted using
the data of 38 patients (19 in each group) who completed
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
operative atelectasis was 13.1 ± 5.3% in the PEEP of 8 cm
H2O group versus 9.5 ± 4.3% in the dynamic compliance–
guided PEEP group (difference, 3.7%; 95% CI, 0.5 to 6.8%;
P = 0.025; table 2; fig. 5). The group difference was 4.5%
(95% CI, 0.9 to 8.0%; P = 0.015) in the right lung, and
3.6% (95% CI, –0.3 to 7.5%; P = 0.069) in the left lung.The
amount of poorly aerated, normally aerated, and hyperaer-
ated tissue in postoperative computed tomography did not
differ significantly between the two groups (table 2).
Oxygenation and Hemodynamics
Arterial blood analysis was not available in two patients
(one in each group) before extubation and one patient in
the dynamic compliance–guided PEEP group at 30 min
after extubation. Pao2/Fio2 did not differ between the two
groups either before intubation (P = 0.536) or after intu-
bation (P = 0.211). Pao2/Fio2 was significantly higher in
the dynamic compliance–guided PEEP group at 1 h after
pneumoperitoneum (P = 0.001) and before extubation
(P = 0.017; fig. 5). Pao2/Fio2 at 30 min after extubation did
not differ between the two groups (P = 0.183). Percentage
of the time with hypoxemia (Spo2 less than 92%) until 8
am the day after surgery was 1.1% (interquartile range, 0.1
to 8.2%) in the PEEP of 8 cm H2O group and 0.6% (inter-
quartile range, 0.1 to 3.0%) in the dynamic compliance–
guided PEEP group (difference, 0.20%; 95% CI, –0.3 to 4.1;
P = 0.407).The rate of hypotension during the recruitment
maneuver and the dosage of phenylephrine throughout the
surgery did not differ between the two groups (table 1).
Persistent hypotension was not observed in either group.
Postoperative Pulmonary Complications
Four patients in each group (20% for both) developed
postoperative pulmonary complications within 7 days after
surgery. No grade 3 or higher postoperative pulmonary
complications were observed.
Discussion
The results from this trial demonstrated that in patients
undergoing laparoscopic bariatric surgery, postopera-
tive atelectasis was lower under dynamic compliance–
guided PEEP versus PEEP of 8 cm H2O. The dynamic
Li et al.
 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
during but not after surgery.
The analysis of computed tomography revealed that
patients in the dynamic compliance–guided PEEP group
developed atelectasis accounting for 9.5% of the total lung
tissue volume, less than the 13.1% in the PEEP of 8 cm H2O
group at 60 to 90 min after extubation. However, the two
groups did not differ in Pao2/Fio2 at 30 min after extubation.
Such a discrepancy indicates intraoperative lung recruit-
ment may not necessarily translate into high postoperative
lung aeration, as previously suggested by Lagier et al.23 The
lack of improvement in postoperative oxygenation in our
trial could be due to the fact that postoperative atelectasis
differed between the two groups by only 3.6%. However,
the similar discrepancy between the reduced postoperative
atelectasis and no improvement in postoperative oxygen-
ation has also been reported in several previous studies,6,8
suggesting the existence of other underlying mechanisms.
One potential mechanism is that morphological appear-
ances of atelectasis (such as computed tomography) occur
later than physiologic changes (such as Pao2/Fio2). Small
airways tend to close in the early period after extubation
and impair gas exchange in distal alveoli in the absence
of postoperative lung stabilization strategies. However, the
morphological performance of collapsed alveoli as revealed
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
oxygen fraction.24 Accordingly, the open lung effects of
individualized PEEP may partly remain in the early extu-
bation period.
We observed a reduced amount of postoperative atel-
ectasis in the dynamic compliance–guided PEEP group in
the right but not in the left lung. In reference to previous
studies of intrapulmonary gas distribution of individual
lungs,25 this finding is not surprising since surgery was con-
ducted in a partial right-leaning lateral decubitus position
in all patients in this trial. Since the effects of individualized
PEEP on lung ventilation in the lateral decubitus position
has not been explored in other studies, this finding cannot
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

Fig. 3. Scatter plot of optimal positive end-expiratory pressure
(PEEP) and body mass index in individual patients. All 40 partic-
ipants received the titration trial and obtained their PEEP value
with maximum dynamic compliance. The Spearman correlation
coefficient between body mass index and titrated PEEP was
0.361 (P = 0.022).
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
optimal PEEP as the originally set PEEP minus transpul-
monary pressure, and showed that in patients with a BMI
greater than 40 kg/m2, optimal PEEP was 16.8 and 21.5 cm
H2O before and after insufflation of pneumoperitoneum,
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,
in our opinion.
As mentioned in the introduction, the goal of optimal
PEEP is to produce the best compromise of atelectasis and
alveolar hyperdistention.6 Excessive PEEP leads to alveolar
hyperdistension and increased elastic resistance, which in
turn counteracts or even exceeds the reduction in airway
resistance. Therefore, during the stepwise decrease of PEEP
from 25 to 5 cm H2O in this trial, the relationship between
dynamic compliance and PEEP followed an inverted
U-shaped pattern (initial increase and then decrease). The
PEEP value with maximum dynamic compliance was
selected as the optimal PEEP to balance small airway clo-
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.

may impact optimal PEEP value,30 but repeating the titra-
tion procedure after insufflation/exsufflation of pneumo-
peritoneum is not pragmatic. Considering increased need
for higher PEEP with pneumoperitoneum, 2 cm H2O was
added to the final dynamic compliance–guided PEEP for
use during the entire surgery. Another consideration is the
change of body position from a reverse Trendelenburg to
supine position upon exsufflation of pneumoperitoneum,
which in turn tends to cancel out the effects of exsufflation.
Thus, we did not remove the additional PEEP value of 2 cm
H2O after exsufflation of pneumoperitoneum.
Although fluids and vasopressor were given in advance
and the maximum plateau pressure was at a relatively low
level (40 cm H2O), hypotension was common during the
recruitment maneuver. No refractory hemodynamic insta-
bility was observed in this trial, perhaps due to the exclusion
criterion of severe cardiopulmonary diseases.31 The safety
of individualized PEEP in patients with compromised car-
diopulmonary function needs further evaluation in future
studies. Consistent with previous trials of individualized
PEEP in both nonobese and obese patients,3,4,6 the dosage
of phenylephrine and fluid volume during anesthesia were
comparable between the two groups, adding support to the
hemodynamic safety of individualized PEEP.9 The poten-
tial reasons of good hemodynamic stability lie in adequate
fluid and vasoactive drugs infusion before maneuver,32 and
preserved right ventricular function due to low pulmonary
vascular resistance caused by individualized PEEP.33
This trial has several limitations. First, recruitment
maneuver with a plateau pressure of 40 cm H2O may be
insufficient for optimal alveolar recruitment in obese
patients. A previous study suggested that a plateau pressure
as high as 55 cm H2O may not be suffiicient.22 This relatively
low level was chosen to minimize the impact on hemo-
dynamic stability. Second, atelectasis was assessed using 10
slices instead of the whole lung, and therefore was subject
to bias. Having said that, good agreement of differently aer-
ated compartments between the extrapolated results based
on 10 sections and those from all computed tomography
sections has been established.18 Accordingly, this method
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
pulmonary complications or Pao2/Fio2. Fourth, the fixed
PEEP value was 8 instead of 5 cm H2O in our trial, which
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
such a condition (favors the PEEP of 8 cm H2O group), the
results (reduced atelectasis) are more solid. Fifth, the aver-
age body mass index in this trial (40 kg/m2) is considerably
lower than in the obese patients undergoing bariatric sur-
gery in Western countries. Sixth, based on previous find-
ings, optimal PEEP in morbidly obese patients was elevated
by approximately 5 cm H2O after pneumoperitoneum
Li et al. Anesthesiology 2023; 139:262–73
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
Individual PEEP in Obesity
insufflation.30 Adding 2 cm H2O to the PEEP with max-
imum dynamic compliance may not be sufficient to bal-
ance the impact of pneumoperitoneum. Last, a fixed PEEP
rather than static compliance-guided PEEP was used as the
control. Accordingly, whether static compliance-guided
individualized PEEP is superior to dynamic compliance–
guided PEEP remains unknown.
Conclusions
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
guided PEEP versus PEEP of 8 cm H2O. Postoperative Pao2/
Fio2 did not differ between the two groups.
Acknowledgments
The authors thank Kehong Zhang, M.D., Ph.D., from
Ivy Medical Editing (Shanghai, China) for revising the
final manuscript. The authors thank the surgical team of
Xiaocheng Zhu, M.D., Ph.D., from the Department of
Gastroenterological Surgery, Affiliated Hospital of Xuzhou
Medical University (Xuzhou, China) for excellent surgery.
Research Support
This work was supported by the National Natural Science
Foundation of China (Beijing, China; #82293641, and
82130033, to Jun-Li Cao), the Jiangsu Provincial Special
Program of Medical Science (Nanjing, China; #BL2014029,
to Jun-Li Cao), the National Natural Science Foundation
of China (#82271295, to Yuan Han), the Natural Science
Foundation of Shanghai (Shanghai, China; #21ZR1411300,
to Yuan Han), and the Shenkang Clinical Study Foundation
of Shanghai (Shanghai, China; #SHDC2020CR4061, to
Yuan Han).The funders have no involvement in study design,
data collection and interpretation, writing of the manuscript,
and the decision to submit the manuscript for publication.
Competing Interests
The authors declare no competing interests.
Reproducible Science
Full protocol available at: yuan.han@fdeent.org. Raw data
available at: yuan.han@fdeent.org.
Correspondence
Address correspondence to Dr. Cao: Jiangsu Province
Key Laboratory of Anesthesia and Analgesia Application
Technology, Xuzhou Medical University, Xuzhou,
221004, Jiangsu, China. caojl0310@aliyun.com or junli-
cao0310@163.com.This article may be accessed for personal
use at no charge through the Journal Web site, www.anes-
thesiology.org.
271
 Perioperative Medicine
Supplemental Digital Content
Table E1, E2, E3, https://links.lww.com/ALN/D153
References
1. Hedenstierna G, Rothen HU: Respiratory function
during anesthesia: Effects on gas exchange. Compr
Physiol 2012; 2:69–96
2. Eichenberger A, Proietti S, Wicky S, Frascarolo P, Suter
M, Spahn DR, Magnusson L: Morbid obesity and post-
operative pulmonary atelectasis: An underestimated
problem. Anesth Analg 2002; 95:1788–92, table of
contents
3. Girrbach F, Petroff D, Schulz S, Hempel G, Lange
M, Klotz C, Scherz S, Giannella-Neto A, Beda A,
Jardim-Neto A, Stolzenburg JU, Reske AW, Wrigge H,
Simon P: Individualised positive end-expiratory pres-
sure guided by electrical impedance tomography for
robot-assisted laparoscopic radical prostatectomy: A
prospective, randomised controlled clinical trial. Br J
Anaesth 2020; 125:373–82
4. Fernandez-Bustamante A, Sprung J, Parker RA,
Bartels K, Weingarten TN, Kosour C, Thompson BT,
Vidal Melo MF: Individualized peep to optimise
respiratory mechanics during abdominal surgery: A
pilot randomised controlled trial. Br J Anaesth 2020;
125:383–92
5. Park M, Ahn HJ, Kim JA, Yang M, Heo BY, Choi JW,
Kim YR, Lee SH, Jeong H, Choi SJ, Song IS: Driving
pressure during thoracic surgery: A randomized clinical
trial. Anesthesiology 2019; 130:385–93
6. Pereira SM, Tucci MR, Morais CCA, Simões CM,
Tonelotto BFF, Pompeo MS, Kay FU, Pelosi P, Vieira
JE, Amato MBP: Individual positive end-expiratory
pressure settings optimize intraoperative mechani-
cal ventilation and reduce postoperative atelectasis.
Anesthesiology 2018; 129:1070–81
7. Ferrando C, Soro M, Unzueta C, Suarez-Sipmann F,
Canet J, Librero J, Pozo N, Peiró S, Llombart A, León
I, India I, Aldecoa C, Díaz-Cambronero O, Pestaña D,
Redondo FJ, Garutti I, Balust J, García JI, Ibáñez M,
Granell M, Rodríguez A, Gallego L, de la Matta M,
Gonzalez R, Brunelli A, García J, Rovira L, Barrios F,
Torres V, Hernández S, Gracia E, Giné M, García M,
García N, Miguel L, Sánchez S, Piñeiro P, Pujol R,
García-Del-Valle S, Valdivia J, Hernández MJ, Padrón
O, Colás A, Puig J, Azparren G,Tusman G,Villar J, Belda
J; Individualized PeRioperative Open-lung VEntilation
(iPROVE) Network: Individualised perioperative
open-lung approach versus standard protective venti-
lation in abdominal surgery (iPROVE): A randomised
controlled trial. Lancet Respir Med 2018; 6:193–203
8. Nestler C, Simon P, Petroff D, Hammermüller S,
Kamrath D, Wolf S, Dietrich A, Camilo LM, Beda A,
272 Anesthesiology 2023; 139:262–73
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
Carvalho AR, Giannella-Neto A, Reske AW, Wrigge
H: Individualized positive end-expiratory pressure in
obese patients during general anaesthesia: A random-
ized controlled clinical trial using electrical impedance
tomography. Br J Anaesth 2017; 119:1194–205
9. Simon P, Girrbach F, Petroff D, Schliewe N, Hempel
G, Lange M, Bluth T, Gama de Abreu M, Beda A,
Schultz MJ, Pelosi P, Reske AW, Wrigge H; PROBESE
Investigators of the Protective Ventilation Network*
and the Clinical Trial Network of the European Society
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
end-expiratory pressure for intraoperative mechani-
cal ventilation in obese patients: A secondary analysis.
