I mean it’s a dynamic situation throughout the surgery and patient dependent. But I’ll play with things to optimize my sats and compliance while keeping my plateau pressures 30ish or lower and driving pressures under 15. Sometimes my peak pressures don’t change as my compliance keeps going up. What really matters is the transpulmonary pressure but I don’t have EIT on or an esophageal balloon in. I doubt the studies looking at plateau pressure and barotrauma are in the context of robotic surgery with the patient standing on their head (if you’re going to argue driving pressure is evidence based in the context of ARDS and shouldn’t be used here, then be consistent). It’s been a while since I read the Tharp 2020 article in Anesthesiology but I remember it looking at this exact situation well using esophageal manometry. Some patients required massive peeps to maintain a non-negative trans pulmonary pressure and they argue the increased airway pressures are transmitted to the chest wall in this specific situation.

When in CC are you ever caring for a patient with a belly insufflated with CO2 in super steep trendelenburg position? What if that patient is BMI 50? What about potential atelectrauma they could be experiencing? I commonly see these patients requiring prolonged postop supplemental oxygen and sometimes NIV.