Intraoperative mechanical ventilation in patients with non-injured lungs: time to talk about tailored protective ventilation?

It is a well-established concept that general anaesthesia can impair lung function postoperatively, even in subjects with healthy lungs (1), and mechanical ventilation itself is considered to play a major role in contributing to such dysfunction. Mortality after surgery was found to be higher than expected (2), with postoperative pulmonary complications (PPCs) having a relevant impact on outcome (3,4). Following these epidemiological findings, several research groups aimed at identifying modifiable risk factors associated with PPCs, in order to plan mitigation strategies to reduce the incidence of such complications and improve patients’ outcome. Among the others, several specific ventilation strategies have been found to be associated with a lower risk of developing PPCs. However, due to the low number of observed events, it is difficult to achieve a definitive answer on optimal intraoperative ventilation strategy to minimize the postoperative incidence of adverse events (5). In fact, general anaesthesia is nowadays considered as a safe procedure with a relatively low incidence of complications (6). The general tendency of the last decade was to translate the concept of “protective mechanical ventilation” borrowed by the critical care setting to non-injured lungs in operating room or intensive care and found to influence clinical outcome (7-9).