Trial reportThe Lancet. Respiratory medicine2026
Effects of intraoperative higher versus lower positive end-expiratory pressure during one-lung ventilation for thoracic surgery on postoperative pulmonary complications (PROTHOR): a multicentre, international, randomised, controlled, phase 3 trial.
Trial report in The Lancet. Respiratory medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 14 papers.
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Who cites it
14 citing papers in PubMed.
- Dexmedetomidine reduces pulmonary complications in older patients undergoing abdominal laparoscopic surgery: a prospective, single-blinded, randomized controlled trial.BMC anesthesiology · 2026Trial
- Article
- Individualised vs. fixed positive end-expiratory pressure: a reply.Anaesthesia · 2026Article
- Perioperative Anesthetic Challenges and Multidisciplinary Management of a Massive Intra-Abdominal Tumor.Journal of medical cases · 2026Article
- Nuances of perioperative lung isolation and airway management.Journal of thoracic disease · 2026Review
- Effects of Permissive Hypercapnia During Lung Surgery on Inflammatory Biomarkers in Serum and Bronchoalveolar Lavage Fluid: A Randomized Controlled Trial.Metabolites · 2026Article
- [WAKWiN minireview: intraoperative ventilation and postoperative pulmonary complications-Current evidence and concepts for lung protection].Die Anaesthesiologie · 2026Review
- Emergency Laparoscopic Appendectomy in a High-Risk Cardiac Patient With Severe Left Main Coronary Artery Disease on Dual Antiplatelet Therapy.Journal of medical cases · 2026Article
- Keeping both lungs open during open-lung surgery: an impossible challenge?Journal of thoracic disease · 2026Article
- Critical appraisal of open lung ventilation strategies in thoracic surgery: the role of PEEP and recruitment maneuvers.Journal of thoracic disease · 2026Article
- Postoperative pulmonary complications and response to recruitment maneuvers during hypoxemia in one lung ventilation.BMC anesthesiology · 2026Observational
- Higher vs. lower positive end-expiratory pressure during one-lung ventilation for thoracic surgery: a systematic review and meta-analysis.Frontiers in surgery · 2026Review
- Postoperative outcomes following anatomical lung resections in relation to intraoperative ventilation practices: a registry-based multicenter study.Frontiers in surgery · 2026Article
- Individualized Perioperative PEEP in Older Surgical Patients: A Three-Dimensional Titration Framework.Clinical interventions in aging · 2026Review
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Authors and funding
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe effect of higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres aimed at lung expansion as compared with lower PEEP without recruitment manoeuvres aimed at permissive atelectasis on postoperative pulmonary complications (PPCs) in patients undergoing one-lung ventilation (OLV) during thoracic surgery is unclear. We aimed to determine the contribution of an intraoperative lung expansion strategy to preventing PPCs.
methodsIn this multicentre, randomised, controlled, international phase 3 trial (PROTHOR) conducted at 74 sites in 28 countries, we enrolled adult patients (aged ≥18 years) with a BMI of less than 35 kg/m
findingsBetween Jan 3, 2017, and Feb 12, 2024, 2200 patients were randomly allocated: 1099 to the high PEEP group and 1101 to the low PEEP group. 43 patients in the high PEEP group and 33 in the low PEEP group were excluded from the modified intention-to-treat analysis after randomisation. The primary outcome occurred in 555 (53·6%) of 1036 patients in the high PEEP group and 592 (56·4%) of 1049 patients in the low PEEP group (absolute risk difference -2·68 percentage points [95% CI -6·36 to 1·01]; p=0·155). Intraoperative complications occurred in 484 (49·8%) of 972 patients in the high PEEP group and in 305 (31·3%) of 974 patients in the low PEEP group (absolute risk difference 18·09 percentage points [95% CI 14·41-21·77]), among which hypotension (360 [37·3%] of 966 patients in the high PEEP group vs 140 [14·3%] of 978 in the low PEEP group) and new arrhythmias (89 [9·9%] of 899 vs 37 [3·9%] of 956) were more frequent in the high PEEP group, while hypoxaemia rescue manoeuvres were more frequent in the low PEEP group (29 [3·3%] of 888 vs 86 [8·8%] of 982). The proportions of patients with extrapulmonary postoperative complications (110 [10·6%] of 1036 vs 107 [10·2%] of 1049 patients), and the numbers of adverse events (209 vs 204 events), did not differ between groups.
interpretationIn patients with a BMI of less than 35 kg/m
fundingClinical Trials Network of the European Society of Anaesthesiology and Intensive Care; Department of Anaesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden (Dresden, Germany); Conselho Nacional de Desenvolvimento Científico e Tecnológico (Brasília, Brazil); and the Association of Anaesthetists of GB and Ireland.
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