Intended for healthcare professionals

Clinical Review State of the Art Review

Perioperative lung protective ventilation

BMJ 2018; 362 doi: (Published 10 September 2018) Cite this as: BMJ 2018;362:k3030
  1. Brian O’Gara, instructor of anesthesia,
  2. Daniel Talmor, professor of anesthesia
  1. Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
  1. Correspondence to: B O’Gara bpogara{at}


Perioperative lung injury is a major source of postoperative morbidity, excess healthcare use, and avoidable mortality. Many potential inciting factors can lead to this condition, including intraoperative ventilator induced lung injury. Questions exist as to whether protective ventilation strategies used in the intensive care unit for patients with acute respiratory distress syndrome are equally beneficial for surgical patients, most of whom do not present with any pre-existing lung pathology. Studied both individually and in combination as a package of intraoperative lung protective ventilation, the use of low tidal volumes, moderate positive end expiratory pressure, and recruitment maneuvers have been shown to improve oxygenation and pulmonary physiology and to reduce postoperative pulmonary complications in at risk patient groups. Further work is needed to define the potential contributions of alternative ventilator strategies, limiting excessive intraoperative oxygen supplementation, use of non-invasive techniques in the postoperative period, and personalized mechanical ventilation. Although the weight of evidence strongly suggests a role for lung protective ventilation in moderate risk patient groups, definitive evidence of its benefit for the general surgical population does not exist. However, given the shift in understanding of what is needed for adequate oxygenation and ventilation under anesthesia, the largely historical arguments against the use of intraoperative lung protective ventilation may soon be outdated, on the basis of its expanding track record of safety and efficacy in multiple settings.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: BOG and DT conceptualized and generated the basic outline of the review. BOG crafted the search strategy with the aid of Paul Bain of the Harvard Countway Library, reviewed the search results for inclusion/exclusion, created tables, created figures with the aid of Jane Hayward of the Beth Israel Deaconess Medical Center’s Media Services Department, and drafted the main body of the manuscript. BOG and DT revised the final version of the manuscript. BOG is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none

  • Provenance and peer review: Commissioned; externally peer reviewed.

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