The Effects of an Open-Lung Approach During One-Lung Ventilation on Postoperative Pulmonary Complications and Driving Pressure: A Descriptive, Multicenter National Study

Abstract

Objective: Thoracic surgical procedures are associated with an increased risk of postoperative pulmonary complications (PPCs), which seem to be related directly to intraoperative driving pressure. The authors conducted this study to describe the incidence of PPCs in patients in whom an individualized open-lung approach was applied during one-lung ventilation.

Design: This was a prospective, multicenter, national descriptive study.

Setting: Thoracic surgery patients undergoing one-lung ventilation.

Participants: Eligible participants were included consecutively from October 1, 2016, to September 30, 2017. A total of 690 patients were included.

Interventions: An individualized open-lung approach that consisted of an alveolar recruitment maneuver followed by a positive end-expiratory pressure adjusted to best respiratory system compliance was performed in all patients.

Measurements and main results: Preoperative and intraoperative data were recorded; the primary outcome was a description of the incidence of PPCs in these patients during the first 7 postoperative days. The patients were mainly male, and half of them had a high risk of PPCs (ARISCAT score exceeding 44). Eleven percent of participants developed a PPC within the first postoperative week. The mean open lung positive end-expiratory pressure was 8 ± 3 cmH₂O. When compared with pre-open lung approach values, the open-lung approach significantly decreased the driving pressure (14 ± 4 cmH₂O v 11 ± 3 cmH₂O; p < 0.001) and increased dynamic compliance (30 ± 10 mL/cmH₂O v 43 ±15 mL/cmH₂O; p < 0.001).

Conclusions: The low incidence of PPCs in patients who underwent an open-lung approach during one-lung ventilation compared with that reported for other thoracic surgery series and the decrease in the driving pressure in these patients justify an additional randomized controlled trial to compare the open-lung approach with the standard protective strategy of low tidal volume and low positive end-expiratory pressure.

Keywords: driving pressure; one-lung ventilation; positive end-expiratory pressure; postoperative pulmonary complications.