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Effect of intraoperative high Positive End-Expiratory Pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients : a randomized clinical trial

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Abstract
IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcomewas a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO(2) <= 92% for > 1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3%[95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P =.23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6%[95% CI, -11.1% to 6.1%]; P <.001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.
Keywords
GENERAL-ANESTHESIA, MECHANICAL VENTILATION, DRIVING PRESSURE, TIDAL-VOLUME, PREVENTION, ATELECTASIS, SURGERY

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MLA
Bluth, Thomas, et al. “Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) with Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients : A Randomized Clinical Trial.” JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, vol. 321, no. 23, 2019, pp. 2292–305.
APA
Bluth, T., Serpa Neto, A., Schultz, M. J., Pelosi, P., de Abreu, M. G., Bobek, I., … Zhong, J. (2019). Effect of intraoperative high Positive End-Expiratory Pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients : a randomized clinical trial. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 321(23), 2292–2305.
Chicago author-date
Bluth, Thomas, Ary Serpa Neto, Marcus J Schultz, Paolo Pelosi, Marcelo Gama de Abreu, Ilona Bobek, Jaume C Canet, et al. 2019. “Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) with Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients : A Randomized Clinical Trial.” JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 321 (23): 2292–2305.
Chicago author-date (all authors)
Bluth, Thomas, Ary Serpa Neto, Marcus J Schultz, Paolo Pelosi, Marcelo Gama de Abreu, Ilona Bobek, Jaume C Canet, Luc De Baerdemaeker, Cesare Gregoretti, Goran Hedenstierna, Sabrine NT Hemmes, Michael Hiesmayr, Markus Hollmann, Samir Jaber, John Laffey, Marc J Licker, Klaus Markstaller, Idit Matot, Gary Mills, Jan Paul Mulier, Christian Putensen, Rolf Rossaint, Jochen Schmitt, Mert Senturk, Paolo Severgnini, Juraj Sprung, Marcos Francisco Vidal Melo, Hermann Wrigge, Fernando Abelha, Suhayla Abitagaoglu, Marc Achilles, Afeez Adebesin, Ine Adriaensens, Charles Ahene, Fatima Akbar, Mohammed Al Harbi, Rita Al Khoury al Kallab, Xavier Albanel, Florence Aldenkortt, Rawan Abdullah Saleh Alfouzan, Reef Alruqaie, Fernando Altermatt, Bruno Luis de Castro Araujo, Genaro Arbesu, Hanna Artsi, Caterina Aurilio, Omer Hilmi Ayanoglu, Alessandro Bacuzzi, Harris Baig, Yolanda Baird, Konstantin Balonov, Jaume Balust, Samantha Banks, Xiaodong Bao, Melanie Baumgartner, Isabel Belda Tortosa, Alice Bergamaschi, Lars Bergmann, Luca Bigatello, Elena Biosca Perez, Katja Birr, Thomas Bluth, Elird Bojaxhi, Chiara Bonenti, Iwona Bonney, Elkem. E Bos, Sara Bowman, Leandro Gobbo Braz, Elisa Brugnoni, Iole Brunetti, Andrea Bruni, Shonie L Buenvenida, Cornelius Johannes Camerini, Jaume Canet, Beatrice Capatti, Javiera Carmona, Jaime Carungcong, Marta Carvalho, Anat Cattan, Carla Cavaleiro, Davide Chiumello, Stefano Ciardo, Mark Coburn, Umberto Colella, Victor Contreras, Pelin Corman Dincer, Elizabeth Cotter, Marcia Crovetto, William Crovetto, William Darrah, Simon Davies, Luc De Baerdemaeker, Stefan De Hert, Enrique Del Cojo Peces, Ellise Delphin, John Diaper, Paulo do Nascimento Junior, Valerio Donatiello, Jing Dong, Maria do Socorro Dourado, Alexander Dullenkopf, Felix Ebner, Hamed Elgendy, Christoph Ellenberger, Dilek Erdogan Ari, Thomas Ermert, Fadi Farah, Ana Fernandez-Bustamante, Cristina Ferreira, Marco Fiore, Ana Fonte, Christina Fortia Palahi, Andrea Galimberti, Najia Garofano, Luca Gregorio Giaccari, Fernando Gilsanz, Felix Girrbach, Luca Gobbi, Marc Bernard Godfried, Nicolai Goettel, Peter A Goldstein, Or Goren, Andrew Gorlin, Manuel Granell Gil, Angelo Gratarola, Juan Graterol, Pierre Guyon, Kevin Haire, Philippe Harou, Antonia Helf, Sabrine NT Hemmes, Gunther Hempel, Maria Jose Hernandez Cadiz, Bjorn Heyse, Markus W Hollmann, Ivan Huercio, Jasmina Ilievska, Lien Jakus, Vijay Jeganath, Yvonne Jelting, Minoa Jung, Barbara Kabon, Aalok Kacha, Maja Karaman Ilic, Arunthevaraja Karuppiah, Ayse Duygu Kavas, Gleicy Keli Barcelos, Todd A Kellogg, Johann Kemper, Romain Kerbrat, Suraya Khodr, Peter Kienbaum, Bunyamin Kir, Thomas Kiss, Selin Kivrak, Vlasta Klaric, Thea Koch, Ceren Koksal, Ana Kowark, Peter Kranke, Bahar Kuvaki, Biljana Kuzmanovska, John Laffey, Mirko Lange, Marilia Freitas de Lemos, Marc-Joseph Licker, Manuel Lopez-Baamonde, Antonio Lopez-Hernandez, Mercedes Lopez-Martinez, Stephane Luise, Mark MacGregor, Danielle Magalhaes, Julien Maillard, Patrizia Malerbi, Natesan Manimekalai, Michael Margarson, Klaus Markstaller, David P Martin, Yvette N Martin, Julia Martinez-Ocon, Ignacio Martin-Loeches, Emilio Maseda, Idit Matot, Niamh McAuliffe, Travis J McKenzie, Paulina Medina, Melanie Meersch, Angelika Menzen, Els Mertens, Bernd Meurer, Tanja Meyer-Treschan, Changhong Miao, Camilla Micalizzi, Morena Milic, Norma Sueli Pinheiro Modolo, Pierre Moine, Patrick Molders, Ana Montero-Feijoo, Enrique Moret, Markus K Muller, Zoe Murphy, Pramod Nalwaya, Filip Naumovski, Paolo Navalesi, Lais Helena Navarro e Lima, Visnja Nesek Adam, Claudia Neumann, Christopher Newell, Zoulfira Nisnevitch, Junaid Nizamuddin, Cecilia Novazzi, Michael O’Connor, Gunther Oprea, Mukadder Orhan Sungur, Sule Ozbilgin, Maria Caterina Pace, Marcos Pacheco, Balaji Packianathaswamy, Estefania Palma Gonzalez, Fotios Papaspyros, Sebastian Paredes, Maria Beatrice Passavanti, Juan Cristobal Pedemonte, Paolo Pelosi, Sanja Peremin, Christoph Philipsenburg, Daniela Pinho, Silvia Pinho, Linda M Posthuma, Vincenzo Pota, Benedikt Preckel, Paolo Priani, Christian Putensen, Mohamed Aymen Rached, Aleksandar Radoeshki, Riccardo Ragazzi, Tamilselvan Rajamanickam, Arthi Rajamohan, Harish Ramakrishna, Desikan Rangarajan, Christian Reiterer, J Ross Renew, Thomas Reynaud, Rhidian Rhys, Eva Rivas, Luisa Robitzky, Rolf Rossaint, Francesca Rubulotta, Humberto S Machado, Catarina S Nunes, Giovanni Sabbatini, Josep Marti Sanahuja, Pasquale Sansone, Alice Santos, Mohamed Sayedalahl, Maximilian S Schaefer, Eduardo Scharffenberg, Martin Scharffenberg, Eduardo Schiffer, Nadja Schliewe, Raoul Schorer, Marcus J Schultz, Roman Schumann, Gabriele Selmo, Mar Sendra, Mert Senturk, Paolo