Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy.
BACKGROUND
Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. The authors hypothesized that intraoperative mechanical ventilation with large tidal volumes (VTs) would be associated with increased risk of postpneumonectomy respiratory failure.


METHODS
Patients undergoing elective pneumonectomy at the authors' institution from January 1999 to January 2003 were studied. The authors collected data on demographics, relevant comorbidities, neoadjuvant therapy, pulmonary function tests, site and type of operation, duration of surgery, intraoperative ventilator settings, and intraoperative fluid administration. The primary outcome measure was postoperative respiratory failure, defined as the need for continuation of mechanical ventilation for greater than 48 h postoperatively or the need for reinstitution of mechanical ventilation after extubation.


RESULTS
Of 170 pneumonectomy patients who met inclusion criteria, 30 (18%) developed postoperative respiratory failure. Causes of postoperative respiratory failure were acute lung injury in 50% (n = 15), cardiogenic pulmonary edema in 17% (n = 5), pneumonia in 23% (n = 7), bronchopleural fistula in 7% (n = 2), and pulmonary thromboembolism in 3% (n = 1). Patients who developed respiratory failure were ventilated with larger intraoperative VT than those who did not (median, 8.3 vs. 6.7 ml/kg predicted body weight; P < 0.001). In a multivariate regression analysis, larger intraoperative VT (odds ratio, 1.56 for each ml/kg increase; 95% confidence interval, 1.12-2.23) was associated with development of postoperative respiratory failure. The interaction between larger VT and fluid administration was also statistically significant (odds ratio, 1.36; 95% confidence interval, 1.05-1.97).


CONCLUSIONS
Mechanical ventilation with large intraoperative VT is associated with increased risk of postpneumonectomy respiratory failure.
Fernández-Pérez
Evans R
ER
Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA. fernandez.evans@mayo.edu
Keegan
Mark T
MT
Brown
Daniel R
DR
Hubmayr
Rolf D
RD
Gajic
Ognjen
O
D000368:Aged; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D006801:Humans; D007432:Intraoperative Period / Q000009:adverse effects / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011013:Pneumonectomy / Q000009:adverse effects* / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D012121:Respiration, Artificial / Q000009:adverse effects; D012131:Respiratory Insufficiency / Q000453:epidemiology / Q000209:etiology*; D012189:Retrospective Studies; D012307:Risk Factors; D013990:Tidal Volume / Q000502:physiology