Protective Ventilation With High Versus Low PEEP During One-lung Ventilation for Thoracic Surgery

Conditions

One-Lung Ventilation

Keywords

Mechanical ventilation, positive end-expiratory pressure, recruitment maneuver, one-lung ventilation, thoracic surgery, postoperative pulmonary complication

Brief summary

One-lung ventilation (OLV) with resting of the contralateral lung may be required to allow or facilitate thoracic surgery. However, OLV can result in severe hypoxemia, requiring a mechanical ventilation approach that is able to maintain adequate gas exchange, while protecting the lungs against postoperative pulmonary complications (PPCs). During OLV, the use of lower tidal volumes is helpful to avoid over-distension, but can result in increased atelectasis and repetitive collapse-and-reopening of lung units, particularly at low levels of positive end-expiratory pressure (PEEP). Anesthesiologists inconsistently use PEEP and recruitment maneuvers (RM) in the hope that this may improve oxygenation and protect against PPC. Up to now, it is not known whether high levels of PEEP combined with RM are superior to lower PEEP without RM for protection against PPCs during OLV. Hypothesis: An intra-operative ventilation strategy using higher levels of PEEP and recruitment maneuvers, as compared to ventilation with lower levels of PEEP without recruitment maneuvers, prevents postoperative pulmonary complications in patients undergoing thoracic surgery under standardized one-lung ventilation.

Writing Committee, Steering Committee, PROTHOR Collaborative Group, PROtective VEntilation Network (PROVE Network) for the Clinical Trial Network of the European Society of Anaesthesiology and Intensive Care.

2025-11-12

10.1016/s2213-2600(25)00330-3

Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial.

Kiss T, Wittenstein J, Becker C, Birr K, Cinnella G, Cohen E, El Tahan MR, Falcão LF, Gregoretti C, Granell M, Hachenberg T, Hollmann MW, Jankovic R, Karzai W, Krassler J, Loop T, Licker MJ, Marczin N, Mills GH, Murrell MT, Neskovic V, Nisnevitch-Savarese Z, Pelosi P, Rossaint R, Schultz MJ, Serpa Neto A, Severgnini P, Szegedi L, Vegh T, Voyagis G, Zhong J, Gama de Abreu M, Senturk M, PROTHOR investigators, Research Workgroup PROtective VEntilation Network (PROVEnet) of the European Society of Anaesthesiology (ESA).

2019-04-1132 citations

10.1186/s13063-019-3208-8

Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study.

Rauseo M, Mirabella L, Grasso S, Cotoia A, Spadaro S, D'Antini D, Valentino F, Tullo L, Loizzi D, Sollitto F, Cinnella G.

2018-10-3122 citations

10.1186/s12871-018-0624-3

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications

The LAS VEGAS investigators

European Journal of Anaesthesiology2017-06-14317 citations

10.1097/eja.0000000000000646

Interventions

PROCEDUREPEEP level

PROCEDUREUse of recruitment maneuvers

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Masking

DOUBLE (Subject, Outcomes Assessor)

Eligibility

Sex/Gender

ALL

Age

18 Years to No maximum

Healthy volunteers

No

Inclusion criteria

* Patient scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV (no emergency surgery) * BMI \< 35 kg/m2 * age ≥ 18 years * expected duration of surgery \> 60 min * planned lung separation with double lumen tube (DLT, not for study purpose only) * most of ventilation time during surgery expected to be in OLV

Exclusion criteria

* COPD GOLD grades III and IV, lung fibrosis, documented bullae, severe emphysema, pneumothorax * uncontrolled asthma * Heart failure NYHA Grade 3 and 4, Coronary Heart Disease CCS Grade 3 and 4 * previous lung surgery * documented pulmonary arterial hypertension \>25mmHg MPAP at rest or \> 40 mmHg syst. (estimated by ultrasound) * documented or suspected neuromuscular disease (thymoma, myasthenia, myopathies, muscular dystrophies, others) * planned mechanical ventilation after surgery * bilateral procedures * lung separation with other method than DLT (e.g. difficult airway, tracheostomy) * surgery in prone position * persistent hemodynamic instability, intractable shock * intracranial injury or tumor * enrollment in other interventional study or refusal of informed consent * pregnancy (excluded by anamnesis and/or laboratory analysis) * esophagectomy, pleural surgery only, sympathectomy surgery only, chest wall surgery only, mediastinal surgery only, lung transplantation * presence before induction of anaesthesia of one of the adverse events, listed as postoperative pulmonary complications (aspiration, moderate respiratory failure, infiltrates, pulmonary infection, atelectasis, cardiopulmonary edema, pleural effusion, pneumothorax, pulmonary embolism, purulent pleuritis, lung hemorrhage) * documented preoperative hypercapnia \> 45mmHg (6kPa)

Design outcomes

Primary

Measure	Time frame
The proportion of patients developing one or more postoperative pulmonary complications	90 days

Countries

Albania, Austria, Brazil, Chile, China, Croatia, Cyprus, Czechia, Egypt, France, Germany, Greece, Hungary, Iraq, Italy, Japan, Latvia, Mexico, Netherlands, Romania, Saudi Arabia, Serbia, Slovenia, Spain, Switzerland, Taiwan, Turkey (Türkiye), United Kingdom, United States

Outcome results

None listed