Lung-protective ventilation and postoperative pulmonary complications during pulmonary resection in children

BACKGROUND Children are more susceptible to postoperative pulmonary complications (PPCs) due to their smaller functional residual capacity and higher closing volume; however, lung-protective ventilation (LPV) in children requiring one-lung ventilation (OLV) has been relatively underexplored. OBJECTIVES To evaluate the effects of LPV and driving pressure-guided ventilation on PPCs in children with OLV. DESIGN Randomised, controlled, double-blind study. SETTING Single-site tertiary hospital, 6 May 2022 to 31 August 2023. PATIENTS 213 children aged < 6 years, planned for lung resection secondary to congenital cystic adenomatoid malformation. INTERVENTIONS Children were randomly assigned to LPV ( n = 142) or ventilation ( n = 71) groups. Children in LPV group were randomly assigned to either driving pressure group ( n = 70) receiving individualised positive end-expiratory pressure (PEEP) to deliver the lowest driving pressure or to conventional protective ventilation group ( n = 72) with fixed PEEP of 5 cmH 2 O. MAIN OUTCOME MEASURES The primary outcome was the incidence of PPCs within 7 days after surgery. Secondary outcomes were pulmonary mechanics, oxygenation and mechanical power. RESULTS The incidence of PPCs did not differ between the LPV (24/173, 16.8%) and the control groups (15/70, 21.4%) ( P = 0.41). The driving pressure was lower in the driving pressure group than in the 5 cmH 2 O PEEP group (15 vs. 17 cmH 2 O; P = 0.001). Lung compliance and oxygenation were higher while the dynamic component of mechanical power was lower in the driving pressure group than in the 5 cmH 2 O PEEP group. The incidence of PPCs did not differ between the driving pressure (11/70, 15.7%) and the 5 cmH 2 O PEEP groups (13/72, 18.1%) ( P = 0.71). CONCLUSIONS LPV did not decrease the occurrence of PPCs compared to non-protective ventilation. Although lung compliance and oxygenation were higher in the driving pressure group than in the 5 cmH 2 O PEEP group, these benefits did not translate into significant reductions in PPCs. However, the study is limited by a small sample size, which may affect the interpretation of the results. Future research with larger sample sizes is necessary to confirm these findings. TRIAL REGISTRATION ChiCTR2200059270.