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1. Acute lung injury and outcomes after thoracic surgery Marc Lickera, Pascal Fauconneta, Yann Villigera and Jean-Marie Tschoppb a Department of Anaesthesiology, Pharmacology and Purpose of review Intensive Care, rue Micheli-du-Crest, University Hospital of Geneva, Geneva and bDepartment of The present review evaluates the evidence available in the literature tracking Internal Medicine, Chest Medical Centre, Montana, perioperative mortality and morbidity as well as the pathogenesis and management of Switzerland acute lung injury (ALI) in patients undergoing thoracotomy. Correspondence to Marc Licker, MD, Service Recent ﬁndings ´ ˆ ` d’Anesthesiologie, Hopitaux Universitaires de Geneve, Rue Micheli-du-Crest, CH-1211 Geneva, Switzerland Over the last decade, despite increasing age and comorbid conditions, the operative Tel: +41 22 3827439; fax: +41 22 3827403; mortality has remained unchanged for patients undergoing lung resection, whereas e-mail: email@example.com procedure-related complications have declined. Better clinical outcomes are achieved Current Opinion in Anaesthesiology 2009, in high-volume hospitals and when procedures are performed by a thoracic surgeon. 22:61–67 Postthoracotomy ALI has become the leading cause of operative death, its incidence has remained stable (2–5%) and earlier diagnosis can be made by assessing the extravascular lung water volume with the single-indicator dilution technique. The pathogenesis of ALI implicates a multiple-hit sequence of various triggering factors (e.g. oxidative stress and surgical-induced inﬂammation) in addition to injurious ventilatory settings and genetic predisposition. Summary Knowledge of the perioperative risk factors of major complications and understanding of the mechanisms of postthoracotomy ALI enable anesthesiologists to implement ‘protective’ lung strategies including the use of low tidal volume (VT) with recruitment maneuvers, a goal-directed ﬂuid approach and prophylactic treatment with inhaled b2-adrenergic agonists. Keywords acute lung injury, lung resection, mechanical ventilation, thoracotomy, tidal volume Curr Opin Anaesthesiol 22:61–67 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 0952-7907 Introduction Risk factors of operative mortality Thoracotomies with lung resection are classiﬁed as inter- Outcomes following lung resection largely differ between mediate-to-major surgical procedures with in-hospital specialized and nonspecialized medical centres. mortality rates expected to be less than 2% for lobectomy Mortality rates as low as 2.2% have been reported in a and less than 6% for pneumonectomy [1,2]. Among French survey including 15 183 patients managed by 512 578 thoracic procedures performed from 1988 to specialized thoracic teams, whereas fatality rates as high 2002 in the United States, several changes have been as 12% have been observed in the US nationally repre- identiﬁed: surgical candidates are more likely to be older sentative samples of Medicare patients aged over 65 years (mean age of 63 years), women (40%) and to undergo [4,5]. Qualiﬁed cardiothoracic surgeons devoting their lobectomy instead of pneumonectomy due to earlier practice entirely or mainly to thoracic surgery achieve diagnosis of cancer stages . Despite higher comorbid better results than nonspecialized surgeons . Improved status, operative mortality has remained unchanged and short and long-term results are also achieved in hospitals the length of hospital stay has become shorter along with with a high volume of any complex procedure, emphasiz- a reduction of procedure-related complications. Nowa- ing the key role of multidisciplinary teams, the avail- days, the main causes of mortality have shifted from ability of intensive care resources with an acute pain cardiac and surgical complications towards infectious service as well as the implementation of scientiﬁcally complications (pneumonia, empyema and sepsis) and evidence-based practices [7,8]. the acute lung injury (ALI) syndrome with its most severe form the acute respiratory distress syndrome Apart from these organizational factors, analysis of the (ARDS). European Thoracic Surgery Database and of the French 0952-7907 ß 2009 Wolters Kluwer Health | Lippincott Williams Wilkins DOI:10.1097/ACO.0b013e32831b466c Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
