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Hyun Joo Ahn, MD, PhD
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From the Samsung Medical Center, Sungkyunkwan University, School of Medicine-Anesthesiology and Pain Medicine.

Correspondence to: Hyun Joo Ahn, MD, PhD, Samsung Medical Center, Sungkyunkwan University, School of Medicine-Anesthesiology and Pain Medicine, 50, Ilwon-Dong, Kangnam-Gu, Seoul 135-710, Republic of Korea; e-mail: hyunjooahn@skku.edu

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Chest. 2011;140(6):1669. doi:10.1378/chest.11-1943
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Published online

To the Editor:

We thank Dr Djalali for his interest in our recent article1 and would like to respond to his questions. First, the sample size is small (n=50 in each group): There have been no reports, to our knowledge, comparing the incidences of Pao2/Fio2 <300 mm Hg and pulmonary complications between the two ventilation strategies; the sample size was calculated based on previous data, which showed a difference in postoperative Pao2/Fio2 between the conventional strategy and protective strategy (PV) groups2; and 47 subjects in each group were required.

Second, as to the comment about having too many variables (different Fio2, tidal volume, positive end-expiratory pressure, mode of ventilation), there are already a number of reports that used a single element or two elements of PV strategy to see the effect of each element in relation to lung injury.3,4 We applied most of the known elements of PV strategy (small tidal volume, low airway pressure and Fio2, application of positive end-expiratory pressure) to see the total effect of PV strategy. Therefore, including many variables was essential for our study.

Third, as to the problem in randomization (differences in surgeons, postoperative pain control methods, operation methods), those variables were not statistically different between the groups. However, we agree that all these factors may have affected the results to some degree. More strict control of these variables is ideal, and we will do that in future studies.

Finally, as to the question about changing ventilation mode to pressure control in 30% of patients of the conventional strategy group: To keep the peak inspiratory pressure (PIP) <30 mm H2O, which was our protocol, we changed ventilation mode to pressure control in those patients who exceeded this limit. Even though these patients got the advantage of reduced PIP compared with their original values, the benefit of PV was still apparent in our study. These patients were included to show the benefit of pressure control mode in PIP. We hope our answers to the questions posed are helpful.

Yang M, Ahn HJ, Kim K, et al. Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery? A randomized controlled trial. Chest. 2011;1393:530-537 [CrossRef] [PubMed]
 
Michelet P, D’Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;1055:911-919 [CrossRef] [PubMed]
 
Fernández-Pérez ER, Keegan MT, Brown DR, Hubmayr RD, Gajic O. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy. Anesthesiology. 2006;1051:14-18 [CrossRef] [PubMed]
 
Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg. 2003;976:1558-1565 [CrossRef] [PubMed]
 

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References

Yang M, Ahn HJ, Kim K, et al. Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery? A randomized controlled trial. Chest. 2011;1393:530-537 [CrossRef] [PubMed]
 
Michelet P, D’Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;1055:911-919 [CrossRef] [PubMed]
 
Fernández-Pérez ER, Keegan MT, Brown DR, Hubmayr RD, Gajic O. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy. Anesthesiology. 2006;1051:14-18 [CrossRef] [PubMed]
 
Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg. 2003;976:1558-1565 [CrossRef] [PubMed]
 
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