High PEEP versus Low PEEP: Major Trial Finds No Benefit in Preventing Postoperative Lung Complications
Netherlands: A new international trial published in JAMA has found that using individualized high positive end-expiratory pressure (PEEP) guided by driving pressure during open abdominal surgery does not lower the risk of postoperative pulmonary complications when compared with standard low PEEP ventilation.
The study was conducted by the DESIGNATION Investigators, led by Dr. David M. P. van Meenen from Amsterdam University Medical Center.
The research addressed an important question in perioperative care: whether adjusting PEEP to minimize driving pressure—along with performing recruitment maneuvers—could offer better protection for the lungs during major abdominal surgery. Patients undergoing such procedures often face a heightened risk of respiratory complications, and optimizing ventilation strategies has long been a focus in anesthesiology.
The randomized clinical trial enrolled 1435 adults at increased risk for pulmonary complications across 29 hospitals in five European countries. Participants were scheduled for open abdominal surgery and received low tidal volume ventilation as part of standard care. They were assigned either to a ventilation protocol using driving pressure–guided high PEEP with recruitment maneuvers or to a standard low PEEP protocol without recruitment maneuvers.
The primary measure was the occurrence of postoperative pulmonary complications within the first five days after surgery. These included conditions such as atelectasis, severe respiratory failure, suspected pulmonary infection, pulmonary infiltrates, aspiration pneumonitis, pneumothorax, and cardiopulmonary edema.
The following were the key findings of the study:
- The study found no significant difference in postoperative pulmonary complications between the two ventilation strategies, with rates of 19.8% in the high PEEP group and 17.4% in the low PEEP group.
- The absolute risk difference (−1.5% to 6.4%) showed no clinically meaningful advantage for high PEEP.
- Intraoperative hypotension occurred more often in the high PEEP group (54%) than in the low PEEP group (45%).
- Use of vasoactive medications was also higher in patients receiving high PEEP.
- Desaturation episodes were more frequent in the low PEEP group, although they remained uncommon overall.
The authors acknowledged several limitations, including the use of a composite outcome with varying severity, which complicates interpretation. Pulmonary complications occurred less frequently than expected, reducing the precision of effect estimates. The exclusion of minimally invasive surgeries limits generalizability, and the lack of standardized neuromuscular monitoring and reversal may have influenced outcomes. Subgroup analyses were also underpowered.
Despite these limitations, the evidence indicates that tailoring intraoperative PEEP to achieve the lowest driving pressure—combined with recruitment maneuvers—does not yield better pulmonary outcomes after open abdominal surgery. The study reinforces that standard low PEEP ventilation remains an appropriate and effective approach for this patient group.
Reference:
Writing and Steering Committees for the DESIGNATION–Investigators. Intraoperative Driving Pressure–Guided High PEEP vs Standard Low PEEP for Postoperative Pulmonary Complications. JAMA. Published online December 03, 2025. doi:10.1001/jama.2025.23373
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