Severgnini, Kate Shaw, Mirjana Shosholcheva, Abdulrazak Sibai, Philipp Simon, Francesca Simonassi, Claudia Sinno, Nukhet Sivrikoz, Vasiliki Skandalou, Neil Smith, Maria Soares, Tania Socorro Artiles, Diogo Sousa Castro, Miguel Sousa, Savino Spadaro, Juraj Sprung, Emmanouil Stamatakis, Luzius A Steiner, Andrea Stevenazzi, Alejandro Suarez-de-la-Rica, Melanie Suppan, Robert Teichmann, Jose Maria Tena Guerrero, Bram Thiel, Raquel Tolos, Gulbin Tore Altun, Michelle Tucci, Zachary A Turnbull, Zana Turudic, Matthias Unterberg, Jurgen Van Limmen, Yves Van Nieuwenhove, Julia Van Waesberghe, Marcos Francisco, Vidal Melo, Bibiana Vitkovic, Luigi Vivona, Marcela Vizcaychipi, Carlo Alberto Volta, Anne Weber, Toby N Weingarten, Jakob Wittenstein, Hermann Wrigge, PIET WYFFELS, Julio Yague, David Yates, Aysen Yavru, Lilach Zac, and Jing Zhong. 2019. “Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) with Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients : A Randomized Clinical Trial.” JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 321 (23): 2292–2305.
Vancouver
1.
Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, de Abreu MG, Bobek I, et al. Effect of intraoperative high Positive End-Expiratory Pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients : a randomized clinical trial. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 2019;321(23):2292–305.
IEEE
[1]
T. Bluth et al., “Effect of intraoperative high Positive End-Expiratory Pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients : a randomized clinical trial,” JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, vol. 321, no. 23, pp. 2292–2305, 2019.
@article{8655072,
  abstract     = {IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. 
OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. 
DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018.
INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight.
MAIN OUTCOMES AND MEASURES The primary outcomewas a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO(2) <= 92% for > 1 minute). 
RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3%[95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P =.23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6%[95% CI, -11.1% to 6.1%]; P <.001). 
CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.},
  author       = {Bluth, Thomas and Serpa Neto, Ary and Schultz, Marcus J and Pelosi, Paolo and de Abreu, Marcelo Gama and Bobek, Ilona and Canet, Jaume C and De Baerdemaeker, Luc and Gregoretti, Cesare and Hedenstierna, Goran and Hemmes, Sabrine NT and Hiesmayr, Michael and Hollmann, Markus and Jaber, Samir and Laffey, John and Licker, Marc J and Markstaller, Klaus and Matot, Idit and Mills, Gary and Mulier, Jan Paul and Putensen, Christian and Rossaint, Rolf and Schmitt, Jochen and Senturk, Mert and Severgnini, Paolo and Sprung, Juraj and Melo, Marcos Francisco Vidal and Wrigge, Hermann and Abelha, Fernando and Abitagaoglu, Suhayla and Achilles, Marc and Adebesin, Afeez and Adriaensens, Ine and Ahene, Charles and Akbar, Fatima and Al Harbi, Mohammed and al Kallab, Rita Al Khoury and Albanel, Xavier and Aldenkortt, Florence and Alfouzan, Rawan Abdullah Saleh and Alruqaie, Reef and Altermatt, Fernando and