Drive Pressure-Guided Individualized Positive End-Expiratory Pressure in Traumatic Brain Injury Surgery: A Randomized Controlled Trial

AIM: Intraoperative lung-protective ventilation strategies (LPVS) have been shown to improve lung oxygenation and prevent postoperative pulmonary problems in surgical patients. However, the application of positive end-expiratory pressure (PEEP)-based LPVS in emergency traumatic brain injury (TBI) has not been thoroughly explored. The purpose of this study is to evaluate the effects of drive pressure-guided individualized PEEP on perioperative pulmonary oxygenation, postoperative pulmonary complications, and recovery from neurological injury in patients with TBI. METHODS: A total of 111 TBI patients who met the inclusion criteria at Northern Jiangsu People's Hospital were randomized into three groups: group A (0 PEEP, 50% inhaled oxygen concentration, and 6 mL/kg tidal volume), group B (5 cmH2O PEEP, 50% inhaled oxygen concentration, and 6 mL/kg tidal volume), and group C (individualized PEEP guided by driving pressure, 50% inhaled oxygen concentration, and 6 mL/kg tidal volume). The primary endpoints were lung ultrasound score (LUS), optic nerve sheath diameter (ONSD), and serum levels of neuron-specific enolase (NSE) and High mobility group box 1 protein (HMGB1). Secondary endpoints included intraoperative hemodynamic and respiratory mechanics parameters, postoperative pulmonary complications, and clinical lung infection scores. RESULTS: Eighty-nine patients completed the final analysis. LUS was significantly lower in group C compared to group A at T4 (least square mean [95% confidence interval (CI)]: 2.50 [1.35, 3.65] vs. 5.25 [4.10, 6.40], p < 0.05). Although ONSD increased gradually in group C, it did not differ substantially from group A postoperatively (least square mean [95% CI]: 5.09 [4.90, 5.27] vs 5.16 [4.97, 5.34] mm, p > 0.05). Serum NSE levels in group C were significantly lower on postoperative days 1 (4.40 [3.89, 4.41] vs. 10.95 [10.44, 11.46], p < 0.05) and 3 (2.79 [2.28, 3.30] vs. 10.95 [10.44, 11.46], p < 0.05). Additionally, serum HMGB1 levels in group C were significantly reduced on postoperative days 1 (229 [200, 258] vs. 662 [633, 691], p < 0.05) and 3 (166 [137, 195] vs. 662 [633, 691], p < 0.05). CONCLUSIONS: Individualized PEEP guided by driving pressure can improve perioperative pulmonary oxygenation and reduce the incidence of postoperative pulmonary complications. Furthermore, this strategy did not significantly elevate intraoperative intracranial pressure (ICP) and promoted recovery from postoperative neurological injury, likely by reducing the inflammatory response. CLINICAL TRIAL REGISTRATION: https://www.chictr.org.cn/ (clinical trial no. ChiCTR2200066795).