Optimization of protective lung ventilation in thoracic surgery

Abstract

Background: Today protective ventilation is the predominant ventilation methodology. It includes the use of low tidal volume, inspiratory pressure limitation, and the application of positive end-expiratory pressure. However, several retrospective studies have shown that tidal volume, inspiratory pressure, and Positive End-Expiratory Pressure (PEEP) are not associated with patients’ treatment outcomes, but could be associated only when they influence driving pressure.Objective: Optimization of the strategy of protective one-lung ventilation under the control of driving pressure, to reduce early postoperative respiratory complications in patients operated for lung cancer.Material and methods: A prospective controlled study was conducted on 110 patients undergoing extended anatomical lung resections with subsequent comparison of clinical results depending on the level of driving pressure during one-lung ventilation. Postoperative pulmonary complications based on the Melbourne scale that appeared within 3 days after surgery became the endpoint.Results: A correlation was established between the level of driving pressure and the level of PaO2 in the intraoperative period – high inverse (r = – 0.901). The greatest value in the development of postoperative respiratory failure is driving pressure, exceeding 15 cm of water (Odds ratio = 18.25). In the first 3 days, postoperative pulmonary complications, determined by the Melbourne group scale, occurred in 9 (8.2%) patients in whom the driving pressure exceeded 15 cm of water, and in 3 patients (2.7%) with a driving pressure level less than 15 cm of water (p = 0.016).Conclusion: Driving pressure excess with values of more than 15 cm of water significantly increases the incidence of postoperative pulmonary complications. Fixed PEEP will be inappropriate both high and low, and individualized PEEP titrated by CStat may reduce driving pressure and become the next step in protective one-lung ventilation.