Anesthesiology 2021; 134:887–900
10. Xu D, Wei W, Chen L, Li S, Lian M: Effects of different
positive end-expiratory pressure titrating strategies on
oxygenation and respiratory mechanics during one-
lung ventilation: A randomized controlled trial. Ann
Palliat Med 2021; 10:1133–44
11. Ball L, Braune A, Corradi F, Brusasco C, Garlaschi A,
Kiss T, Bluth T, Simonassi F, Bergamaschi A, Kotzerke
J, Schultz MJ, de Abreu MG, Pelosi P: Ultra-low-dose
sequential computed tomography for quantitative lung
aeration assessment-a translational study. Intensive Care
Med Exp 2017; 5:19
12. Van Hecke D, Bidgoli JS,Van der Linden P: Does lung
compliance optimization through peep manipulations
reduce the incidence of postoperative hypoxemia in
laparoscopic bariatric surgery? A randomized trial.
Obes Surg 2019; 29:1268–75
13. Ferrando C, Mugarra A, Gutierrez A, Carbonell JA,
Garcia M, Soro M, Tusman G, Belda FJ: Setting indi-
vidualized positive end-expiratory pressure level with a
positive end-expiratory pressure decrement trial after a
recruitment maneuver improves oxygenation and lung
mechanics during one-lung ventilation. Anesth Analg
2014; 118:657–65
14. Pintado MC, de Pablo R, Trascasa M, Milicua JM,
Sanchez-Garcia M: Compliance-guided versus fio2-
driven positive-end expiratory pressure in patients with
moderate or severe acute respiratory distress syndrome
according to the berlin definition. Med Intensiva 2017;
41:277–84
15. Jeong H, Tanatporn P, Ahn HJ, Yang M, Kim JA, Yeo
H, Kim W: Pressure support versus spontaneous ven-
tilation during anesthetic emergence-effect on post-
operative atelectasis: A randomized controlled trial.
Anesthesiology 2021; 135:1004–14
16. Lundquist H, Hedenstierna G, Strandberg A, Tokics L,
Brismar B: Ct-assessment of dependent lung densities
in man during general anaesthesia. Acta Radiol 1995;
36:626–32
17. Kroenke K, Lawrence VA, Theroux JF, Tuley MR:
Operative risk in patients with severe obstructive pul-
monary disease. Arch Intern Med 1992; 152:967–71
Li et al.

18. Reske AW, Reske AP, Gast HA, Seiwerts M, Beda A,
Gottschaldt U, Josten C, Schreiter D, Heller N, Wrigge
H, Amato MB: Extrapolation from ten sections can
make ct-based quantification of lung aeration more
practicable. Intensive Care Med 2010; 36:1836–44
19. Puybasset L, Cluzel P, Gusman P, Grenier P, Preteux F,
Rouby JJ: Regional distribution of gas and tissue in
acute respiratory distress syndrome. I. Consequences
for lung morphology. CT Scan ARDS Study Group.
Intensive Care Med 2000; 26:857–69
20. Rylander C, Tylén U, Rossi-Norrlund R, Herrmann P,
Quintel M, Bake B: Uneven distribution of ventilation
in acute respiratory distress syndrome. Crit Care 2005;
9:R165–71
21. Cressoni M, Gallazzi E, Chiurazzi C, Marino A, Brioni
M, Menga F, Cigada I, Amini M, Lemos A, Lazzerini M,
Carlesso E, Cadringher P, Chiumello D, Gattinoni L:
Limits of normality of quantitative thoracic ct analysis.
