Individualised positive end-expiratory pressure to minimise driving pressure and postoperative pulmonary complications in minimally invasive thoracic and abdominal surgery a systematic review and meta-analysis

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Background Mechanical ventilation during minimally invasive surgery is associated with postoperative pulmonary complications. Limiting driving pressure appears to reduce pulmonary complications with lung-protective ventilation strategies. Whether individualising PEEP minimises driving pressure to reduce pulmonary complications is unknown. In this systematic review, we assessed whether individualised PEEP strategies during minimally invasive surgery reduce postoperative pulmonary outcomes and driving pressures or both. Methods We searched Medline, Central, LILACS, Embase, and Scopus for studies comparing individualised PEEP to lung-protective ventilation in minimally invasive thoracic and abdominal surgery (PROSPERO CRD42023495377). The primary outcome was postoperative pulmonary complication. Random-effects models generated risk ratios (RRs) with 95% confidence intervals (95% CIs) for binary outcomes. We conducted prespecified subgroup analyses by surgery type and post hoc subgroup analyses by individualised PEEP strategy and patient factors. We compared driving pressure differences between individualised PEEP and lung-protective strategies. Statistical heterogeneity was assessed using the I 2 index and the risk of bias with Cochrane (RoB2) and ROBINS-I. Results Thirty studies were included ( n =3295 participants). Individualised PEEP was associated with reduced risk of postoperative pulmonary complications, compared with lung-protective ventilation (RR=0.67, 95% CI=0.56–0.79, I 2 =0.4%). This association was consistent in abdominal and thoracic surgery, and in subgroup analyses. Individualised PEEP was associated with lower driving pressures (mean difference=−3.17, 95% CI=−3.84 to −2.50); I 2 =86.6%). The certainty of evidence for PPCs was moderate, with a low risk of bias. Conclusion Individualised PEEP was associated with fewer postoperative pulmonary complications and lower driving pressures during minimally invasive surgery; showing causality requires further research.