Araujo, Bruno Luis de Castro and Arbesu, Genaro and Artsi, Hanna and Aurilio, Caterina and Ayanoglu, Omer Hilmi and Bacuzzi, Alessandro and Baig, Harris and Baird, Yolanda and Balonov, Konstantin and Balust, Jaume and Banks, Samantha and Bao, Xiaodong and Baumgartner, Melanie and Tortosa, Isabel Belda and Bergamaschi, Alice and Bergmann, Lars and Bigatello, Luca and Biosca Perez, Elena and Birr, Katja and Bluth, Thomas and Bojaxhi, Elird and Bonenti, Chiara and Bonney, Iwona and Bos, Elkem. E and Bowman, Sara and Braz, Leandro Gobbo and Brugnoni, Elisa and Brunetti, Iole and Bruni, Andrea and Buenvenida, Shonie L and Camerini, Cornelius Johannes and Canet, Jaume and Capatti, Beatrice and Carmona, Javiera and Carungcong, Jaime and Carvalho, Marta and Cattan, Anat and Cavaleiro, Carla and Chiumello, Davide and Ciardo, Stefano and Coburn, Mark and Colella, Umberto and Contreras, Victor and Corman Dincer, Pelin and Cotter, Elizabeth and Crovetto, Marcia and Crovetto, William and Darrah, William and Davies, Simon and De Baerdemaeker, Luc and De Hert, Stefan and Peces, Enrique Del Cojo and Delphin, Ellise and Diaper, John and do Nascimento Junior, Paulo and Donatiello, Valerio and Dong, Jing and Dourado, Maria do Socorro and Dullenkopf, Alexander and Ebner, Felix and Elgendy, Hamed and Ellenberger, Christoph and Ari, Dilek Erdogan and Ermert, Thomas and Farah, Fadi and Fernandez-Bustamante, Ana and Ferreira, Cristina and Fiore, Marco and Fonte, Ana and Fortia Palahi, Christina and Galimberti, Andrea and Garofano, Najia and Giaccari, Luca Gregorio and Gilsanz, Fernando and Girrbach, Felix and Gobbi, Luca and Godfried, Marc Bernard and Goettel, Nicolai and Goldstein, Peter A and Goren, Or and Gorlin, Andrew and Gil, Manuel Granell and Gratarola, Angelo and Graterol, Juan and Guyon, Pierre and Haire, Kevin and Harou, Philippe and Helf, Antonia and Hemmes, Sabrine NT and Hempel, Gunther and Cadiz, Maria Jose Hernandez and Heyse, Bjorn and Hollmann, Markus W and Huercio, Ivan and Ilievska, Jasmina and Jakus, Lien and Jeganath, Vijay and Jelting, Yvonne and Jung, Minoa and Kabon, Barbara and Kacha, Aalok and Karaman Ilic, Maja and Karuppiah, Arunthevaraja and Kavas, Ayse Duygu and Keli Barcelos, Gleicy and Kellogg, Todd A and Kemper, Johann and Kerbrat, Romain and Khodr, Suraya and Kienbaum, Peter and Kir, Bunyamin and Kiss, Thomas and Kivrak, Selin and Klaric, Vlasta and Koch, Thea and Koksal, Ceren and Kowark, Ana and Kranke, Peter and Kuvaki, Bahar and Kuzmanovska, Biljana and Laffey, John and Lange, Mirko and de Lemos, Marilia Freitas and Licker, Marc-Joseph and Lopez-Baamonde, Manuel and Lopez-Hernandez, Antonio and Lopez-Martinez, Mercedes and Luise, Stephane and MacGregor, Mark and Magalhaes, Danielle and Maillard, Julien and Malerbi, Patrizia and Manimekalai, Natesan and Margarson, Michael and Markstaller, Klaus and Martin, David P and Martin, Yvette N and Martinez-Ocon, Julia and Martin-Loeches, Ignacio and Maseda, Emilio and Matot, Idit and McAuliffe, Niamh and McKenzie, Travis J and Medina, Paulina and Meersch, Melanie and Menzen, Angelika and Mertens, Els and Meurer, Bernd and Meyer-Treschan, Tanja and Miao, Changhong and Micalizzi, Camilla and Milic, Morena and Modolo, Norma Sueli Pinheiro and