Effects of driving pressure-guided lung-protective ventilation strategy on respiratory mechanics, oxygenation, and postoperative pulmonary complications in patients undergoing minimally invasive esophagectomy: a randomized clinical trial

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIE) is a primary treatment option for esophageal cancer. However, intraoperative pneumoperitoneum and one-lung ventilation (OLV) significantly alter respiratory mechanics, potentially leading to hypoxemia and postoperative pulmonary complications (PPCs). The objective of this study was to evaluate the effects of a driving pressure (DP)-guided lung-protective ventilation strategy on respiratory mechanics, oxygenation levels, and the occurrence of PPCs in patients undergoing MIE. METHODS: This study was a single-center, prospective, randomized controlled clinical trial. Sixty patients undergoing MIE were randomly assigned to either a conventional lung-protective ventilation strategy group (VC group) or a DP-guided lung-protective ventilation strategy group (VD group). In the VC group, positive end-expiratory pressure (PEEP) was set at a fixed level of 5 cmH2O. In the VD group, PEEP was individualized and adjusted based on DP at three specific times: 5 min after tracheal intubation, at the start of OLV, and when total lung ventilation resumed. The primary outcome was dynamic lung compliance (Cdyn). Data on respiratory mechanics, PaO2, PaCO2, pH, and hemodynamic parameters were collected. Additionally, the occurrence of PPCs within 7 days was recorded. RESULTS: A total of 59 patients were analyzed, including 30 in the VC group and 29 in the VD group. The VD group showed significantly higher Cdyn than the VC group, especially at 30 min after OLV (median difference of 9.0 mL/cmH2O; 95% confidence interval: 4.00 to 10.00; P<0.001). Compared to the VC group, the VD group showed significantly lower peak pressure and plateau pressure during surgery (P<0.05). During OLV, patients in the VD group showed significantly higher PaO2 and PaCO2 levels than those in the VC group (P<0.05). There were no statistically significant differences in hemodynamic parameters between the two groups. The incidence of PPCs was lower in the VD group (24.1% vs. 43.3%), but this difference failed to achieve statistical significance (P>0.05). CONCLUSIONS: In patients undergoing MIE, implementing a DP-guided lung-protective ventilation strategy significantly improved intraoperative respiratory mechanics and oxygenation parameters while maintaining relatively stable hemodynamics, but failed to reduce clinically relevant outcomes such as PPCs within 7 days. TRIAL REGISTRATION: This study was registered at Chinese Clinical Trial Registry (ChiCTR2400089494).