Intraoperative Tidal Volume as a Risk Factor for Respiratory Failure after Pneumonectomy

TLDR

Respiratory failure is a leading cause of postoperative morbidity and mortality after pneumonectomy. The study hypothesized that using large intraoperative tidal volumes would increase the risk of postoperative respiratory failure after pneumonectomy. The authors retrospectively studied 170 elective pneumonectomy patients, collecting demographics, comorbidities, pulmonary function, operative details, ventilator settings, and fluid administration to assess the association between tidal volume and respiratory failure. In multivariate analysis, each 1 ml/kg increase in intraoperative tidal volume raised the odds of postoperative respiratory failure by 56 % (OR 1.56, 95 % CI 1.12–2.23), and larger tidal volumes combined with higher fluid administration further increased risk; 18 % of patients developed respiratory failure, most commonly due to acute lung injury.

Abstract

Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. The authors hypothesized that intraoperative mechanical ventilation with large tidal volumes (VTs) would be associated with increased risk of postpneumonectomy respiratory failure.Patients undergoing elective pneumonectomy at the authors' institution from January 1999 to January 2003 were studied. The authors collected data on demographics, relevant comorbidities, neoadjuvant therapy, pulmonary function tests, site and type of operation, duration of surgery, intraoperative ventilator settings, and intraoperative fluid administration. The primary outcome measure was postoperative respiratory failure, defined as the need for continuation of mechanical ventilation for greater than 48 h postoperatively or the need for reinstitution of mechanical ventilation after extubation.Of 170 pneumonectomy patients who met inclusion criteria, 30 (18%) developed postoperative respiratory failure. Causes of postoperative respiratory failure were acute lung injury in 50% (n = 15), cardiogenic pulmonary edema in 17% (n = 5), pneumonia in 23% (n = 7), bronchopleural fistula in 7% (n = 2), and pulmonary thromboembolism in 3% (n = 1). Patients who developed respiratory failure were ventilated with larger intraoperative VT than those who did not (median, 8.3 vs. 6.7 ml/kg predicted body weight; P < 0.001). In a multivariate regression analysis, larger intraoperative VT (odds ratio, 1.56 for each ml/kg increase; 95% confidence interval, 1.12-2.23) was associated with development of postoperative respiratory failure. The interaction between larger VT and fluid administration was also statistically significant (odds ratio, 1.36; 95% confidence interval, 1.05-1.97).Mechanical ventilation with large intraoperative VT is associated with increased risk of postpneumonectomy respiratory failure.