Tailored single-lung ventilation approaches and postoperative pulmonary outcomes in thoracic surgery

Traditional lung-protective ventilation [low tidal volume (VT) with fixed positive end-expiratory pressure (PEEP)] reduces intraoperative lung injury but exhibits limited efficacy in preventing postoperative pulmonary complications (PPCs) following thoracic surgery requiring one-lung ventilation (OLV). This review systematically examines the multifactorial mechanisms of OLV-associated lung injury, encompassing hypoxemia [device malposition, atelectasis, ventilation/perfusion (V/Q) mismatch, impaired hypoxic pulmonary vasoconstriction (HPV)], oxidative stress, ischemia-reperfusion injury (IRI) (glycocalyx degradation, mechanical stress, inflammation), and ventilator-induced trauma (volutrauma, biotrauma). To address these limitations, we propose an open-lung protective ventilation strategy integrating alveolar recruitment maneuvers (RMs) with individualized PEEP (iPEEP) titration based on optimal respiratory compliance. Furthermore, we innovatively introduce oxygen reserve index (ORI)-guided titration of fraction of inspired oxygen (FiO2), enabling dynamic determination of the minimum effective FiO2 to mitigate hyperoxia-related toxicity. This synergistic "RM-iPEEP-FiO2 triad" facilitates personalized intraoperative respiratory management by stabilizing alveoli, optimizing V/Q matching, and minimizing oxidative stress, thereby significantly reducing PPCs risk compared to conventional fixed-parameter approaches. Current limitations include insufficient multicenter validation, technical dependency on advanced monitoring/ventilators, and lack of subgroup analyses for high-risk populations. Future research should prioritize multicenter randomized controlled trials to establish universal thresholds for tailored parameters. Integration of artificial intelligence (AI) for real-time respiratory mechanics analysis and multimodal imaging is essential to refine precision thresholds. Ultimately, this strategy aims to establish an evidence-based, precision perioperative ventilation framework that optimizes clinical outcomes in thoracic surgical patients by overcoming the constraints of standardized ventilation protocols.