Lung-protective ventilation and postoperative pulmonary complications during pulmonary resection in children: A prospective, single-centre, randomised controlled trial.

Abstract

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 control ( 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 (24/142, 16.9%) and the control groups (15/71, 21.1%) ( P  = 0.45). 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.