Postoperative pulmonary complications and response to recruitment maneuvers during hypoxemia in one lung ventilation

Pulmonary atelectasis during one-lung ventilation (OLV) can cause intraoperative hypoxemia and is a risk factor for postoperative pulmonary complications (PPCs). We hypothesized that patients whose hypoxemia improves with recruitment maneuvers (RMs) have atelectasis-related hypoxemia and a higher risk of PPCs compared to those with hypoxemia unresponsive to RMs. Retrospective and observational study. Single-entry study conducted in a University Hospital. Adults patients (n = 195) with elective pulmonary lobectomy. Between April 2022 and March 2023, all thoracic surgergy patients were classified into three groups: no intraoperative hypoxemia, hypoxemia responsive to RMs, and hypoxemia non-responsive to RMs. Postoperative outcomes were compared among groups, including incidence of respiratory distress, pneumonia, and RALE scores. Patients responsive to RMs had significantly higher rates of early (Day 0–4) respiratory distress (21.4% vs. 0% vs. 8.7%; p = 0.04) and late (Day 5–7) pneumonia (28.6% vs. 9% vs. 7%; p < 0.001). Non-responders showed higher intraoperative airway pressures and higher RALE scores on Day 1, which normalized by Day 3. No significant differences in mechanical ventilation duration or ICU stay were observed. Patients with hypoxemia responsive to RMs during OLV are at increased risk of PPCs, particularly respiratory distress and pneumonia, suggesting that intraoperative atelectasis is a major contributor. Identifying the hypoxemia profile could guide tailored perioperative strategies to minimize PPCs in these high-risk patients. • Patients with hypoxemia responsive to recruitment maneuvers during one-lung ventilation have higher rates of postoperative pulmonary complications. • Patients with hypoxemia non responsive to recruitment maneuvers during one-lung ventilation have lower rates of postoperative pulmonary complications than patients with hypoxemia responsive to recruitment maneuvers. • Per operative atelectasis is a key contributor to postoperative pulmonary complications. • Patients with intraoperative atelectasis need for tailored perioperative management.