Closed-Loop Ventilation Strategies During Major Surgical Procedures

Abstract

Closed-loop ventilation systems continuously adjust minute ventilation, tidal volume, or inspired oxygen fraction using real-time capnography and pulse oximetry, offering an alternative to the intermittent manual titration typical of conventional intraoperative ventilator management. This review synthesizes the evidence for closed-loop ventilation and oxygen titration across cardiac, thoracic, and general surgical populations, alongside the literature establishing individualized, driving-pressure-minimizing PEEP as a lung-protective target. Closed-loop platforms such as IntelliVent-ASV and automated FiO2 titration systems consistently keep patients within protective ventilation and oxygenation targets more often than manual management, with evidence spanning intensive care, cardiac surgery, trauma care, and one-lung ventilation. Evidence that this tighter physiological control reduces postoperative pulmonary complications or improves neurocognitive outcomes remains limited, whereas meta-analytic data on individualized, driving-pressure-guided PEEP show a firmer association with fewer pulmonary complications after abdominal and thoracic surgery. We conclude that closed-loop ventilation usefully maintains protective targets with less manual effort, and that pairing it with driving-pressure-guided titration across the perioperative period is the most promising direction for future outcome trials.