62 Thoracic anaesthesia Table 1 Overview of studies on the postthoracotomy acute lung injury syndrome Incidence (%) Reference n Risk factors Overall P L L Mortality (%) Licker et al.  879 MV, high Pinsp aw, ﬂuid overload (ﬁrst 24 h), 4.2 8.4 3.1 3.4 37 pneumonectomy, alcohol abuse Rufﬁni et al.  1221 NA 2.2 3.8 2 3.2 52 Kutlu et al.  1139 Age 60 years, male sex, lung cancer, extended 3.9 6 3.7 1 64 resection Alam et al.  1428 ppoFEV1, ppoDLC0, ﬂuid overload (intraoperative) 3.1 10.1 5.5 4.1 25 Dulu et al.  2192 NA 2.5 7.9 3 0.9 40 Fernandez-Perez  170a High VT (8.3 vs. 6.7 ml/kg), ﬂuid overload NA 8.8 40 (intraoperative) van der Werff et al.  197 MV, high Pinspir aw, fresh-frozen plasma 2.5 100 Turnage et al.  806 NA 2.6 100 Verheijen-Breemhar et al.  243 NA 4.5 27 Waller et al.  205 NA 4.4 56 Algar et al.  242a Operative time, ppoFEV1, prior cardiac disease, 2.5 2.5 COPD, no chest therapy (preoperative) Song et al.  635 NA 3.6 48 Katzenelson et al.  146a Prior chemotherapy, prior chemotherapy, FEV1 15 15 45% predicted, predicted postoperative lung perfusion 55%, ﬂuid overload (intraoperative) COPD, chronic obstructive pulmonary disease; L, lesser resection than lobectomy; L, lobectomy; MV, mechanical ventilation; Pinspir aw, inspiratory airway pressure; P, pneumonectomy; ppoDLCO, predicted postoperative diffusion lung capacity to carbon monoxide; ppoFEV1, predicted post- operative forced expiratory volume in 1 s; VT, tidal volume; NA, not applicable. a Only pneumonectomy cases. national dataset have identiﬁed independent risk factors from almost 100% to less than 40% owing to improved of perioperative death: age, male sex, dyspnea score, ICU medical management (Table 1) [11–22]. functional performance status, American Society of Anesthesiologists (ASA) score and the extent of surgical New semiinvasive monitoring tools have appeared in the resection [4,9]. These models of risk have been validated perioperative arena providing valuable information for in second sets of population, with good predictive accu- early diagnosis of ALI and haemodynamic treatment. racies (c-index ! 0.85). The single-indicator thermal dilution method (Pulsion, Munich, Germany) has been validated against the gravi- metric method to assess the extravascular lung water Epidemiology and diagnostic criteria of acute index (EVLWI) . This simple technique has proven lung injury sensitive to detect infraclinical variations in EVLWI, to The guidelines set out by the American–European estimate a pulmonary vascular permeability index while Consensus Conference on ARDS have been widely monitoring cardiac output using pulse contour analysis of adopted to describe postthoracotomy ALI, previously the arterial pressure . Pulmonary artery catheters coined postpneumonectomy pulmonary oedema, low- have been replaced by ultrasound imaging for cardiocir- pressure oedema or permeability pulmonary oedema. culatory assessment. Chest ultrasound scans can also be Although the diagnosis of ALI/ARDS relies on speciﬁc used to detect excess lung water content. ‘Comet-tail criteria [acute onset of hypoxemia, arterial oxygen pres- images’ fanning out from the lung surface and originating sure (PaO2)/fraction of inspired oxygen (FIO2) less than from water-thickened interlobular septa have been 300 for ALI and less than 200 for ARDS, diffuse radio- shown to correlate closely with lung water content logical inﬁltrates and no evidence of elevated hydrostatic [25,26]. capillary pressure], a wide spectrum of lung injuries is encountered . Importantly, two clinical patterns of postthoracotomy ALI should be distinguished corre- Clinical risk factors and pathophysiology of sponding to different pathogenic triggers: ALI develop- postthoracotomy acute lung injury ing within 48–72 h after lung resection (primary ALI) and Several risk factors of the early form of postthoracotomy a delayed form triggered by postoperative complications ALI have been identiﬁed in cohorts of thoracic surgical such as bronchoaspiration or pneumonia . patients. Using multivariate regression analysis, the strongest predictors of postthoracotomy ALI are related Contrasting with other cardiopulmonary complications, to the preoperative condition of the patient (severe the incidence of postthoracotomy ALI has not shown any pulmonary dysfunction and chronic alcohol consump- noticeable decrease over the last two decades (between 2 tion) and to perioperative medical care (extended lung and 4%) although the case-fatality rate has decreased resection, ‘injurious’ ventilation and ﬂuid overhydration) Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
