Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial

Background: Airway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear. Methods: In this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n650) with fixed PEEP of 5 cm H 2 O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively. Results: The modified intention-to-treat analysis included 1170 patients (mean [standard deviation, SD]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H 2 O in the driving pressure group vs 9.2 cm H 2 O in the protective ventilation group (mean difference [95% confidence interval, CI]; 2.1 [2.4 to 1.9] cm H 2 O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference 2.3%; 95% CI, 8.0% to 3.3%; P0.42). Intraoperatively, lung compliance (mean [SD], 42.7 [12.4] vs 33.5 [11.1] ml cm H 2 O 1 ; P<0.001) and Pa o2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs