The Paradox of Personalized PEEP: Why Driving Pressure-Guided Ventilation Failed to Improve Outcomes in Emergency Surgery

Introduction: The Quest for Lung-Protective Ventilation in the OR

For decades, the cornerstone of lung-protective ventilation (LPV) has been the use of low tidal volumes to prevent volutrauma. However, attention has recently shifted toward the role of airway driving pressure (DP)—the difference between plateau pressure and positive end-expiratory pressure (PEEP)—as a more refined marker of lung strain. While lower driving pressures have been associated with improved survival in patients with Acute Respiratory Distress Syndrome (ARDS), its utility in the perioperative setting remains a subject of intense debate.

The logic appears sound: by individualizing PEEP to minimize driving pressure, clinicians can theoretically optimize lung recruitment and prevent cyclic atelectasis. Yet, two major recent publications—the IMPROVE-2 randomized clinical trial and a comprehensive systematic review—provide a complex, and at times contradictory, picture of whether this physiological optimization actually translates into better patient outcomes.