ALI and outcomes after thoracic surgery Licker et al. 63 . Moreover, the occurrence of ALI is more frequently [e.g. antioxidant, heat-shock protein, p75 receptor for reported after right pneumonectomy in elderly patients tumor necrosis factor (TNF)-a] counteract the initial with colonized airways or in those requiring multiple inﬂammatory and oxidative responses [38,39]. The in- transfusions or receiving neoadjuvant chemoradiotherapy creased permeability of the alveolar–capillary barrier along [27–29]. with a decreased lung compliance initially results from the disruption of intercellular endothelial cell junction, cytos- Rather than a uniﬁed stereotyped response, a multiple- keleton contraction and alveolar cell death consequent hit sequence of deleterious events likely interacts to activation of endothelial/epithelial cell receptors by resulting in alveolar epithelial and capillary endothelial systemic/alveolar inﬂammatory mediators [e.g. thrombine, injuries, with alterations in extracellular matrix (ECM), vascular endothelial growth factor (VEGF), transforming ultimately leading to the characteristic histopathological growth factor-beta (TGF-b) and thromboxane A2 (TxA2)] features of ALI . [40–42]. The ‘neutrophil hypothesis’ suggests that circulating Clinical studies neutrophils are activated by proinﬂammatory mediators In the ICU setting, the beneﬁts of a protective lung such as granulocyte and macrophage–colony stimulating ventilation (PLV) strategy have been clearly documented factors in concert with various chemokines. These neu- in large observational studies and meta-analysis of random- trophils experience delayed apoptosis and sustained ized controlled trials (RCTs) . In clinical practice, PLV release of proteolytic enzymes, reactive oxygen inter- entails the delivery of low VT (less than 7 ml/kg) with mediates/reactive nitrogen intermediates (ROIs/RNIs) pressure-limited ventilation (less than 30 cm of H2O) and as well as proinﬂammatory mediators . the application of positive end-expiratory pressure (PEEP) with periodic recruitment maneuvers . The ‘epithelial hypothesis’ emphasizes the role of both lung parenchymal cell apoptosis and chemotactic/inﬂam- During short periods of mechanical ventilation (4–6 h), matory responses, which are associated with increased atelectatic areas are common and so-called ‘low-volume’ expression of Fas on epithelial cells, along with enhanced injuries may result from repetitive opening and closing of extravasation of Fas ligand-expressing cells . unstable lung units owing to inactivation of surfactant and excessive mechanical stress between neighboring lung Ventilatory strategy areas [45,46]. Recent experimental and clinical studies have empha- sized the ‘injurious’ aspects of physical stress and hyper- Several RCTs including surgical patients with healthy oxia associated with mechanical ventilation that may lungs have questioned whether different ventilatory set- trigger inﬂammatory changes at the alveolar–capillary tings could modulate pulmonary/systemic inﬂammation barrier in ‘vulnerable’ surgical patients as characterized while inﬂuencing oxygenation index and respiratory by genetic factors, disrupted lympathic vessels and pro- mechanical properties . As summarized in Table 2 inﬂammatory circulating mediators associated with pre- [48–59], no beneﬁt could be demonstrated by varying the existing lung disease or surgical trauma. VT for surgical procedures lasting less than 5 h [48,49]. In contrast, in all studies, except one including more severe Basic science surgical stresses (e.g. major operations exceeding 5 h and Even ‘physiological’ low VT (4–8 