Intraoperative Ventilatory Strategies in Patients Undergoing Video-Assisted Thoracic Surgery: A Narrative Review

Video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) are commonly used in thoracic surgery, yet postoperative complications still occur in up to 10% of the patients. The aim of our narrative review was to summarize the best available evidence on mechanical ventilation settings, particularly with regard positive end-expiratory pressure (PEEP) selection, tidal volume (VT) and ventilation mode, as well as the feasibility of two-lung ventilation in patients undergoing thoracic surgery using VATS or RATS techniques. We searched the MEDLINE/PubMed database using the terms "VATS" or "RATS" and "ventilation" between 1 January 2007 and 1 February 2025. Publications were screened by title or abstract. We discussed studies according to their methodological quality, ventilation mode, as well as the feasibility of two-lung ventilation in patients undergoing thoracic surgery using VATS or RATS techniques. In patients receiving one-lung ventilation (OLV), the application of a protective lung ventilation using an intermediate VT ranged between 5 and 8 ml (mL) of predicted body weight (PBW) and a PEEP of 5-8 cmH₂O was not found to be associated with a lower incidence of postoperative pulmonary complications and improved hospital outcomes. Titrating PEEP based on mechanical properties appears to enhance perioperative oxygenation and ventilatory mechanics and to reduce postoperative pneumonia. However, no conclusions can be drawn regarding ventilation modes, because only few studies have compared the same low VT using different pressure versus volume control modes. The feasibility of two-lung ventilation during specific thoracic surgery procedures has recently been positively evaluated, with no differences in postoperative complications found. The level of evidence for the ventilatory settings in patients undergoing VATS or RATS remains low. In conclusion, large randomized controlled trials (RCTs) are needed to determine whether certain intraoperative ventilatory strategies can reduce postoperative pulmonary complications (PPCs) in patients.