Intraoperative ventilation strategies during thoracic surgery to reduce the perioperative inflammatory response: a narrative review from in vivo to clinical evidence

Summary: General thoracic surgery encompasses a range of procedures requiring one-lung ventilation. This technique is essential for surgical exposure but is associated with significant physiological changes that contribute to both local and systemic inflammatory responses from tissue injury. This narrative review summarises perioperative ventilation strategies aimed at minimising lung injury and inflammation, focusing on their impact on inflammatory markers. A literature search was conducted in PubMed, MEDLINE, and Embase up to July 2025, excluding non-English articles. When positive pressure ventilation is used, protective ventilation strategies including low tidal volume (5–6 ml kg −1 ), individualised PEEP, and adaptive control or pressure-controlled ventilation seem to confer advantages in terms of inflammatory outcomes and ventilator-induced lung injury. Careful titration of inspired oxygen is essential in the balancing of adequate oxygenation with the risk of oxidative damage. Partial lung collapse or continuous application of positive airway pressure in the non-ventilated lung may help attenuate tissue injury from atelectasis and re-expansion injury. In selected patients, non-intubated video-assisted thoracoscopic surgery can potentially result in the attenuation of perioperative inflammatory responses by eliminating positive pressure ventilation entirely, although clinical evidence remains limited. Although these strategies have been shown to result in consistent attenuation of perioperative inflammatory responses, their translation into clinical outcomes was found to be inconsistent across the reviewed studies. Further well-designed studies with standardised cytokine measurement methodology and validated clinical endpoints are needed to establish definitive perioperative ventilation recommendations during one-lung ventilation.