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. 2025 Aug;39(4):739-744.
doi: 10.1007/s10877-025-01318-7. Epub 2025 Jun 27.

Intraoperative PEEP selection by pressure-based capnography: a proof of concept study

Gerardo Tusman  1 , Matías Nicolás  2 , Alejandro Carmona  2 , Fernando Suarez Sipmann  3   4 , Ulises Tusman  5 , Peter Kremeier  6 , Stephan H Böhm  7
Affiliations

Intraoperative PEEP selection by pressure-based capnography: a proof of concept study

Gerardo Tusman et al. J Clin Monit Comput. 2025 Aug.

Abstract

Purpose: We aimed to test a new method to determine the positive-end expiratory pressure (PEEP) that maintains the lungs open after a recruitment maneuver (RM).

Methods: In eleven anesthetized patients, we compared the standard RM searching for the optimal PEEP based on the highest respiratory compliance (PEEPCrs), with a new method. This method performs a RM during a slow pressure-volume curve and detects the optimal PEEP using the novel barometric capnography curve (BCap); i.e. the plot of expired carbon dioxide versus airway pressure. The lungs' closing pressure was detected when the slope of phase III of the BCap changed along this slow expiration (PEEPBCap). The main objective was to compare PEEPBCap with the reference PEEPCrs. As a secondary objective, we explored the association between PEEPBCap and the polarity change in end-expiratory transpulmonary pressure (PEEPPL) during the deflation phase of a slow flow PV curve.

Results: We found a PEEPBCap of 8.5(3.3) cmH2O that was no statistically different from the PEEPCrs of 10.0(4.0) cmH2O (p = 0.72). Both methods correlated well with a Rho of 0.84 (p < 0.001). The Bland-Altman plot showed a bias of 0.19 and LOA of 1.92 cmH2O (95%CI -0.39 to 0.77 cmH2O). During the PV slow deflation limb, PEEPPL was 9.3(4.3), which was statistically similar to PEEPBCap (p = 0.61). Both pressures were strongly correlated (Rho = 0.93, p < 0.001) with a bias of -0.3 cmH2O and LOA of 1.52 (95%CI -0.76 to 0.16 cmH2O).

Conclusions: We concluded that BCap is feasible to detect lungs collapse using a constant flow PV curve.

Keywords: Capnography; PEEP; Pressure; Recruitment maneuver.

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Conflict of interest statement

Declarations. Competing interests: GT is the inventor of a patent on barometric capnography. FSS is member of the advisory board of Maquet Critical Care. PK paid consultant to the Löwenstein Medical Innovation GmbH & Co KG, Germany. Conflict of interest: GT is the inventor of a patent on barometric capnography. FSS is member of the advisory board of Maquet Critical Care. PK paid consultant to the Löwenstein Medical Innovation GmbH & Co KG, Germany. Ethics approval: This study was approved by the local ethical committee (Date: 16 February 2023). Clinicaltrials ID: NCT05873998.

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