Crit Care 2013; 17:R93
22. Reinius H, Jonsson L, Gustafsson S, Sundbom M,
Duvernoy O, Pelosi P, Hedenstierna G, Fredén F:
Prevention of atelectasis in morbidly obese patients
during general anesthesia and paralysis:A computerized
tomography study. Anesthesiology 2009; 111:979–87
23. Lagier D, Zeng C, Fernandez-Bustamante A,Vidal Melo
MF: Perioperative pulmonary atelectasis: Part ii. Clinical
implications. Anesthesiology 2022; 136:206–36
24. Magnusson L, Spahn DR: New concepts of atelec-
tasis during general anaesthesia. Br J Anaesth 2003;
91:61–72
25. Rehder K, Hatch DJ, Sessler AD, Fowler WS:The func-
tion of each lung of anesthetized and paralyzed man
during mechanical ventilation. Anesthesiology 1972;
37:16–26
26. Hemmes SN, Gama de Abreu M, Pelosi P, Schultz MJ;
PROVE Network Investigators for the Clinical Trial
Network of the European Society of Anaesthesiology:
High versus low positive end-expiratory pressure
during general anaesthesia for open abdominal surgery
(PROVHILO trial): A multicentre randomised con-
trolled trial. Lancet 2014; 384:495–503
27. Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, Gama
de Abreu M, Bluth T, Bobek I, Canet JC, Cinnella G,
de Baerdemaeker L, Gama de Abreu M, Gregoretti
C, Hedenstierna G, Hemmes SNT, Hiesmayr M,
Hollmann MW, Jaber S, Laffey J, Licker MJ, Markstaller
K, Matot I, Mills GH, Mulier JP, Pelosi P, Putensen
C, Rossaint R, Schmitt J, Schultz MJ, Senturk M,
Serpa Neto A, Severgnini P, Sprung J, Vidal Melo MF,
Li et al. Anesthesiology 2023; 139:262–73
Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
Individual PEEP in Obesity
Wrigge H; Writing Committee for the PROBESE
Collaborative Group of the PROtective VEntilation
Network (PROVEnet) for the Clinical Trial Network
of the European Society of Anaesthesiology: Effect
of intraoperative high positive end-expiratory pres-
sure (peep) with recruitment maneuvers vs low peep
on postoperative pulmonary complications in obese
patients: A randomized clinical trial. JAMA 2019;
321:2292–305
28. Nielsen J, Østergaard M, Kjaergaard J, Tingleff J,
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
maneuver depresses central hemodynamics in patients
following cardiac surgery. Intensive Care Med 2005;
31:1189–94
29. Spadaro S, Karbing DS, Mauri T, Marangoni E, Mojoli
F,Valpiani G, Carrieri C, Ragazzi R,Verri M, Rees SE,
Volta CA: Effect of positive end-expiratory pressure
on pulmonary shunt and dynamic compliance during
abdominal surgery. Br J Anaesth 2016; 116:855–61
30. Tharp WG, Murphy S, Breidenstein MW, Love C,
Booms A, Rafferty MN, Friend AF, Perrapato S, Ahern
TP, Dixon AE, Bates JHT, Bender SP: Body habitus
and dynamic surgical conditions independently impair
pulmonary mechanics during robotic-assisted laparo-
scopic surgery. Anesthesiology 2020; 133:750–63
31. Cavalcanti AB, Suzumura A, Laranjeira LN, Paisani
DM, Damiani LP, Guimarães HP, Romano ER,
Regenga MM, Taniguchi LNT, Teixeira C, Pinheiro
de Oliveira R, Machado FR, Diaz-Quijano FA, Filho
MSA, Maia IS, Caser EB, Filho WO, Borges MC,
Martins PA, Matsui M, Ospina-Tascón GA, Giancursi
TS, Giraldo-Ramirez ND,Vieira SRR, Assef M, Hasan
MS, Szczeklik W, Rios F, Amato MBP, Berwanger O,
Ribeiro de Carvalho CR: Effect of lung recruitment
and titrated positive end-expiratory pressure (PEEP) vs
low PEEP on mortality in patients with acute respi-
ratory distress syndrome: A randomized clinical trial.
JAMA 2017; 318:1335–45
32. Bohm SH, Thamm OC, von Sandersleben A, Bangert
K, Langwieler TE, Tusman G, Strate TG, Standl TG:
Alveolar recruitment strategy and high positive
end-expiratory pressure levels do not affect hemody-
namics in morbidly obese intravascular volume-loaded
patients. Anesth Analg 2009; 109:160–3
33. Gernoth C, Wagner G, Pelosi P, Luecke T: Respiratory
and haemodynamic changes during decremental open
lung positive end-expiratory pressure titration in
patients with acute respiratory distress syndrome. Crit
Care 2009; 13:R59
273