Postpneumonectomy respiratory failure and acute respiratory distress syndrome: risk factors and outcome

Pneumonectomy is related with a high postoperative morbidity and mortality rate, ranging from 5% to 9%. Post-pneumonectomy respiratory failure (ARF) acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are grave and disastrous complications in these patients, necessitating invasive mechanical ventilation (IMV). In different series reported in literature, ARDS after lung resection occurred in 1–8% of patients and the mortality amounts in a range between 30% to 80%. We have reviewed the literature in order to clarify the different risk factors in the development of ARDS post pneumonectomy. According to different papers, the most important pre-operative risk factors are represented by age and sex, comorbidities (smoking, diabetes, COPD), pre-operative respiratory function and right side of pneumonectomy. Concerning peri and immediately post-operative management of these patients, the key role is represented by the IMV and the fluid infusion and cardiac preload during and after surgery. In summary, ALI and ARDS after pneumonectomy are closely linked to any direct or indirect pulmonary insult, responsible of endo-alveolar oedema. An inappropriate fluid infusion during or after surgery, may be exacerbate endo-alveolar oedema and encourage the development of ALI and ARDS. In this perspective, the best management of these patients should be achieved by a multidisciplinary team made by thoracic surgeons, respiratory physicians, anaesthesiologists, physiotherapists and nurses dedicated in ICUs.