• E R Fernández-Pérez, J Sprung, B Afessa, D O Warner, C M Vachon, D R Schroeder, D R Brown, R D Hubmayr, and O Gajic.
• Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Jewish Health, 1400 Jackson Street, G10a, Denver, CO 80206, USA. FernandezEvans@njc.org
• Thorax. 2009 Feb 1;64(2):121-7.

BackgroundWhile acute lung injury (ALI) is among the most serious postoperative pulmonary complications, its incidence, risk factors and outcome have not been prospectively studied.ObjectiveTo determine the incidence and survival of ALI associated postoperative respiratory failure and its association with intraoperative ventilator settings, specifically tidal volume.DesignProspective, nested, case control study.SettingSingle tertiary referral centre.Patients4420 consecutive patients without ALI undergoing high risk elective surgeries for postoperative pulmonary complications.MeasurementsIncidence of ALI, survival and 2:1 matched case control comparison of intraoperative exposures.Results238 (5.4%) patients developed postoperative respiratory failure. Causes included ALI in 83 (35%), hydrostatic pulmonary oedema in 74 (31%), shock in 27 (11.3%), pneumonia in nine (4%), carbon dioxide retention in eight (3.4%) and miscellaneous in 37 (15%). Compared with match controls (n = 166), ALI cases had lower 60 day and 1 year survival (99% vs 73% and 92% vs 56%; p<0.001). Cases were more likely to have a history of smoking, chronic obstructive pulmonary disease and diabetes, and to be exposed to longer duration of surgery, intraoperative hypotension and larger amount of fluid and transfusions. After adjustment for non-ventilator parameters, mean first hour peak airway pressure (OR 1.07; 95% CI 1.02 to 1.15 cm H(2)O) but not tidal volume (OR 1.03; 95% CI 0.84 to 1.26 ml/kg), positive end expiratory pressure (OR 0.89; 95% CI 0.77 to 1.04 cm H(2)O) or fraction of inspired oxygen (OR 1.0; 95% CI 0.98 to 1.03) were associated with ALI.ConclusionALI is the most common cause of postoperative respiratory failure and is associated with markedly lower postoperative survival. Intraoperative tidal volume was not associated with an increased risk for early postoperative ALI.

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