Driving pressure guided ventilation in robot-assisted laparoscopic surgery with steep Trendelenburg position: a randomized controlled study

Background: Robot-assisted laparoscopic prostatectomy (RALP) with pneumoperitoneum and steep Trendelenburg positioning impairs ventilation and increases the risk of pulmonary complications. Although positive end-expiratory pressure (PEEP) may reduce atelectasis, the optimal levels remain unclear. This study evaluated the effects of driving pressure (DP)-guided PEEP titration on patients undergoing RALP.Methods: This single-center, randomized controlled trial enrolled adults undergoing RALP (American Society of Anesthesiologists < 3, without pulmonary disease) for either DP minimization-guided individualized PEEP (DP group) or fixed 5 cmH2O PEEP (control). DP was calculated as the plateau pressure minus PEEP, with individualized PEEP determined using decremental titration. Atelectasis was quantified using modified lung ultrasound score (LUS), incorporating B-lines and consolidations. Primary outcome was LUS at end-Trendelenburg. Secondary outcomes included oxygenation and pulmonary complications.Results: Of 101 assessed, 63 completed analysis. The DP group (n=31) received individualized PEEP (median 8.0 cmH2O during Trendelenburg) vs. 5.0 cmH2O in controls (n=32). Mean DP was lower in the DP group during Trendelenburg (19.0 ± 3.4 vs. 21.3 ± 4.7 cmH2O, P=0.035). LUS were significantly lower in the DP group at the end-Trendelenburg (median [1Q, 3Q]: 9.0 [8.0, 11.5] vs. 11.0 [9.0, 13.0]; median difference, −2.0 [95% confidence interval, −3.5 to −0.2]; P=0.031) and recovery (9.0 vs. 13.5, P<0.001). Intraoperative PaO2 was higher in the DP group (154.6 ± 33.1 vs. 133.3 ± 34.7 mmHg, P=0.015 during Trendelenburg). No differences were observed in postoperative complications or hospital stay.Conclusions: DP-guided PEEP titration during RALP reduced continuous lung de-aeration burden assessed by modified LUS, though benefits did not translate to reduced postoperative pulmonary complications.