Driving Pressure-Guided Dynamic PEEP Titration Reduces Atelectasis and Improves Oxygenation in Pediatric Laparoscopy: A Randomized Trial on Personalized Ventilation Strategies

Objective : Pediatric laparoscopic surgery often induces atelectasis due to pneumoperitoneum, postural changes, and immature respiratory physiology, increasing postoperative pulmonary complications (PPCs). Fixed PEEP may fail to address perioperative variability. This study evaluated whether dynamic PEEP adjustment reduces atelectasis and improves oxygenation. Methods : Children at moderate or high risk of PPCs undergoing elective laparoscopic surgery were randomized into two groups. Group A had driving pressure-guided individualized PEEP titration at three specified time points: after intubation, before pneumoperitoneum initiation, and after pneumoperitoneum completion. Group B had individualized PEEP titration only after intubation, with this PEEP maintained until the end of ventilation. Both groups received lung recruitment maneuvers. Observations were conducted at 5 minutes after tracheal intubation (T1), 20 minutes post-pneumoperitoneum (T2), 60 minutes post-pneumoperitoneum (T3), at the end of surgery (T4), and at extubation (T5). The primary outcome measures were intraoperative lung ultrasound score, incidence of atelectasis, and oxygenation index. Secondary outcomes included peak airway pressure, plateau pressure, PEEP, driving pressure, dynamic lung compliance, mean arterial pressure, and heart rate. Results : At T4 and T5, Group A showed significantly lower subpleural consolidation scores, total lung ultrasound scores, and atelectasis rates versus Group B (P<0.05). Oxygenation indices in Group A were higher at T3–T5 (P<0.05). Post-pneumoperitoneum, Group A’s median PEEP increased to 8 cmH₂O (vs. Group B), with lower driving pressure and higher dynamic compliance (P<0.05). Hemodynamic parameters showed no intergroup differences (P>0.05). Conclusion : Dynamic PEEP titration guided by driving pressure reduces postoperative lung ultrasound abnormalities and atelectasis while improving oxygenation and respiratory mechanics in pediatric laparoscopy, without compromising hemodynamic stability. This strategy supports personalized PEEP optimization. Clinical Trial Registration: ChiCTR2300070193.