PEEP Strategies and Mechanical Power in Robotic Surgery

Comparison of Incremental, Decremental, and Fixed PEEP Strategies on Mechanical Power and Postoperative Oxygenation in Robotic Surgery: A Prospective Randomized Controlled Trial

Robotic surgery requires pneumoperitoneum and steep Trendelenburg positioning, which significantly impair respiratory mechanics and increase the risk of postoperative pulmonary complications.

Positive end-expiratory pressure (PEEP) is a key determinant of lung recruitment; however, fixed PEEP strategies may not be optimal for all patients. Individualized PEEP titration strategies, including incremental and decremental approaches, may better optimize lung mechanics.

This randomized controlled trial aims to compare the effects of incremental, decremental, and fixed PEEP strategies on cumulative mechanical power (MP-AUC) and postoperative oxygenation in patients undergoing robotic surgery.

Study Overview

• Status: Not yet recruiting
• Conditions: Mechanical Ventilation; Postoperative Pulmonary Complications; Impaired Oxygenation
• Intervention / Treatment: Procedure: Fixed PEEP Ventilation; Procedure: Decremental PEEP Strategy; Procedure: Incremental PEEP Strategy

• Study Type: Interventional
• Enrollment (Estimated): 120
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Age>= 18
• ASA I-III
• Elective robotic surgery

Exclusion Criteria:

• COPD GOLD ≥2

  • Restrictive lung disease
  • BMI >40 kg/m²
  • Heart failure
  • Preoperative oxygen requirement
  • Need for postoperative mechanical ventilation
  • Refusal to participate

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Fixed PEEP; Ventilation with constant PEEP of 5 cmH₂O throughout surgery.	Procedure: Fixed PEEP Ventilation; Patients receive mechanical ventilation with a constant positive end-expiratory pressure (PEEP) of 5 cmH₂O throughout the surgical procedure.; Procedure: Decremental PEEP Strategy; PEEP is gradually decreased from a higher level to determine the optimal PEEP associated with the lowest driving pressure or lowest mechanical power, and this level is maintained during surgery.; Procedure: Incremental PEEP Strategy; PEEP is gradually increased from a lower level to identify the optimal PEEP corresponding to the lowest driving pressure or mechanical power, and this level is maintained during surgery.
Experimental: Decremental PEEP; PEEP is gradually decreased to identify the level associated with the lowest driving pressure or lowest mechanical power.	Procedure: Fixed PEEP Ventilation; Patients receive mechanical ventilation with a constant positive end-expiratory pressure (PEEP) of 5 cmH₂O throughout the surgical procedure.; Procedure: Decremental PEEP Strategy; PEEP is gradually decreased from a higher level to determine the optimal PEEP associated with the lowest driving pressure or lowest mechanical power, and this level is maintained during surgery.; Procedure: Incremental PEEP Strategy; PEEP is gradually increased from a lower level to identify the optimal PEEP corresponding to the lowest driving pressure or mechanical power, and this level is maintained during surgery.
Experimental: Incremental PEEP; PEEP is gradually increased to determine the optimal level corresponding to the lowest driving pressure or mechanical power.	Procedure: Fixed PEEP Ventilation; Patients receive mechanical ventilation with a constant positive end-expiratory pressure (PEEP) of 5 cmH₂O throughout the surgical procedure.; Procedure: Decremental PEEP Strategy; PEEP is gradually decreased from a higher level to determine the optimal PEEP associated with the lowest driving pressure or lowest mechanical power, and this level is maintained during surgery.; Procedure: Incremental PEEP Strategy; PEEP is gradually increased from a lower level to identify the optimal PEEP corresponding to the lowest driving pressure or mechanical power, and this level is maintained during surgery.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cumulative Mechanical Power (MP-AUC)	Total energy delivered to the respiratory system during surgery	During surgery (from intubation to extubation)

Secondary Outcome Measures

Outcome Measure	Time Frame
PaO₂/FiO₂ ratio	Intraoperative period and postoperative period (within 2 hours)
Oxygenation Index (OSI)	Postoperative 2 hours
Postoperative Pulmonary Complications (PPC)	Within 7 postoperative days

Collaborators and Investigators

• Sponsor: Ankara City Hospital Bilkent

Study record dates

Study Major Dates

• Study Start (Estimated): April 15, 2026
• Primary Completion (Estimated): May 1, 2026
• Study Completion (Estimated): June 30, 2026

Study Registration Dates

• First Submitted: April 11, 2026
• First Submitted That Met QC Criteria: April 11, 2026
• First Posted (Actual): April 17, 2026

Study Record Updates

• Last Update Posted (Actual): April 17, 2026
• Last Update Submitted That Met QC Criteria: April 11, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: E26-14833

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No