During thoracic surgery, one-lung ventilation (OLV) is associated with hypoxemia, lung injury, and perioperative respiratory complications. The level of positive-end expiratory pressure (PEEP) to apply during OLV remains controversial. The open-lung approach consists in setting a level of PEEP corresponding to the best lung compliance, using an esophageal catheter to measure the transpulmonary pressure. This approach has been effective in laparoscopic surgeries or acute respiratory distress syndrome, but has never been evaluated in thoracic surgery.
To be over 18 years old,
To be able to attend all scheduled visits and to comply with all trial procedures,
To be scheduled for a lung cancer resection surgery (performed by either video-assisted thoracoscopy or thoracotomy).
Non-carcinologic indication of lung resection (e.g. Lung volume reduction for bullous emphysema reduction, lung abscess),
Bilateral pulmonary resection surgery or history of lung resection surgery,
Lung resection under sternotomy
Non intubated video-assisted thoracoscopy
Parallel
"Open-lung" protective ventilation strategy
Procedure/SurgeryIn the "open-lung" group, the positive end-tidal pressure (PEEP) is titrated to match the best lung compliance. During a "PEEP decrement trial", PEEP is decreased from 20 cmH2O to 4 cmH2O by steps of 2 cmH2O/minute, and the driving the transpulmonary pressure (PTP) is calculated at each level of PEEP. In the "open-lung" group, the targeted PEEP corresponds to the lowest driving PTP during the "PEEP decrement trial", meaning the best lung compliance. Thereafter, the PEEP is set at this level and maintained until extubation.
"Standard" protective ventilation strategy
Procedure/SurgeryIn the "standard" group, the positive end-tidal pressure (PEEP) is arbitrarily set at 5 cmH2O, since this is the currently recommended level of PEEP, commonly used in control groups of previous clinical trials.
The incidence of intraoperative hypoxemia
A SpO2\<92% while the FiO2 is progressively decreased to 50% according to a standardized algorithm.
Hypoxemia events
The number of hypoxemia events, depth, and duration of hypoxemia.
The ventilatory parameters
Plateau pressure (mbar)
The ventilatory parameters
Driving PTP (cmH2O)
The ventilatory parameters
Airway driving pressure (cmH2O)
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