Pathogenesis and management of respiratory insufficiency following pulmonary resection

The underlying principle of the surgical treatment of non-small-cell lung c ancer (NSCLC) is complete removal of the local/regional disease within the thorax. Pulmonary resection should be as conservative as possible without c ompromising the adequacy of tumor removal. A multitude of factors influence the incidence and severity of complications following pulmonary resection including the pre-operative physical and psychological status of the patien t, the pathologic process requiring resection, the physiologic impact of th e procedure, and the addition of pre-operative or postoperative adjuvant th erapy. The insidious onset of interstitial changes on chest X-ray (CXR) 1 t o 2 days after pulmonary resection forewarns of respiratory distress; howev er, the pathophysiology of adult respiratory distress syndrome (ARDS) with progression to respiratory failure requiring mechanical ventilation and adv anced critical care often unfolds. Management of patients with severe respi ratory failure remains primarily supportive. "Good critical care" is the ma instay of therapy: this includes gentle mechanical ventilation to avoid ven tilator-induced barotrauma and over-extension of remaining functional alveo li, diuresis, infection identification and management, and nutritional supp ort. New therapeutic strategies that may impact on outcomes in the adult po pulation include pressure-limited ventilation (permissive hypercapnia), inv erse ratio ventilation, high-frequency jet ventilation, high-frequency osci llatory ventilation, intratracheal pulmonary ventilation, and prone positio n ventilation. In addition, alternative therapies such as partial liquid ve ntilation, inhaled nitric oxide, and extracorporeal techniques including ex tracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide rem oval (ECCO2R), intravascular oxygenation (IVOX), and arteriovenous carbon d ioxide removal (AVCO(2)R), provide additional modalities. A component of so me or all of these strategies is finding a role in clinical practice. (C) 2 000 Wiley-Liss, Inc.