Contemporary concepts in intraoperative ventilation during thoracic surgery

PURPOSE OF REVIEW: Thoracic surgery requiring one-lung ventilation (OLV) remains one of the most challenging settings in perioperative respiratory care. During OLV, anesthesiologists must continuously balance two frequently competing goals: maintaining adequate gas exchange despite a markedly reduced ventilated lung volume while simultaneously minimizing ventilator-induced lung injury (VILI) through lung-protective ventilation. Despite widespread adoption of lower tidal volume ventilation, postoperative pulmonary complications (PPCs) remain frequent. This review summarizes contemporary concepts in mechanical ventilation during noncardiac thoracic surgery, focusing on ventilatory modes, individualized ventilator settings, mechanical and chemical power, and perioperative respiratory support strategies. RECENT FINDINGS: Recent randomized trials and meta-analyses suggest that individualized approaches to positive end-expiratory pressure and driving pressure may improve intraoperative respiratory mechanics and oxygenation during OLV, although consistent reductions in PPCs remain unproven. Mechanical power has emerged as a potentially important determinant of VILI, whereas chemical power represents a novel framework integrating hyperoxia, oxidative stress, and carbon dioxide management. Emerging ventilatory approaches, such as flow-controlled ventilation, have shown promising physiological effects during OLV, but their impact on patient-centered outcomes remains to be established. In addition, perioperative respiratory support bundles incorporating postoperative high-flow nasal oxygen may further contribute to perioperative lung protection. SUMMARY: Contemporary thoracic ventilation is evolving from isolated ventilatory variables toward individualized perioperative respiratory management concepts. Although physiological benefits are increasingly demonstrated, robust evidence linking these approaches to improved patient-centered outcomes remains limited. Future studies should clarify the roles of individualized ventilation, mechanical and chemical power, and postoperative respiratory support within integrated perioperative respiratory care pathways.