Postpneumonectomy respiratory failure and acute respiratory distress syndrome: risk factors and outcome

Abstract

Pneumonectomy is related with a high postoperative morbidity and mortality rate, ranging from 5% to 9%. Post-pneumonectomy respiratory failure (ARF) acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are grave and disastrous complications in these patients, necessitating invasive mechanical ventilation (IMV). In different series reported in literature, ARDS after lung resection occurred in 1-8% of patients and the mortality amounts in a range between 30% to 80%. We have reviewed the literature in order to clarify the different risk factors in the development of ARDS post pneumonectomy.According to different papers, the most important pre-operative risk factors are represented by age and sex, comorbidities (smoking, diabetes, COPD), pre-operative respiratory function and right side of pneumonectomy. Concerning peri and immediately post-operative management of these patients, the key role is represented by the IMV and the fluid infusion and cardiac preload during and after surgery.In summary, ALI and ARDS after pneumonectomy are closely linked to any direct or indirect pulmonary insult, responsible of endo-alveolar oedema. An inappropriate fluid infusion during or after surgery, may be exacerbate endo-alveolar oedema and encourage the development of ALI and ARDS. In this perspective, the best management of these patients should be achieved by a multidisciplinary team made by thoracic surgeons, respiratory physicians, anaesthesiologists, physiotherapists and nurses dedicated in ICUs.

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“…ARDS is unquestionably one of the worst and most feared complications after pneumonectomy; it is well known that development of ARDS is closely linked to any direct or indirect pulmonary insult. Thus, on the surface of the alveolar endothelium, we witnessed an upregulation of inflammatory cytokines and an increase in the growth of reactive oxygen species (ROS) and of activated neutrophils with the initiation of the inflammation cascade; these events increase micro-vascular alveolar permeability, and this last aspect is probably responsible for postoperative pulmonary edema, representing the first stage of ALI and ARDS [ 13 , 16 , 18 , 19 ].…”

“…Some studies [ 12 , 17 , 18 ] suggest that reduced tidal volume (<10 mL/kg), pressure-controlled ventilation and reduced PEEP during lung surgery limit peak alveolar pressures and ensure maximum alveolar recruitment. On the other hand, high tidal volume and increased PEEP determine important barotrauma on endothelium cells [ 17 , 19 ], stretch-activation of cation channels, subsequent upregulation of inflammatory cytokines, augmentation of oxygen-derived free radicals and activated neutrophils, and finally, an increase in alveolar permeability.…”

“…Reviewing the different series reported in the literature, ARDS after lung resection occurred in 1% to 8% of patients with an ARDS-related mortality rate ranging from 30% to 80% [ 4 , 5 , 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ].…”