Intraoperative mechanical ventilation during thoracic surgery: contemporary controversies and evolving strategies

Purpose of review To investigate and synthesize recent evidence on intraoperative mechanical ventilation strategies during thoracic surgery, with a focus on the controversies of fixed versus individualized positive end-expiratory pressure (PEEP), high versus low PEEP, mechanical and chemical power, driving pressure, and the integration of therapy bundles. Recent findings Recent randomized controlled trials and meta-analyses have claimed that individualized PEEP titration reduces postoperative pulmonary complications (PPCs) compared with fixed PEEP. High PEEP does not universally confer benefit and may increase hemodynamic risk, while low PEEP risks atelectasis. Driving pressure has emerged as a potential modifiable risk factor for PPCs, with individualized strategies to minimize driving pressure showing improved outcomes. Mechanical power, is increasingly recognized as a predictor of PPCs, while chemical power is emerging as a new concept. Therapy bundles, including perioperative open-lung approaches and individualized postoperative care, are promising but require further validation. Summary The current literature shows a trend toward individualized perioperative ventilation strategies in thoracic surgery, particularly individualized PEEP titration. Therapy bundles and individualized postoperative care, including high-flow nasal oxygen, are emerging as adjuncts to reduce PPCs. Large-scale, definitive trials are needed to determine the clinical value of these strategies and clarify the role of chemical power and therapy bundles.