Measure ID

Percentage of cases in which Positive End Expiratory Pressure (PEEP) is used for patients undergoing mechanical ventilation during anesthesia. PUL 03 will determine if PEEP was administered (as defined by median PEEP ≥ 2) and also analyze distribution of PEEP levels:

  • No PEEP (<2 cm H2O)
  • Low PEEP (2-4 cm H2O)
  • Moderate PEEP (≥ 4 to < 8 cm H2O)
  • High PEEP (≥8 cm H2O)
Measure Type

The use of lung protective ventilation techniques (low tidal volumes and positive end expiratory pressure) should be part of standard anesthetic practice for most cases that require positive pressure ventilation. Several randomized controlled trials, as well as a meta-analysis in 2015 describe the benefit with low vs high tidal volume techniques and use of PEEP.1-6 Unfortunately, there is not enough evidence to suggest specific PEEP levels. Therefore, specific threshold indicators will not be defined for PUL 03 initially.

Measure Time Period

Case start to case end (see other measure build details)


Patients undergoing endotracheal intubation.

  • ASA 5 and 6 cases
  • Patients <20kg.
  • Cases in which patients are mechanically ventilated for less than 45 cumulative minutes.
  • One lung ventilation procedures as indicated by intraoperative notes or note details mapped to one of the following MPOG concepts:
    • 50501: Thoracic: Single-lung ventilation
    • 50202: Thoracic: Single-lung ventilation, side detail
Success Criteria

Median PEEP ≥ 2 cm H2O (Assuming values less than 2 cm H2O is equivalent to no PEEP administered) during ventilation.

Other Measure Details
  • If no weight is recorded, the case is included.
  • For a case to be included, there must be at least 45 cumulative minutes of actual tidal volume or 45 minutes of set tidal volume (if actual is not present).
    • For a given case, this measure will exclude periods when patients are not under positive pressure ventilation (as defined by peak inspiratory pressure – positive end expiratory pressure of ≤ 6).
      • Peak Inspiratory Pressure determined by values mapped to MPOG Concept 3185.
      • PEEP will be determined using values associated with the following variables:
        1. Use Measured PEEP (MPOG Concept: 3210). If not documented,
        2. Use Set PEEP (MPOG Concept: 3212). If not documented,
        3. Assume PEEP = 0.
  • Median PEEP will be determined using values associated with the following variables:
    1. Use Measured PEEP. If not documented,
    2. Use Set PEEP. If not documented,
    3. Determine no PEEP data available.
  • PEEP values before case start, after case end, and during periods where PIP - PEEP ≤ 6 are not included in calculating the median.

Algorithm for determining Case Start/End Times:

  • Start
    • Patient In Room. If not available, then
    • Induction End. If not available, then
    • Anesthesia Start
  •  End
    • Patient out of room. If not available, then
    • Anesthesia End
Provider Attribution

This measure is informational only. Attribution not yet determined by the MPOG Quality Committee.

MPOG Concept Used

Endotracheal Tube

  • 50121    Intubation Endotracheal Tube Stylet Used
  • 50122    Intubation Endotracheal Tube Size
  • 50123    Intubation Endotracheal Tube Type
  • 50124    Intubation Endotracheal Tube Secured Mechanism
  • 50125    Intubation Endotracheal Tube Secured Distance
  • 50126    Intubation Endotracheal Tube Secured Reference Point
  • 50202    Emergence- Patient Extubated
  • 50205    Intubation Tube Note
  • 50671    Intubation- endotracheal tube in situ

PEEP, PIP, Tidal Volume

  • 3190       Tidal Volume Actual
  • 3192       Tidal Volume Set
  • 3185       Peak Inspiratory Pressure
  • 3210       Positive End Expiratory Pressure- Measured
  • 3212       Positive End Expiratory Pressure- Set

One-Lung Ventilation

  • 50501    Thoracic-Single lung ventilation
  • 50202    Thoracic-Single lung ventilation side detail


  1. Fernandez-Perez ER, Keegan MT, Brown DR, Hubmayr RD, Gajic O. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy. Anesthesiology. 2006;105(1):14-18.
  2. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. The New England journal of medicine. 2013;369(5):428-437.
  3. Guldner A, Kiss T, Serpa Neto A, et al. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers. Anesthesiology. 2015;123(3):692-713.
  4. Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis. Anesthesiology. 2015;123(1):66-78.
  5. Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology. 2013;118(6):1307-1321.
Measure Authors

 Measure Author


 Nirav Shah, MD

 University of Michigan

 Kate Buehler, MS, RN

 University of Michigan

 Genevieve Bell

 University of Michigan

 MPOG Quality Committee



Measure Reviewer(s)
Next Review: 2025
 Date Reviewed  QC Presentation  Reviewer  Institution  Summary  QC Vote



 Joel Kileny, MD

 Trinity Health - Ann Arbor


 No Change

Published Date: 12/2018
 Date  Criteria  Revision