ElecTrical Impedance TomogRaphy vs dynamic compliANce guided positive end-expiratory pressure Titration during laparoscopic gynaecological surgery (TITRANT): protocol for a multicentre randomised trial.

introductionInappropriate mechanical ventilation plays a pivotal role in the development of ventilator-induced lung injury (VILI) and subsequent postoperative pulmonary complications (PPCs), thus individualised lung protective ventilation became a hot topic of research during the past decades. Despite promising results from early trials focusing on separated ventilatory parameters, the incidence of PPCs has not decreased significantly, hence a new conceptual direction emerged in the last few years by evaluating the potential role of mechanical power of ventilation (MP), since MP encompasses all mechanical ventilation parameters that can be responsible for lung injury and recent research confirmed correlation between high MP values and the severity of VILI. Reducing MP by optimising positive end-expiratory pressure (PEEP) is rational, and electrical impedance tomography (EIT) appears to be a promising tool in achieving this goal, as it has the potential to distinguish alveolar recruitment from overdistension, thus providing a more accurate picture of the lungs thereby being superior to other approaches. Therefore, it is worth testing this hypothesis in a clinical trial. METHODS AND ANALYSIS: This multicentric, single-blinded, interventional, superiority, randomised controlled trial will include 200 patients aged 18 years and older undergoing laparoscopic gynaecological surgeries. The trial will be conducted in three Hungarian centres (two non-university teaching hospitals and one university medical centre). Participants will be allocated in a 1:1 ratio to two groups. Patients in the PEEP-EIT group will receive an EIT-guided PEEP titration, while in the PEEP-dynamic pulmonary compliance (Cdyn) group a dynamic pulmonary compliance-guided PEEP titration will be performed in order to determine the optimal level of PEEP. We aim to evaluate the superiority of using EIT-guided PEEP titration versus the Cdyn-guided approach by comparing their effects on MP, as the primary endpoint, measured immediately after the titration procedure and at the end of surgery. Secondary endpoints are oxygenation, respiratory mechanics parameters, global inhomogeneity index, overdistension/collapse and PPCs. Participants will be followed up until the 28th postoperative day for mortality. ETHICS AND DISSEMINATION: This study was approved by the Hungarian Scientific and Medical Research Council Ethics Committee (Registration number: NNGYK/21074-6/2025) on 17 June 2025. Written informed consent will be obtained from all participants (or their legally authorised representatives) prior to enrolment in the study. The trial results will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER: NCT07170514.