{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T05:04:35Z","timestamp":1780635875867,"version":"3.54.1"},"reference-count":22,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,5,31]],"date-time":"2026-05-31T00:00:00Z","timestamp":1780185600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background: Obesity increases the risk of postoperative pulmonary complications (PPCs), and active smoking may further amplify this risk. Whether smoking status identifies a subgroup of obese surgical patients with differential PPC risk or a different response to intraoperative Positive End-Expiratory Pressure (PEEP) strategy remains unclear. We evaluated whether smoking status influences PPCs and modifies the effect of intraoperative PEEP strategy in obese patients undergoing surgery. Methods: In this single-center randomized trial, 95 obese surgical patients were assigned to either a low-PEEP strategy (4 cmH2O without recruitment maneuvers) or a high-PEEP strategy (12 cmH2O with recruitment maneuvers). The primary endpoint was PPC incidence within 5 postoperative days in the overall randomized population. Smoking status was recorded at baseline, and pre-specified exploratory subgroup analyses assessed PPC incidence according to smoking status and the smoking-by-PEEP interaction. Results: The overall incidence of postoperative pulmonary complications (PPCs) was 8.9% in the low-PEEP group and 8.0% in the high-PEEP group (p &gt; 0.05). Among smokers, complications occurred in 18.2% in the low-PEEP group and 11.8% in the high-PEEP group. For non-smokers, rates were 5.9% and 6.1%, respectively. No statistically significant differences were observed. Conclusions: Active smoking was associated with a numerically higher incidence of PPCs in obese patients; however, this finding was not statistically significant. The high-PEEP strategy with recruitment maneuvers did not reduce PPC incidence compared with the low-PEEP strategy. Trial Registration: Approval number 003208\/2016.<\/jats:p>","DOI":"10.3390\/medsci14020284","type":"journal-article","created":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T17:11:01Z","timestamp":1780333861000},"page":"284","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Intraoperative PEEP Strategy and Postoperative Pulmonary Complications in Obese Patients: A Randomized Trial with Exploratory Analysis of Smoking Status"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2367-4468","authenticated-orcid":false,"given":"Luca Gregorio","family":"Giaccari","sequence":"first","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"},{"name":"Service of Anesthesia and Intensive Care, Vito Fazzi Hospital, 73100 Lecce, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-8191-9914","authenticated-orcid":false,"given":"Simona","family":"Brunetti","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1362-7393","authenticated-orcid":false,"given":"Francesco","family":"Coppolino","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Caterina","family":"Pace","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9659-0847","authenticated-orcid":false,"given":"Maria Beatrice","family":"Passavanti","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9999-3388","authenticated-orcid":false,"given":"Vincenzo","family":"Pota","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0873-3586","authenticated-orcid":false,"given":"Pasquale","family":"Sansone","sequence":"additional","affiliation":[{"name":"Department of Woman, Child and General and Specialized Surgery, University of Campania \u201cLuigi Vanvitelli\u201d, Piazza Luigi Miraglia 2, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,31]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2016). 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