ml/kg) delivered over cardiac surgery), intraoperative ventilation with lower VT several hours in healthy lungs may produce subtle lung (5–6 ml/kg) and PEEP was associated with stable or injuries: neutrophil inﬁltration, rupture of alveolar–bron- improved oxygenation, reduced expression of alveolar chial attachment and chondroitin–sulfate proteoglycan and systemic inﬂammation and reduced procoagulant fragmentation in the ECM . With larger VT, there is activity in the bronchoalveolar lavage ﬂuid (BALF) [50– further macromolecular fragmentation, activation of 55]. In agreement with these data, Lee et al.  reported a matrix metalloprotease and upregulation of collagen syn- trend for lower incidence in pulmonary complications and thesis in the ECM that represent an autoregulatory for shorter intubation periods in patients ventilated with response to maintain low pulmonary compliance while small VT (6 vs. 12 ml/kg) after major noncardiac surgery. protecting the ECM against ﬂuid overload [34–36]. Inter- estingly, induction of unilateral ventilator-induced injury In patients undergoing thoracotomy and requiring one- (VILI) in one lung with high VT does not trigger a lung ventilation (OLV), three RCTs have evaluated concomitant inﬂammatory response in the contralateral the impact of different ventilatory settings. Schilling normally ventilated lung . et al.  found reduced alveolar concentrations of TNF-a and soluble intercellular adhesion molecules Ventilation with large VT is not sufﬁcient per se to induce (ICAMs) in patients ventilated with small vs. large VT ALI in healthy lungs, as defense and repair mechanisms (5 vs. 10 ml/kg). Conﬁrming these positive results, Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
64 Thoracic anaesthesia Table 2 Randomized controlled trials assessing the effects of different modes of ventilation Reference n Type of surgery Ventilation strategy Effects of low vs. high VT Two-lung ventilation Wrigge et al.  39 Visceral, orthopedic 5 ml/kg ZEEP vs. 5 ml/kg Similar plasma cytokine levels and vascular 10 cmH2O PEEP vs. 15 ml/kg 10 PEEP Wrigge et al.  32 Visceral 6 ml/kg 10 cmH2O PEEP Similar time course of cytokines in tracheal vs. 12–15 ml/kg ZEEP aspirate and plasma Choi et al.  40 Visceral 6 ml/kg cmH2O PEEP Thrombin–antithrombin complex, activated vs. 12 ml/kg ZEEP protein C in BALF, thrombomodulin in BALF Wolthuis et al.  40 Visceral 6 ml/kg 10 cmH2O PEEP Similar levels of TNF-a, IL-1, MIP-1 in BALF, vs. 12 ml/kg ZEEP IL-8 in BALF, myeloperoxidase and elastase in BALF, similar levels of IL-6 and IL-8 in plasma Reis-Miranda et al.  62 Cardiac 4–6 ml/kg 10 cmH2O IL-8 and IL-10 in plasma PEEP þ RM vs. 6–8 ml/kg 3 cmH2O PEEP Chaney et al.  25 Cardiac 6 ml/kg 10 cmH2O PEEP PaO2/FIO2, static lung compliance vs. 12 ml/kg ZEEP Zupancich et al.  40 Postcardiac 6 ml/kg 10 cmH2O PEEP IL-6 and IL-8 in BALF and plasma vs. 10–12 ml/kg 3 cmH2O PEEP Koner et al.  44 Cardiac 6 ml/kg 5 cmH2O PEEP Similar plasma TNF-a and IL-1, similar vs 0.10 ml/kg ZEEP vs. PaO2/FIO2 10 ml/kg 10 cmH2O PEEP Lee et al.  103 General 6 vs. 12 ml/kg Pulmonary infection, duration of MV Wrigge et al.  44 Cardiac 6 ml/kg 10 PEEP TNF-a in BALF, similar plasma cytokine levels vs. 12 ml/kg ZEEP One-lung ventilation Wrigge et al.  32 Lung resection 6 ml/kg 10 cmH2O PEEP Similar time course of cytokines in tracheal vs. 12–15 ml/kg ZEEP aspirate and plasma Schilling et al.  32 Lung resection 5 ml/kg ZEEP vs. 10 ml/kg ZEEP TNF-a and sICAM in BALF, similar levels of albumine, elastase, IL-8 and IL-10 Michelet et al.  52 Esophagectomy 5 ml/kg 5 cmH2O PEEP vs. IL-1, IL-6, IL-8 in plasma, PaO2/FiO2 and 9 ml/kg ZEEP lung water content, duration of MV BALF, bronchoalveolar lavage ﬂuid; MV, mechanical ventilation; PaO2/FIO2, ratio of arterial oxygen pressure to fractional inspiratory oxygen pressure; PEEP, positive end-expiratory pressure; RM, recruitment maneuver; sICAM, soluble intercellular adhesion molecules; TNF, tumor necrosis factor; ZEEP, zero-end expiratory pressure. Michelet et al.  reported an attenuated systemic proin- trigger formation of ROIs/RNIs and induce complex ﬂammatory response [lower plasma levels of interleukin patterns of cell death. These ﬁndings have been