Intraoperative mechanical ventilation management in COPD: A state of the art review

Chronic Obstructive Pulmonary Disease (COPD) is a prevalent condition in surgical patients and is recognized as a significant risk factor for negative postoperative outcomes. Such adverse outcomes include increased admissions to intensive care units, extended hospitalizations, prolonged ventilation, and elevated rates of perioperative morbidity and mortality. Intraoperative mechanical ventilation is a crucial strategy for managing COPD and improving postoperative outcomes in this high-risk population. However, typical ventilation measures employed during general anesthesia may exacerbate COPD-related physiological dysfunctions if not appropriately optimized. Patients with COPD are particularly susceptible to expiratory flow limitation, dynamic hyperinflation, Intrinsic Positive End-Expiratory Pressure (PEEPi), and Ventilation-Perfusion (V/Q) mismatch during positive-pressure ventilation. Controlled tidal volumes, longer expiratory duration, appropriate external PEEP, and cautious ventilation mode selection are needed to address these pathophysiological concerns. This narrative review synthesizes the current evidence on preoperative assessments relevant to ventilation in patients with COPD, examines intraoperative ventilation strategies, and highlights the underlying physiological principles and clinical implications of various approaches used during surgery. Overall, the available evidence supports adopting a personalized, patient-guided approach to intraoperative ventilation rather than uniform ventilatory targets. Although COPD is a notable risk factor for respiratory and non-respiratory complications in the perioperative context, there is a lack of studies specifically addressing intraoperative ventilation management in COPD. Therefore, there is a pressing need for future research to inform decision-making for personalized intraoperative ventilation strategies and to improve clinical outcomes and prognosis in this most vulnerable population.