Risk Factors for Post-pneumonectomy Acute Lung Injury/Acute Respiratory Distress Syndrome in Primary Lung Cancer Patients

Abstract

Pulmonary resection remains the best curative option for patients with localised non small cell lung carcinoma 1 . Despite advances in surgical technique, anaesthesia and perioperative care, the morbidity and mortality rates for lung resection remain significant 2 . The majority of postoperative complications after lung resection are cardiopulmonary in nature; however, pulmonary complications are the main cause of postoperative death 3-6 . Although the causes of postoperative respiratory failure vary and include pneumonia, aspiration, atelectasis and pulmonary emboli, the most dreaded pulmonary complication after lung resection is acute lung injury/acute respiratory distress syndrome (ALI/ARDS) 7 .Pneumonectomy, surgical removal of an entire lung, is associated with higher rates of postoperative respiratory failure and death, compared with lesser resections 2 . The reported rates of respiratory failure following pneumonectomy for SUMMARY Acute lung injury/acute respiratory distress syndrome (ALI / ARDS) is the most serious pulmonary complication after lung resection. This study investigated the incidence and outcome of patients with ALI / ARDS who required mechanical ventilation within one week of undergoing pneumonectomy for primary lung cancer and analysed the risk factors. We retrospectively reviewed the medical records of 146 patients who underwent pneumonectomy for primary lung cancer between May 2001 and April 2006. Preoperative, perioperative and postoperative clinical data were analysed. Post-pneumonectomy ALI / ARDS developed within the first postoperative week in 18 (12%) patients. Patients who developed ALI / ARDS had a longer hospital duration of stay (median [interquartile range], 26 [18 to 75] vs. 8 [7 to 11] days; P <0.001) and higher in-hospital mortality (12 [67%] vs. 0 [0%]; P <0.001). In an univariate analysis, post-pneumonectomy ALI / ARDS was associated with larger tidal volume (V T ) and higher airway pressure (P aw ) during one-lung ventilation (V T , 8.2 [7.5 to 9.0] vs. 7.7 [6.9 to 8.2] ml/kg predicted body weight, P=0.016; P aw , 28.9 [27.6 to 30.0] vs. 27.2 [25.6 to 28.5] cmH 2 O, P=0.001). V T during two-lung ventilation was also greater in patients who developed ALI / ARDS (P=0.014) than in those who did not, but P aw during two-lung ventilation did not differ (P=0.950). In a multiple logistic regression analysis, post-pneumonectomy ALI / ARDS was independently associated with a larger V T (OR 3.37 per 1 ml/kg predicted body weight increase; 95% confidence interval 1.65 to 6.86) and higher P aw (OR 2.32 per 1 cmH 2 O increase; 95% confidence interval 1.46 to 3.67) during the period of one-lung ventilation. In conclusion, a large V T and high P aw during one-lung ventilation were associated with an increased risk of post-pneumonectomy ALI / ARDS in primary lung cancer patients.

Preoperative and Intraoperative Predictors of Postoperative Acute Respiratory Distress Syndrome in a General Surgical Population

“…26-30 Although there is some literature investigating the development of ARDS postoperatively, most of this work has focused on high-risk elective surgeries such as cardiac and thoracic interventions. 3-7, 31 This study focused on a relatively common surgical population, a group of patients seen in hospitals throughout the world with a low incidence of ARDS that has precluded prospective study.…”

Comparison of pressure-controlled ventilation with volume-controlled ventilation during one-lung ventilation: a systematic review and meta-analysis

“…Although arterial hypoxemia is still a critical intraoperative problem, avoidance of lung injury has become the major concern in OLV [3, 4]. Elevated airway pressure associated with mechanical ventilation is the important risk factor for ventilator-induced lung injury [5, 6]. In addition, inflammatory reactions and tissue injuries associated with lung re-expansion cause the ventilator-induced lung injury after OLV [7–10].…”

Prehospital amiodarone may increase the incidence of acute respiratory distress syndrome among patients at risk

“…Three of 11 patients in the amiodarone group developed ARDS after a right-sided pneumonectomy compared with none in the other 2 treatment arms. Notably, ARDS is not uncommon after a pneumonectomy, with reported incidence of up to 12% [24]. Thus, although most randomized clinical trials of amiodarone have not noted any concerns for ALI/ARDS, in specific patient contexts such as after a pneumonectomy, immediate prophylactic administration of amiodarone (which is not the intent of this report) may still pose a risk for ARDS.…”