**5. References**


blood gas analysis provides a direct view on the oxygenation status; CT and EIT evaluate the local ventilation distribution. Obviously, it is rational to combine these different variables to guide PEEP titration. We suggest selecting PEEP according to a weighted combination of Crs, GI index (EIT analysis) and SpO2 (or PaO2) to include all available information on the patient's lung status. The disease state of the patient and strategic treatment goals may lead to different weighted combinations. A practical way to define these weighting factors is still warrant and should be achieved in the future with further

Besides, ventilator settings, such as tidal volume (Suter *et al.*, 1978) and inspired oxygen concentration (FiO2) (Rouby *et al.*, 2002) may strongly influence the "optimal" level of PEEP. The National Institutes of Health's ARDS Network has developed a recommendation in form of a PEEP/FiO2 titration table to adjust these variables (Brower *et al.*, 2004). As mentioned before, lung protective ventilation strategies are more than just PEEP optimization. The patients will also benefit from adequate tidal volumes and body positioning which may additionally limit hyperinflation and reduce the amount of non-

Perioperative ventilation support is indispensable for patients under thoracic surgery. Inadequate settings of ventilation support may cause a number of problems, including hypoxemia, shear stress trauma, barotraumas and pulmonary edema. A suitable PEEP level maintains dependent lung regions open and thereby improves oxygenation and reduces the risk of inflammation. The selection of optimal PEEP is still under debate. We propose to combine indices of lung mechanics, blood gas analysis and imaging techniques to titrate PEEP. Besides, application of PEEP should be complemented with other strategies (e.g. low tidal volume, appropriate body positioning, recruitment maneuver), to achieve the best

This review was developed within the project MOTiF-A supported by a grant (1781X08) of the German Research and Development Department (BMBF), and the project PAR

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outcome of the patient.

**4. Acknowledgment** 

**5. References** 

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**20** 

 *Spain* 

**Perioperative Pulmonary** 

Germán Peces-Barba Romero1 and Miguel Ángel Palomero Rodríguez2

Pulmonary resection is the first therapeutic option of various lung pathologies, among which localized non-microcytic bronchogenic carcinoma is the most prevalent. Due to the fact that many patients who develop non-microcytic bronchogenic carcinoma present significant comorbidity, lung resection is associated with an increased risk (between 2 and 5%) of perioperative death (Little et al., 2005). Therefore, it is important to assess the patient's operability, which is defined as the ability to survive the lung resection without

As most of these patients are or have been smokers, many of them have varying degree of obstructive lung disease. It is known that the pulmonary obstruction increases the risk of lung resection (Miller et al., 1981), which is why the decision to perform resection depends largely on the functional integrity of the lung not affected by tumor. As the excision supposes a loss of lung function, many years of research have led to a reasonably solid scientific evidence that the postoperative risk depends on post-surgery lung function, which can be estimated preoperatively by knowing the amount of tissue to be resected basing on anatomical size or quantifying it by perfusion scintigraphy (Wernly et

On the other hand, it is also known that the functional capacity measured by exercise tests is associated with postoperative mortality (Puente & Ruiz., 2003). This has led to the development of integrated strategies in which basal functional tests are followed by postoperative function estimate and, in borderline patients, by stress testing (Marshall &

The major cardiopulmonary complications that alter normal lung function occur as a result of surgery (thoracotomy and resection of lung parenchyma) and anaesthesia (table 1). The thoracic surgery causes restrictive changes in the lung function characterized by moderate to severe reductions (50%) in vital capacity and up to 70% decrease of functional residual capacity (FRC). As a result of the FRC decrease, the volume of airway closure is shifted, so

**1. Introduction** 

al., 1980).

Olsen 1993).

leaving any disabling sequelae.

**2. Perioperative pulmonary physiology** 

*1Department of Pneumology, IIS Fundación Jiménez Díaz, CIBERES,* 

*2Department of Anesthesiology, Hospital La Paz, Madrid,* 

**Functional Assessment** 

Felipe Villar Álvarez1,

