Clinical guidelines on perioperative management strategies for enhanced recovery after lung surgery

The concept of enhanced recovery after surgery (ERAS) was first developed in Denmark in 1997 by Dr. Kehlet (1). ERAS is designed to optimize perioperative management, improve patient prognosis, reduce complications, shorten hospital stay, and lower cost (2-5). In recent years, this multi-disciplinary and multi-modal perioperative rehabilitation concept has been widely applied in open and endoscopic procedures including colorectal surgery (6,7), gynecological surgery (8,9), liver surgery (10,11), breast surgery (12,13), urologic surgery (14,15), and spinal surgery (16-18). Advances in thoracic surgery, especially the popularization of minimally invasive techniques, have dramatically expanded or changed the concept of surgical treatment (19-21). Early recovery from thoracic surgery is now routine (22-24). In Jan 2019, the European Society of Thoracic Surgeons published guidelines for enhanced recovery after lung surgery (25) on: preoperative counselling, nutritional screening, smoking cessation, rehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anesthetics to facilitate early emergence, regional anesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters, and early mobilization after surgery. The lung is a unique organ in that it receives the total cardiac output and acts as a giant filter for systemic venous blood (26). It is, in addition, an open organ; through the airway, the alveoli interact with the surrounding environment. Due to its unique anatomy and physiology, the lung is susceptible to injuries caused by a variety of harmful endogenous and exogenous factors (27). Perioperative risk factors and treatment measures can result in damage to the lungs, which in turn can lead to postoperative pulmonary complications (PPCs) (e.g., atelectasis and pneumonia) and pleural complications, affecting early and long-term recovery (28-30), and accounting for up to 84% of all deaths (31). Perioperative airway and protective ventilatory management in lung surgery are an important part of ERAS (32,33). Given the circumstances, we have established clinical guidelines based primarily on an extensive literature review, with discussion and consensus focused on the issue of perioperative airway management for enhanced recovery following lung surgery. In addition, we will briefly review other perioperative measures designed toward the goal of ERAS for thoracic surgery.