A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications

Abstract

Background: Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery.

Methods: The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications.

Results: A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a "protective ventilation" strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications.

Conclusions: In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications.

Conflict of interest statement

Conflicts of Interest:

Dr. Colquhoun declares Research Grant Support paid to Institution from Merck & Co. Inc. unrelated to the presented work.

Dr. Kheterpal declares research support paid to institution from Merck & Co., Inc and Apple, Inc both unrelated to the presented work.

Dr. Chang declares travel reimbursement from American Board of Thoracic Surgery, Expert witness fees from defendant attorney and peer review services/reimbursement from Department of Defense, all unrelated to the presented work.

Dr. Schonberger declares research grant support paid to institution from Merck and Co. Incorporated unrelated to the present work.

Dr. Schonberger reports having an equity stake in Johnson and Johnson unrelated to the present work.

Dr. Blank declares research support paid to institution from the Association of University Anesthesiologists unrelated to the presented work.

Copyright © 2021, the American Society of Anesthesiologists, Inc. All Rights Reserved.

Figures

Figure 1

Flow of patients through study.

Figure 2

Mean Positive End Expiratory Pressure (PEEP) in centimeters of water (cm H2O), Mean Tidal Volume milliliters per kilogram of weight by predicted body weight and Percentage of Cases Meeting Protective Ventilation criteria over time by study year.

Figure 3

Mean and 95% confidence interval predictive probability of pulmonary complications by modified driving pressure and peak inspiratory pressure (cm H2O). Pressure was analyzed in five-unit increments.