con- (IL)-6], reduced EVLWI and improved oxygenation index ﬁrmed in animal and human studies. allowing earlier extubation in patients undergoing esopha- gectomy who received low VT (5 ml/kg) with a PEEP level In rabbits ventilated with large VT and moderate hyperoxia of 5 cmH2O (compared with VT of 10 ml/kg with zero (FIO2 ¼ 0.5), Sinclair et al.  reported a loss of alveolar– PEEP). In contrast, Wrigge et al.  failed to document capillary barrier integrity and larger increase in local any difference in systemic inﬂammatory markers, blood inﬂammatory mediators (IL-8 and TNF-a) than animals oxygenation index and respiratory mechanics between exposed either to room air or to hyperoxia without large VT. thoracic surgical patients assigned to receive either mech- Consistent with these results, Funakoshi et al.  anical ventilation with VT of 6 ml/kg and PEEP of reported an upregulation of proinﬂammatory cytokines 10 cmH2O or a VT of 12–15 ml/kg without PEEP. and myeloperoxidase upon reventilation, though indices of pulmonary capillary permeability remained unchanged. Although a growing body of scientiﬁc knowledge indicates Likewise, in anesthetized pigs subjected to thoracotomy that the ‘traditional’ ventilatory settings may be injurious and OLV (VT of 10 ml/kg, PEEP of 5 cmH2O and FIO2 of in the healthy lungs, a clear demonstration of clinical 0.4), Kozian et al.  showed hyperperfusion, ventilation– outcome beneﬁts induced by LPV is still lacking. There- perfusion mismatch and diffuse tissue damage that pre- fore, we are awaiting the results of well designed RCTs dominated in the dependent nonoperated lung. with sufﬁcient power and pertinent clinical endpoints, comparing conventional ventilation to LPV protocols. In three patients with reexpansion pulmonary oedema, Her and Mandy  observed leukocyte-mediated ALI Hyperperfusion and oxidative injuries in the contralateral lung along with decreased leuko- In-vitro studies have shown that cyclic stretch and hyper- cytes and platelet counts upon reoxygenation of the col- oxic exposure of lung epithelial and endothelial cells lapsed lung. In another clinical study involving patients Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
ALI and outcomes after thoracic surgery Licker et al. 65 undergoing lobectomy, Cheng et al.  reported for- have been incriminated as initiating or aggravating factors mation of ROIs during lung reinﬂation after OLV (VT of . Likewise, the interactions with ROIs/RNIs and 10 ml/kg and FIO2 of 1.0) although antioxidant markers nuclear factor-kB-dependent activation of the inducible and EVLWI remained unchanged. nitric oxide synthase may result in downregulation of b2- adrenergic receptor in response to surgical trauma and Taken together, these data suggest that hyperoxic/ OLV/reoxygenation. Hence, early and severe interstitial/ mechanical injuries predominate in the nonoperated alveolar lung edema may develop in patients with lung, whereas the operated lung is prone to atelectasis deﬁcient b-adrenergic-mediated ﬂuid clearance mechan- formation due to impaired surfactant and direct surgical isms. manipulation. An imbalance between antioxidants and excess production of RNIs/ROIs has been incriminated in perpetuating the inﬂammatory process and causing Novel perioperative approaches cellular damage by oxidizing nucleic acids, proteins and Preliminary data suggest some advantages for volatile membrane lipids . anesthetics during OLV. Indeed, desﬂurane has been associated with lesser recruitment of neutrophils and Genetic factors reduced concentrations of inﬂammatory biomarkers in Only a fraction of patients exposed to ALI-inciting events the BALF [elastase, soluble intercellular adhesion mol- progress to the full clinical syndrome. Hence, major ecules (sICAM), TNF-a, IL-8 and IL-10] than propofol interest has been focused on the identiﬁcation of genetic anesthesia . factors characteristic of ALI susceptibility. Relevant gene variants or single-nucleotide polymorphisms (SNPs) in Regarding ventilatory settings, the emerging concept of these ALI candidate genes have been tested for differ- PLV based on the ‘open-lung approach’ aims to limit ences in allelic frequency in cohort studies . This alveolar