Driving pressure-guided ventilation during one-lung ventilation for thoracic surgery: a systematic review and meta-analysis

Background Driving pressure-guided ventilation has been proposed as a physiologically rational lung-protective strategy during one-lung ventilation for thoracic surgery. However, no previous systematic review has specifically focused on trials in which driving pressure was the explicit primary ventilatory target during one-lung ventilation. We aimed to assess the effects of driving pressure-guided ventilation on postoperative pulmonary complications (PPCs) and related perioperative outcomes in adults undergoing thoracic surgery. Methods We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus, and trial registries from inception to 19 March 2026. We included randomized controlled trials comparing explicit driving pressure-guided ventilation with conventional non-driving-pressure-guided ventilation during one-lung ventilation in adults undergoing thoracic surgery. Observational studies were summarised narratively. Random-effects meta-analyses were performed using restricted maximum likelihood estimation with Hartung–Knapp adjustment. Certainty of evidence was assessed using GRADE. The review was registered in PROSPERO (CRD420261329253). Results Four randomized controlled trials (654 patients) were included in the primary analysis. The pooled effect on PPCs was not statistically significant in the primary random-effects analysis (risk ratio RR: 0.60, 95% confidence interval CI: 0.26–1.35; p = 0.14; I 2 = 49.7%). Exploratory supportive analyses—including a fixed-effect model (RR 0.61; p = 0.007), the pooled absolute risk difference (−7.6%; p = 0.027), and a broadened sensitivity analysis of six trials incorporating individualised PEEP strategies (RR 0.70; p = 0.12)—were directionally concordant but should not be interpreted as independent confirmation of effect, given the imprecision of the primary estimate and variation in baseline PPC risk. Four observational studies provided mixed supplementary evidence. The overall certainty of evidence was low according to GRADE, owing to inconsistency and imprecision. Conclusion The primary randomized evidence did not demonstrate a statistically significant reduction in postoperative pulmonary complications, and the overall certainty of evidence was low. The available data are therefore hypothesis-generating. Larger, multicentre, and geographically diverse randomized trials with harmonised outcome definitions are needed to clarify whether driving pressure-guided ventilation improves postoperative outcomes and should be adopted more broadly in thoracic anaesthesia. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261329253 , Unique Identifier: CRD420261329253.