Moine, Pierre and Molders, Patrick and Montero-Feijoo, Ana and Moret, Enrique and Muller, Markus K and Murphy, Zoe and Nalwaya, Pramod and Naumovski, Filip and Navalesi, Paolo and Navarro e Lima, Lais Helena and Nesek Adam, Visnja and Neumann, Claudia and Newell, Christopher and Nisnevitch, Zoulfira and Nizamuddin, Junaid and Novazzi, Cecilia and O'Connor, Michael and Oprea, Gunther and Orhan Sungur, Mukadder and Ozbilgin, Sule and Pace, Maria Caterina and Pacheco, Marcos and Packianathaswamy, Balaji and Palma Gonzalez, Estefania and Papaspyros, Fotios and Paredes, Sebastian and Passavanti, Maria Beatrice and Pedemonte, Juan Cristobal and Pelosi, Paolo and Peremin, Sanja and Philipsenburg, Christoph and Pinho, Daniela and Pinho, Silvia and Posthuma, Linda M and Pota, Vincenzo and Preckel, Benedikt and Priani, Paolo and Putensen, Christian and Rached, Mohamed Aymen and Radoeshki, Aleksandar and Ragazzi, Riccardo and Rajamanickam, Tamilselvan and Rajamohan, Arthi and Ramakrishna, Harish and Rangarajan, Desikan and Reiterer, Christian and Renew, J Ross and Reynaud, Thomas and Rhys, Rhidian and Rivas, Eva and Robitzky, Luisa and Rossaint, Rolf and Rubulotta, Francesca and Machado, Humberto S and Nunes, Catarina S and Sabbatini, Giovanni and Sanahuja, Josep Marti and Sansone, Pasquale and Santos, Alice and Sayedalahl, Mohamed and Schaefer, Maximilian S and Scharffenberg, Eduardo and Scharffenberg, Martin and Schiffer, Eduardo and Schliewe, Nadja and Schorer, Raoul and Schultz, Marcus J and Schumann, Roman and Selmo, Gabriele and Sendra, Mar and Senturk, Mert and Severgnini, Paolo and Shaw, Kate and Shosholcheva, Mirjana and Sibai, Abdulrazak and Simon, Philipp and Simonassi, Francesca and Sinno, Claudia and Sivrikoz, Nukhet and Skandalou, Vasiliki and Smith, Neil and Soares, Maria and Socorro Artiles, Tania and Sousa Castro, Diogo and Sousa, Miguel and Spadaro, Savino and Sprung, Juraj and Stamatakis, Emmanouil and Steiner, Luzius A and Stevenazzi, Andrea and Suarez-de-la-Rica, Alejandro and Suppan, Melanie and Teichmann, Robert and Tena Guerrero, Jose Maria and Thiel, Bram and Tolos, Raquel and Tore Altun, Gulbin and Tucci, Michelle and Turnbull, Zachary A and Turudic, Zana and Unterberg, Matthias and Van Limmen, Jurgen and Van Nieuwenhove, Yves and Van Waesberghe, Julia and Francisco, Marcos and Melo, Vidal and Vitkovic, Bibiana and Vivona, Luigi and Vizcaychipi, Marcela and Volta, Carlo Alberto and Weber, Anne and Weingarten, Toby N and Wittenstein, Jakob and Wrigge, Hermann and WYFFELS, PIET and Yague, Julio and Yates, David and Yavru, Aysen and Zac, Lilach and Zhong, Jing},
  issn         = {0098-7484},
  journal      = {JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION},
  keywords     = {GENERAL-ANESTHESIA,MECHANICAL VENTILATION,DRIVING PRESSURE,TIDAL-VOLUME,PREVENTION,ATELECTASIS,SURGERY},
  language     = {eng},
  number       = {23},
  pages        = {2292--2305},
  title        = {Effect of intraoperative high Positive End-Expiratory Pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients : a randomized clinical trial},
  url          = {http://dx.doi.org/10.1001/jama.2019.7505},
  volume       = {321},
  year         = {2019},
}

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