Impact of Chest Wall on Respiratory Mechanics, Ventilation and Ventilation-Perfusion Matching During Cardiac Surgery

To evaluate how sternotomy and subsequent sternal closure affect respiratory mechanics, ventilation heterogeneity, ventilation-perfusion (V/Q) matching, and oxygenation in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Prospective consecutive self-controlled clinical investigation.

A university hospital.

53 patients undergoing elective cardiac surgery.

Measurements performed at 4 protocol stages: before sternotomy, immediately after sternotomy, after weaning from CPB, and after sternal closure.

Respiratory mechanics (airway resistance, tissue damping, and elastance) were assessed using forced oscillations, and ventilation heterogeneity was evaluated via capnographic slopes (phase 2 and phase 3). Physiologic dead spaces (Bohr and Enghoff fractions), V/Q matching, and oxygenation (partial pressure of oxygen [PaO₂]/fraction of inspired oxygen [FiO₂] ratio, intrapulmonary shunt fraction) were analyzed as well. Sternotomy significantly improved airway resistance (-30%), tissue damping (-25%), and elastance (-35%), thereby enhancing ventilation homogeneity (phase 3 slope reduced by 20%; p < 0.001). Conversely, CPB markedly deteriorated respiratory mechanics and ventilation efficiency (airway resistance, +45%; elastance, +50%; p < 0.001). Sternal closure led to further worsening in respiratory mechanics and ventilation heterogeneity, although without any additional significant impact on V/Q matching or oxygenation parameters (PaO₂/FiO₂ were unchanged after closure).

Reestablishing chest wall integrity significantly deteriorates respiratory mechanics and ventilation homogeneity, mirroring improvements initially gained from sternotomy. The absence of additional V/Q mismatch underscores the protective role of pulmonary vascular regulation.