Authors: Billstein, Charlotte et al.
Pediatric Anesthesia, first published October 23 2025.
DOI: 10.1111/pan.70066
This prospective, randomized pilot study investigated whether maintaining lung-protective ventilation (LPV) during aortic cross-clamping on cardiopulmonary bypass (CPB) in pediatric cardiac surgery influences postoperative lung function compared with apnea or continuous positive airway pressure (CPAP). The study aimed to address concerns that arresting ventilation during CPB may promote atelectasis, lung injury, or inflammatory responses.
Children were randomized into three intraoperative ventilation strategies: apnea, CPAP (5 mbar), or LPV (pressure-controlled ventilation with individualized driving pressure at 20% of pre-cross-clamp inspiratory pressure, PEEP 5 mbar, and age-adjusted respiratory rate). Electrical impedance tomography assessed ventilation distribution pre- and post-operatively, and inflammatory biomarkers were analyzed.
Across all groups, driving pressure rose slightly and dynamic compliance decreased after surgery, consistent with mild postoperative pulmonary changes. The number of ventilated lung regions and the center of ventilation both shifted during mechanical ventilation but normalized after surgery. Importantly, these physiologic measures and inflammatory markers did not differ among the three strategies. LPV was technically feasible and well tolerated.
The authors conclude that under standardized recruitment maneuvers at the end of CPB, LPV, CPAP, and apnea produced comparable postoperative respiratory outcomes in pediatric cardiac surgery. Although LPV is feasible, its benefit over simpler approaches remains unproven in this small pilot study.
What You Should Know
• LPV, CPAP, and apnea yielded similar postoperative lung mechanics and ventilation distribution in children on CPB.
• Recruitment maneuvers after bypass likely minimized inter-group differences.
• LPV was safe and feasible but did not confer measurable physiologic advantage in this pilot setting.
• Larger studies are needed to clarify whether intra-CPB ventilation strategies can improve pediatric postoperative pulmonary recovery.
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