Anesthetic Management of One-Lung Ventilation in Thoracic Trauma: A Retrospective Observational Cohort Study

Background One-lung ventilation (OLV) in acute thoracic trauma presents physiological and technical challenges distinct from elective thoracic anesthesia. Preexisting hypoxemia, hemodynamic instability, and the inflammatory milieu of polytrauma increase susceptibility to ventilator-induced lung injury and postoperative pulmonary complications (PPCs). Data on anesthetic management, technique selection, and outcomes in this population remain limited. We report our experience with OLV in 117 consecutive trauma patients, characterizing clinical practice patterns and identifying predictors of acute respiratory distress syndrome (ARDS). Methods We conducted a retrospective observational cohort study of all trauma patients requiring OLV at the Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, over six years (January 2020 to December 2025). Patient demographics, mechanism of injury, injury patterns, preoperative physiology, OLV technique, intraoperative ventilation parameters, surgical approach, and postoperative outcomes were systematically recorded. Subgroup analyses compared blunt vs penetrating injury, OLV techniques, and video-assisted thoracoscopic surgery (VATS) vs open thoracotomy. Predictors of ARDS were identified through univariate and multivariate binary logistic regression. Results The mean patient age was 35.8 ± 13.1 years; 93.2% were male. Road traffic accidents (52.1%) and blunt chest trauma (70.1%) predominated. Double-lumen tubes were used in 50.4% of cases. Intraoperative hypoxia occurred in 48.3% of patients, and ARDS developed in 23.9%. VATS was associated with a significantly lower ARDS rate (10.3% vs 36.2%; P = 0.001) and reduced intraoperative blood transfusion (13.8% vs 31.0%; P = 0.026) compared with open thoracotomy. On multivariate analysis, the principal independent predictors of ARDS were preoperative mechanical ventilation (adjusted OR (aOR) 5.26; 95% CI 1.21-22.75; P = 0.026), maximum intraoperative fraction of inspired oxygen (FiO₂) (aOR 1.05 per percentage point; 95% CI 1.01-1.09; P = 0.021), and surgical approach, with VATS strongly protective relative to open thoracotomy (aOR 0.13; 95% CI 0.04-0.48; P = 0.002). The model demonstrated good discrimination (area under the receiver operating characteristic curve = 0.850) and calibration (Hosmer-Lemeshow P = 0.905). Conclusions OLV in thoracic trauma is associated with frequent perioperative hypoxia and PPCs, with preoperative mechanical ventilation, higher intraoperative FiO₂ requirements, and open thoracotomy independently associated with increased ARDS risk, whereas VATS was associated with a lower incidence of ARDS.