Protective intraoperative mechanical ventilation has been associated with reduced postoperative pulmonary complication risk. Obesity is associated with an increased risk of atelectasis and impaired respiratory function. In this setting, high positive end-expiratory pressure with alveolar recruitment maneuvers have been proposed for routine intraoperative mechanical ventilation to prevent these physiologic alterations. Limited data exists regarding whether this approach has benefit in terms of postoperative outcomes. Examining whether an intraoperative mechanical ventilation strategy with higher PEEP and alveolar recruitment maneuvers reduces the incidence of postoperative pulmonary complications within the first five postoperative days in obese surgical patients, The Protective Intraoperative Ventilation With Higher Versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial randomized 2013 adult non-cardiac, non-neurological surgical patients with body mass indices of 35 or greater with substantial postoperative pulmonary complication risk across a high level PEEP group with alveolar recruitment maneuvers (n=989) or a low level PEEP group (n=987). The primary outcome was a composite of pulmonary complications within the first five postoperative days. Based on an intention-to-treat analysis, the primary outcome was reported in 21.3% of patients in the high PEEP group versus 23.6% in the low PEEP group (difference -2.3%, 95% CI -5.9% to 1.4%; RR 0.93, 95% CI 0.83 to 1.04). High PEEP was also associated with a decreased incidence of hypoxemia (5.0% vs. 13.6%; difference -8.6%, 95% CI -11.1% to 6.1%, p<0.001). The findings of this study therefore show no significant reduction in postoperative pulmonary complications with higher level of PEEP for intraoperative mechanical ventilation in obese surgical patients undergoing general anesthesia but do show evidence of decreased hypoxemia.
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