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. 2025 Aug 21.
doi: 10.1007/s00134-025-08082-x. Online ahead of print.

Personalized driving pressure-guided positive end-expiratory pressure in patients at risk of postoperative respiratory failure (IMPROVE-2): a multicenter, pragmatic, randomized clinical trial

Emmanuel Futier #  1   2 , Audrey De Jong  3 , Cédric Cirenei  4 , Thomas Godet  5 , Matthieu Jabaudon  5   6 , Jean-Michel Constantin  7 , Nicolas Grillot  8 , Pierre Bouzat  9 , Lois Henry  10 , Dimitri Margetis  7 , Gilles Lebuffe  4 , Marc Garnier  5   11 , Céline Lambert  12 , Bruno Pereira  12 , Samir Jaber #  3 ; IMPROVE-2 Trial investigators
Collaborators, Affiliations

Personalized driving pressure-guided positive end-expiratory pressure in patients at risk of postoperative respiratory failure (IMPROVE-2): a multicenter, pragmatic, randomized clinical trial

Emmanuel Futier et al. Intensive Care Med. .

Abstract

Purpose: Airway driving pressure has garnered considerable attention for lung-protective ventilation. We evaluated the clinical effectiveness of airway driving pressure as a target to individualize positive-end-expiratory pressure (PEEP) setting in mechanically ventilated patients at risk for postoperative respiratory failure.

Methods: We conducted a multicenter, pragmatic, assessor-masked, randomized trial among adult patients undergoing emergency abdominal surgery in 22 hospitals in France. Patients were assigned 1:1 to receive individually adjusted highest PEEP targeting a driving pressure < 13 cmH2O after an initial recruitment maneuver (intervention group) or to a fixed PEEP level of 5 cmH2O (control group). The primary outcome was a composite of postoperative respiratory failure (failure to wean from the ventilator or the composite of reintubation or curative non-invasive ventilation) or all-cause mortality at 30 days. Secondary outcomes included components of the composite primary outcome.

Results: The primary outcome occurred in 87 out of 338 (25.7%) intervention patients and in 69 out of 341 (20.2%) control patients (difference, 5.5%; 95% confidence interval [CI] - 0.8 to 11.8; relative risk, 1.27; 95%CI 0.96-1.68; p = 0.08). The difference was primarily due to an increased incidence of reintubation or need for curative non-invasive ventilation among intervention patients (difference, 7.1%; 95% CI 2.5-11.9; relative risk, 1.97; 95% CI 1.24-3.11; p = 0.004). Other secondary outcomes did not differ.

Conclusion: Among patients at risk for postoperative respiratory failure after emergency abdominal surgery, a strategy of individually adjusted highest PEEP in targeting driving pressure lower than 13 cmH2O did not reduce postoperative respiratory failure or death.

Trial registration: ClinicalTrials.gov Identifier: NCT03987789.

Keywords: Clinical trial; Emergency surgery; Mechanical ventilation; Postoperative respiratory failure.

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Conflict of interest statement

Declarations. Conflicts of interest: All authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ethics approval: The trial was approved for all centers by the French Committee for the Protection of Research Subjects (CPP Sud-Est III, number 2019-009B) prior to enrolment.

References

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