Lung protective ventilation during pulmonary resection in children: a prospective, single-centre, randomised controlled trial

Background: Perioperative ventilatory strategies for lung protection in children are underexplored. This study evaluated the effects of lung protective ventilation (LPV) on postoperative clinical outcomes in children requiring one-lung ventilation (OLV) for pulmonary resection. Methods: Children age <= 5 yr scheduled for video-assisted thoracoscopic lung lobectomy or segmentectomy were randomly assigned to LPV or control ventilation. For LPV, tidal volume (V-T) was 6 ml kg(-1) during two-lung ventilation (TLV(VT)), 4 ml kg(-1) during OLV, with 6 cm H2O PEEP maintained throughout. In the control group, TLV(VT) was 10 ml kg(-1), 8 ml kg(-1) during OLV, but without PEEP. The primary outcome was the incidence of pulmonary complications within 72 h after operation. Secondary outcomes included intraoperative desaturation, arterial oxygen partial pressure/inspiratory fraction of oxygen (P/F) ratio >40 kPa, and development of consolidation and B-lines (assessed by lung ultrasound at the end of surgery, by an investigator masked to group allocation). Odds ratio (OR) with 95% confidence intervals are reported. Results: Overall, 19/110 (17.3%) children sustained pulmonary complications after surgery. LPV reduced pulmonary complications (5/55; 9.1%), compared with 14/55 (25.5%) children sustaining complications in the control group (OR=0.29 [0.10-0.88]; P=0.02). Masked ultrasound assessment showed less consolidation, and fewer B-lines, after LPV (P<0.001). Intraoperative desaturation was more common in control mode (eight/55; 14.5%), compared with 1/55 (1.8%) after LPV (OR=9.2 [1.1-76]; P=0.015). LPV maintained (P/F) ratio >40 more frequently (53/55; 96.4%) than control-mode (45/55; 81.8%) ventilation (OR=5.9 [1.2-28.3%]; P<0.01). Conclusions: Lung protective ventilation decreased postoperative pulmonary complications compared with conventional ventilation in children requiring one-lung ventilation for pulmonary resection.