Thoracoscopic segmental lung resection has gained traction in pediatric thoracic surgery due to its minimally invasive nature and improved recovery outcomes. This procedure employs one-lung ventilation (OLV) to isolate and protect the operative lung, enhancing surgical field visibility and facilitating precise anatomical dissection. However, OLV poses significant physiological challenges, especially in children, potentially leading to absorption atelectasis and ventilation-perfusion mismatch, which are primary contributors to intraoperative hypoxemia.
Beyond gas exchange abnormalities, the collapse-reexpansion cycle and the inflammatory response to regional hypoxia can activate and release inflammatory cytokines such as interleukins and tumor necrosis factor-alpha (TNF-α). These cytokines play a crucial role in lung ischemia-reperfusion injury, potentially leading to perioperative pulmonary complications like pneumonia and persistent atelectasis, thereby prolonging hospital stays and increasing morbidity.
Research in adults suggests that stepwise lung recruitment as a lung-protective ventilation strategy during thoracoscopic segmental lung resection under OLV can reduce acute lung injury severity and decrease postoperative pulmonary complications. While this method’s efficacy is well-documented in adults, its impact on pediatric populations remains under-explored. Pediatric patients, with reduced lung functional residual capacities and elevated closing volumes, are more susceptible to atelectasis post-anesthesia induction.
Study Overview and Methodology
This single-center study assessed the effects of stepwise lung recruitment on intraoperative oxygenation and postoperative lung outcomes in pediatric patients undergoing thoracoscopic segmentectomy with OLV. A total of 78 pediatric patients, aged 1 to 5 years, were selected between April 2021 and September 2022. Participants were randomly assigned to either the stepwise lung recruitment group (SR) or the controlled lung inflation recruitment group (CR).
Inclusion criteria required participants to have an ASA classification of I to II, a preoperative hemoglobin level ≥ 10 gm/dl, and no severe cardiac arrhythmias, among other factors. The study adhered to ethical guidelines, with informed consent obtained from the participants’ families.
Anesthesia and Surgical Procedures
Both groups followed a 6-hour fasting protocol before surgery, with anesthesia managed by pediatric anesthesiologists. The surgical team employed a three-port technique for thoracoscopic access, guided by preoperative enhanced chest CT scans. The stepwise lung recruitment technique involved setting inspiratory peak pressure at 28 cm H2O, with PEEP adjustments to optimize oxygen saturation and lung expansion.
Results and Observations
The study found no significant differences in baseline characteristics or surgical details between the two groups. However, the SR group demonstrated superior outcomes in terms of hemodynamic stability and reduced postoperative complications. At T1, the SR group showed lower peak airway pressure and higher mean airway pressure, compliance, and oxygenation index compared to the CR group.
Postoperative complications were significantly lower in the SR group, with pneumonia incidence dropping from 25.6% (CR) to 0% (SR), and atelectasis from 25.6% to 5.1%.
These results suggest that stepwise lung recruitment enhances compliance, gas exchange, and alveolar recruitment, contributing to better postoperative recovery.
Discussion and Implications
Lung re-expansion procedures are crucial in general anesthesia surgery, aiming to open collapsed alveoli and enhance oxygenation. The SR group’s gradual PEEP increase minimized hemodynamic fluctuations and improved postoperative outcomes. The study highlights the technique’s potential in reducing peak airway pressure, increasing mean airway pressure, and improving dynamic lung compliance.
Stepwise lung recruitment appears to stabilize intrathoracic and pulmonary pressures, preventing abrupt spikes and ensuring a consistent transition. This approach reduces intrapulmonary shunt, facilitates the re-expansion of collapsed alveoli, and decreases dead space ventilation.
Conclusion and Future Directions
The stepwise lung recruitment technique proves advantageous in safeguarding lung function and minimizing pulmonary complications in infants. However, the study’s limitations, including a small sample size and single-center design, may introduce bias. Future research should explore this technique’s protective effects on lung function in a larger, multicenter study.
Overall, stepwise lung recruitment offers a promising strategy for improving pediatric surgical outcomes, warranting further investigation and potential adoption in clinical practice.
