Management of 1-Lung Ventilation-Variation and Trends in Clinical Practice: A Report From the Multicenter Perioperative Outcomes Group

BACKGROUND: Lung-protective ventilation (LPV) has been demonstrated to improve clinical outcomes in surgical patients. There are very limited data on the current use of LPV for patients undergoing 1-lung ventilation (1LV) despite evidence that 1LV may be a particularly important setting for its use. In this multicenter study, we report trends in ventilation practice for patients undergoing 1LV. METHODS: The Multicenter Perioperative Outcomes Group database was used to identify patients undergoing 1LV. We retrieved and calculated median initial and overall tidal volume (VT) for the cohort and for high-risk subgroups (female sex, obesity [body mass index > 30 kg/m2], and short stature), percentage of patients receiving positive end-expiratory pressure (PEEP) = 5 cm H2O, LPV during 1LV (VT = 6 mL/kg predicted body weight [PBW] and PEEP = 5 cm H2O), and ventilator driving pressure (Delta P; plateau airway pressure - PEEP). RESULTS: Data from 5609 patients across 4 institutions were included in the analysis. Median VT was calculated for each case and since the data were normally distributed, the mean is reported for the entire cohort and subgroups. Mean of median VT during 1LV for the cohort was 6.49 +/- 1.82 mL/kg PBW. VT (mL/kg PBW) for high-risk subgroups was significantly higher; 6.86 +/- 1.97 for body mass index = 30 kg/m2, 7.05 +/- 1.92 for female patients, and 7.33 +/- 2.01 for short stature patients. Mean of the median VT declined significantly over the study period (from 6.88 to 5.72; P <.001), and the proportion of patients receiving LPV increased significantly over the study period (from 9.1% to 54.6%; P <.001). These changes coincided with a significant decrease in Delta P during the study period, from 19.4 cm H2O during period 1 to 17.3 cm H2O in period 12 (P =.003). CONCLUSIONS: Despite a growing awareness of the importance of protective ventilation, a large proportion of patients undergoing 1LV continue to receive VT PEEP levels outside of recommended thresholds. Moreover, VT remains higher and LPV less common in high-risk subgroups, potentially placing them at elevated risk for iatrogenic lung injury.