distension with low (but physiological) VT while approach has yielded a number of candidate genes con- attenuating the loss of functional residual volume and tributing towards an ALI phenotype, namely genes cod- preventing the formation of atelectasis with PEEP and ing for angiotensin-converting enzyme (ACE), surfactant lung recruitment maneuvers [74,75]. Using ‘low VT’ protein B, heat-shock protein 70, pre-B-cell colony combined with PEEP does not favor the development enhancing factor, myosin light-chain kinase and macro- of atelectasis, whereas the pressure-controlled mode of phage migration inhibitory factor. ventilation (vs. volume-controlled mode) may lower peak airway pressure with similar blood oxygenation indices, at Using microarray technology, the transcription factor least in patients without severe lung disease [76,77]. Nrf2 (NF-E2 related factor 2) has been shown to up- regulate the protective detoxifying enzymes in response Controversies still surround the question of the optimal to oxidative stress . Genetic disruption of the Nrf2 FIO2; high levels (60–80%) may reduce the risk of surgi- has been associated with an overexpression of proinﬂam- cal-site infections but promote atelectasis and ROI for- matory cytokines and increased risk of ALI due to hyper- mation . Conversely, low–moderate FIO2 (30–50%) oxia and high VT. In line with these results, Marzec et al. might be an appropriate compromise to ensure satisfactory  identiﬁed six novel SNPs for Nrf2 in a nested case– blood oxygenation and limit secondary lung injuries. control study. Patients with the À617 SNP (A/or C/A allele) were at greater risk of posttrauma ALI relative to Considering the importance of the hydrostatic pulmonary patients bearing the wild type (À617 C) [odds ratio (OR) pressure, a restrictive or goal-directed ﬂuid approach 6.4; 95% conﬁdence interval (CI) 1.3–30.8]. coupled with the assessment of intrapulmonary ﬂuid volume is strongly recommended for the intraoperative In patients undergoing esophagectomy (n ¼ 152), pul- period and the ﬁrst 24–48 h after major lung resection. monary morbidity has been associated with an ACE insertion/deletion polymorphism; the D/D genotype Postoperatively, high-risk thoracic patients may beneﬁt was found to be highly predictive of major pulmonary from noninvasive ventilation and inhaled b2-adrenergic complications (adjusted OR 3.12; 95% CI 1.01–9.65) . therapy. In a small RCT including 32 patients with a moderate degree of chronic obstructive pulmonary dis- Edema clearance mechanisms ease, better postoperative recovery of pulmonary func- Removal of the excess intraalveolar ﬂuid is mainly inﬂu- tion was reported when noninvasive pressure support enced by epithelial b-adrenergic receptors and lectin-like ventilation was applied prophylactically before and domain of TNF-a that regulate the active sodium trans- shortly after lung resection . In 21 patients at high port through alveolar type I and II cells [70–72]. In heart risk of pulmonary edema from either a cardiogenic or failure, high-altitude lung edema and various models of noncardiogenic cause, the impact of aerosolized broncho- ALI, alterations in these b-adrenergic signaling pathways dilators has been investigated using the single-dilution Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
66 Thoracic anaesthesia 9 Berrisford R, Brunelli A, Rocco G, et al. The European Thoracic Surgery indicator method . Using a crossover design, salbu- Database project: modelling the risk of in-hospital death following lung tamol (vs. ipratropium) was shown to accelerate the resection. Eur J Cardiothorac Surg 2005; 28:306–311. resolution of postoperative lung edema and improve 10 Villar J, Perez-Mendez L, Lopez J, et al. An early PEEP/FIO2 trial identiﬁes different degrees of lung injury in patients with acute respiratory distress blood oxygenation without causing adverse cardiac syndrome. Am J Respir Crit Care Med 2007; 176:795–804. events. In addition, b2-adrenergic agonists may also pre- 11 Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury vent or attenuate ALI by blunting the release of proin- after thoracic surgery for lung cancer. 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