Sun Xiaochen, Gao Yuan, Jin Xinyu, Lin Wendong
Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China.
Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China.
J Cardiothorac Vasc Anesth. 2025 Jul 11. doi: 10.1053/j.jvca.2025.06.019.
To evaluate the impact of individualized positive end-expiratory pressure (PEEP) versus fixed PEEP on postoperative pulmonary complications (PPCs), intraoperative oxygenation, and respiratory mechanics in thoracic surgery. One-lung ventilation (OLV) poses potential risks of PPCs. PEEP may mitigate lung injury, but the optimal PEEP level remains uncertain.
We searched PubMed, Embase, Web of Science, and Cochrane for randomized controlled trials (RCTs) comparing individualized PEEP versus fixed PEEP during OLV published up to December 2024. The primary outcome was the occurrence of overall PPCs during hospitalization. Secondary outcomes included postoperative hypoxemia, atelectasis, pneumonia, acute respiratory distress syndrome (ARDS), intraoperative oxygenation, dynamic compliance, driving pressure, and hospital length of stay. Risk ratios (RRs) and mean differences were calculated using the DerSimonian-Laird method. Study quality was evaluated using the Cochrane Risk of Bias tool version 2 for RCTs trials. Trial sequential analysis (TSA) was used to assess result reliability.
Six RCTs (with a total of 1,844 patients) were included, with 5 studies (1,814 patients) reporting PPCs. Individualized PEEP did not significantly reduce overall PPCs (RR, 0.78; 95% confidence interval, 0.59-1.03; p = 0.08), hypoxemia, pneumonia, or atelectasis; however, it reduced postoperative ARDS and improved intraoperative oxygenation and lung compliance. TSA revealed that the current sample size of 1,814 in PPCs was below the required 3,660, and that the z-curve did not cross the TSA monitoring boundaries.
Individualized PEEP in thoracic surgery may improve intraoperative oxygenation, pulmonary mechanics, and reduce postoperative ARDS but does not significantly lower overall PPCs. Overall, the quality of the evidence is low and inconclusive, and further investigation is warranted.
评估个体化呼气末正压（PEEP）与固定PEEP对胸外科手术后肺部并发症（PPCs）、术中氧合及呼吸力学的影响。单肺通气（OLV）存在发生PPCs的潜在风险。PEEP可能减轻肺损伤，但最佳PEEP水平仍不确定。
我们检索了PubMed、Embase、Web of Science和Cochrane数据库，以查找截至2024年12月发表的比较OLV期间个体化PEEP与固定PEEP的随机对照试验（RCTs）。主要结局是住院期间总体PPCs的发生情况。次要结局包括术后低氧血症、肺不张、肺炎、急性呼吸窘迫综合征（ARDS）、术中氧合、动态顺应性、驱动压及住院时间。采用DerSimonian-Laird方法计算风险比（RRs）和均值差。使用Cochrane偏倚风险工具第2版对RCTs试验的研究质量进行评估。采用试验序贯分析（TSA）评估结果的可靠性。
纳入6项RCTs（共1844例患者），5项研究（1814例患者）报告了PPCs。个体化PEEP并未显著降低总体PPCs（RR，0.78；95%置信区间，0.59 - 1.03；p = 0.08）、低氧血症、肺炎或肺不张；然而，它降低了术后ARDS的发生率，并改善了术中氧合及肺顺应性。TSA显示，目前PPCs方面1814例的样本量低于所需的3660例，且z曲线未越过TSA监测边界。
胸外科手术中个体化PEEP可能改善术中氧合、肺力学，并降低术后ARDS的发生率，但并未显著降低总体PPCs。总体而言，证据质量较低且尚无定论，有必要进一步研究。
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