With high BMI, no benefit from higher PEEP, recruitment maneuvers during surgery

  • Bluth T & al.
  • JAMA
  • 3 jun. 2019

  • de Jenny Blair, MD
  • Clinical Essentials
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  • In patients with obesity and undergoing surgery, higher intraoperative positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers (ARM) does not reduce postoperative pulmonary complications.
  • Editorial : results do not support routine high-level PEEP or permissive atelectasis; multimodal prevention needed.

Why this matters

  • Postsurgery pulmonary complications affect almost 1 in 5 patients with obesity. 
  • Atelectasis, impaired respiratory function during anesthesia are common in this population.
  • Higher PEEP and ARM improve those problems, but postoperative effects had not been examined.

Key results

  • 90.1% had abdominal operations.
  • High PEEP/ARM vs low PEEP:
    • Primary outcome: 21.3% (211) vs 23.6% (233);
    • Risk ratio, 0.93 (95% CI, 0.83-1.04; P=.23).
    • Hypoxemia less frequent in high PEEP/ARM group; 
    • Hypotension, bradycardia, pleural effusion more frequent.

Study design

  • Randomized clinical PROBESE trial in 23 countries (n=1976).
  • Participants were adults with BMI ≥35 kg/m2 at risk for postoperative pulmonary complications undergoing surgery under general anesthesia. 
  • During volume-control ventilation with low tidal volume, they were randomly assigned to high PEEP (12 cm H2O)+ARM vs low PEEP (4 cm H2O).
  • Outcome: composite of 5-day pulmonary complications, including respiratory failure, acute respiratory distress syndrome, pulmonary infection. 
  • Funding: European Society of Anaesthesiology; nonprofits, government agencies.


  • Optimal ARM method unclear.
  • PEEP not individually titrated.