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BACKGROUND:Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS:Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS:Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS:Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.

Original publication






Publication Date





667 - 677


From the Research Group in Perioperative Medicine (G.M., O.D-C., N.G-G., B.A-M., M.P.A.N.) the Department of Anaesthesiology (G.M., O.D-C., J.M.A.-I., N.G-G., B.A-M., M.P.A.N.) the Department of Hepatobiliopancreatic Surgery (J.L.I., J.M.), Hospital Universitario y Politécnico la Fe, Valencia, Spain the Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.S.N.) the Cardio-Pulmonary Department, Pulmonary Division, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil (A.S.N.) the Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands (A.S.N., M.J.S.) Policlinico San Martino Hospital - Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neurosciences, Genoa, Italy (L.B., P.P.) the Department of Surgical Sciences and Integrated Diagnostics, University of Genoa Italy (L.B., P.P.) the Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, Technische Universität Dresden, Dresden, Germany (M.G.d.A.) the Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand (M.J.S.) the Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (M.J.S.).


Abdomen, Humans, Pneumoperitoneum, Tidal Volume, Laparoscopy, Monitoring, Intraoperative, Positive-Pressure Respiration, Cross-Over Studies, Aged, Middle Aged, Female, Male