What is the optimal Positive End-Expiratory Pressure (PEEP) for intraoperative ventilation during robotic laparoscopic surgery?

From the Guidelines

In robotic laparoscopic surgery, a PEEP of 5 cmH2O is recommended as the initial setting for optimizing intraoperative ventilation, with subsequent individualization based on patient characteristics, as suggested by the international expert panel-based consensus recommendations 1. The specific PEEP should be tailored to the patient's needs, taking into account factors such as obesity, pre-existing respiratory conditions, and the unique ventilation challenges posed by pneumoperitoneum and steep Trendelenburg positioning.

• Key considerations for PEEP setting include:
  • Preventing atelectasis (collapsed alveoli) while avoiding excessive airway pressure
  • Maintaining alveolar recruitment and improving oxygenation
  • Monitoring airway pressures, oxygen saturation, and hemodynamic parameters continuously
  • Adjusting PEEP as needed to optimize ventilation
• Lung-protective ventilation strategies, including tidal volumes of 6-8 mL/kg ideal body weight and regular recruitment maneuvers, should also be considered to further optimize ventilation during robotic laparoscopic procedures 1. The international expert panel-based consensus recommendations provide a framework for lung-protective ventilation in surgical patients, emphasizing the importance of individualized PEEP and lung-protective ventilation strategies to minimize the risk of postoperative pulmonary complications 1.

From the Research

Optimal PEEP for Intraoperative Ventilation in Robotic Laparoscopic Surgery

• The optimal positive end-expiratory pressure (PEEP) for intraoperative ventilation in robotic laparoscopic surgery is a topic of ongoing research, with various studies investigating different PEEP strategies and their effects on oxygenation and respiratory mechanics 2, 3, 4, 5, 6.
• A systematic review and network meta-analysis of randomized controlled trials found that individualized PEEP combined with recruitment maneuvers was superior to other PEEP and recruitment maneuver settings in terms of oxygenation index and dynamic compliance 2.
• Another study found that a combination of lung recruitment maneuvers and positive airway pressure before extubation did not improve oxygenation in the post-anesthesia care unit, suggesting that the benefits of recruitment maneuvers may not persist after operation 3.
• A randomized controlled trial investigating the effects of different PEEP titrating strategies on oxygenation and respiratory mechanics during one-lung ventilation found that titrating PEEP to achieve maximum dynamic compliance improved respiratory mechanics, but had no significant effects on oxygenation 5.
• A study comparing optimal PEEP and recruitment maneuvers during lung-protective mechanical ventilation in patients with acute lung injury/acute respiratory distress syndrome found that sighs superimposed on lung-protective mechanical ventilation with optimal PEEP improved oxygenation and static compliance 6.

Key Findings

• Individualized PEEP combined with recruitment maneuvers may be the optimal strategy for intraoperative ventilation in robotic laparoscopic surgery 2.
• The benefits of recruitment maneuvers may not persist after operation, and further research is needed to elucidate the mechanism of atelectasis on emergence from anesthesia 3.
• Titrating PEEP to achieve maximum dynamic compliance may improve respiratory mechanics during one-lung ventilation, but may not have significant effects on oxygenation 5.
• Sighs superimposed on lung-protective mechanical ventilation with optimal PEEP may improve oxygenation and static compliance in patients with acute lung injury/acute respiratory distress syndrome 6.

PEEP Strategies

• Individualized PEEP: setting PEEP based on individual patient characteristics and respiratory mechanics 2.
• Recruitment maneuvers: using techniques such as sustained inflation or sigh breaths to recruit alveoli and improve oxygenation 2, 3, 4, 6.
• Dynamic compliance: titrating PEEP to achieve maximum dynamic compliance, which may improve respiratory mechanics 5.
• Optimal PEEP: setting PEEP at a level that balances oxygenation and respiratory mechanics, which may vary depending on the patient and the specific clinical context 6.