Setting the best positive end-expiratory pressure (PEEP) in patients with obesity is a challenge for anesthesiologists, as addressed by two featured articles in this issue of Anesthesiology.1,2  Using different approaches for identifying the optimal PEEP level, both studies found individualized PEEP levels to be greater than 15 cm H2O in obese (body mass index 30 kg/m2 or greater) and superobese (body mass index 50 kg/m2 or greater) patients.

Obese patients may present to the operating room with lower peripheral oxygen saturation since their end-expiratory lung volume is more than 20% lower than normal. As we induce general anesthesia and start mechanical ventilation, end-expiratory lung volume decreases further by about 50%. This is associated with hypoxemia and shortens the apneic time available for airway management. The extremely low end-expiratory lung volume is primarily due to atelectasis, and it may...

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