The prospective cohort study by Acosta et al., focusing on the effects of capnoperitoneum on lung strain and stress in children aged 3 to 7 yr, is particularly notable.  The significance of atelectasis in healthy children following general anesthesia and mechanical ventilation has attracted considerable interest.  This study employs individualized lung recruitment and tailored positive end-expiratory pressure (PEEP) strategies to mitigate atelectasis, demonstrating that lung-protective ventilation can reduce lung strain, albeit with a slight increase in lung stress during laparoscopic surgery.

There is a notable gap in the literature concerning the mechanisms of ventilator-induced lung injury in healthy, anesthetized children. Addressing this, the study utilizes a comprehensive methodology, incorporating ultrasonography, the air-test, and end-expiratory transpulmonary pressure measurements. These noninvasive, reliable techniques allow for the early detection of atelectasis in pediatric surgical patients, enabling timely interventions.  Additionally, the study’s statistical analysis, especially the use of linear mixed models that include longitudinal patient data, offers improved data interpretation and insights.

However, several areas within this trial necessitate further consideration and improvement. First, the study’s relatively small sample size of only 20 children limits the generalizability of its findings. Second, its design as a before-and-after self-controlled observational cohort study may restrict the clinical applicability of the results, highlighting the necessity for a randomized controlled trial. Third, the study’s focus on intraoperative data to assess sustained lung function changes leaves questions regarding the impact of individualized lung protective ventilation on postoperative lung function and clinical outcomes. Fourth, the exclusive use of inhaled sevoflurane for anesthesia induction, which can increase patient apprehension and decrease comfort levels, suggests that using propofol for induction in patients who can tolerate intravenous access, particularly those slightly older, might be more beneficial. Lastly, despite employing pulmonary recruitment and individualized PEEP, six children still had positive air tests, indicating that the strategies for lung protection in children require further investigation.

For optimizing ventilation and enhancing lung function in pediatric surgeries, the following clinical protocols and lung-protective ventilation techniques may serve as references: (1) Emphasizing low tidal volume during intraoperative mechanical ventilation is crucial for perioperative lung protection, more so than PEEP, recruitment maneuvers, or their combination.  (2) Pressure-controlled ventilation with volume guarantee has shown superiority over volume-controlled ventilation in providing lower peak inspiratory pressure and improved dynamic compliance in adults undergoing laparoscopic surgery.  Given the physiologic characteristics of children, exploring the use of pressure-controlled ventilation with volume guarantee to reduce the incidence of atelectasis in pediatric laparoscopic surgery is advisable. (3) The impact of varying inspired oxygen fractions on the development of atelectasis in mechanically ventilated patients remains unclear.  Lower concentrations of inhaled oxygen may not effectively reduce the occurrence of atelectasis and postoperative pulmonary complications in children.  (4) Furthermore, a preemptive 2-h session of high-flow nasal oxygen following extubation has been shown to enhance postoperative oxygen exchange and decrease atelectasis compared to traditional oxygen therapy strategies.  High-flow nasal oxygen could also be considered to lower the risk of atelectasis in children undergoing laparoscopic surgery.