Major lung surgery requires temporary collapse of one lung while the other is mechanically ventilated, a process that increases strain on the functioning lung and raises the risk of complications such as respiratory failure and pneumonia. Until now, it was unclear which intraoperative ventilation strategy best reduces these risks without compromising circulation. New findings from a large international clinical study now provide evidence-based guidance to support safer anesthesia decisions during complex lung operations.

The PROTHOR trial, conducted by researchers at the University Hospital Dresden (Dresden, Germany) and Dresden University of Technology (Dresden, German), focused on ventilation strategies used during one-lung ventilation, specifically comparing higher positive end-expiratory pressure with recruitment maneuvers against lower positive end-expiratory pressure (PEEP) without such maneuvers. Recruitment maneuvers are designed to reopen collapsed alveoli but may also influence blood pressure stability.

Over eight years, the PROTHOR study enrolled 2,200 patients undergoing major lung surgery across 74 centers in 28 countries. Researchers evaluated whether higher PEEP combined with recruitment maneuvers could reduce postoperative pulmonary complications compared with a lower PEEP strategy. Outcomes included gas exchange, circulatory stability during anesthesia, and rates of postoperative lung complications.

Ventilation using higher PEEP and recruitment maneuvers resulted in improved gas exchange in the lungs, while lower PEEP was associated with more stable blood pressure during surgery. Importantly, the incidence of postoperative pulmonary complications did not differ between the two strategies. The results were published in Lancet Respiratory Medicine, marking the largest patient safety study to date in major lung surgery.

The findings indicate that no single ventilation strategy is universally superior for all patients undergoing one-lung ventilation. Instead, ventilation settings should be tailored to each patient’s physiological condition during surgery, balancing respiratory benefits against circulatory stability. The researchers emphasize that individualized decision-making can enhance patient safety without increasing complication rates.

“These new research findings enable improved ventilation during complex lung surgery and contribute to patient safety. The PROTHOR study shows the responsibility we take on in patient care,” said Prof. Uwe Platzbecker, Medical Director at the University Hospital.

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