Deutschlandweite Umfrage zur Thoraxanästhesie

Perioperative pain management in thoracic surgery: A survey of practices in Australia and New Zealand

There are few data on current trends in pain management for thoracic surgery in Australia and New Zealand. Several new regional analgesia techniques have been introduced for these operations in the past few years. Our survey aimed to assess current practice and perceptions towards various modalities of pain management for thoracic surgery among anaesthetists in Australia and New Zealand. A 22-question electronic survey was developed and distributed in 2020 with the assistance of the Australian and New Zealand College of Anaesthetists Cardiac Thoracic Vascular and Perfusion Special Interest Group. The survey focused on four key domains-demographics, general pain management, operative technique, and postoperative approach. Of the 696 invitations, 165 complete responses were obtained, for a response rate of 24%. Most respondents reported a trend away from the historical standard of thoracic epidural analgesia, with a preference towards non-neuraxial regional analgesia techniques. If representative of anaesthetists in Australia and New Zealand more widely, this trend may result in less exposure of junior anaesthetists to the insertion and management of thoracic epidurals, potentially resulting in reduced familiarity and confidence in the technique. Furthermore, it demonstrates a notable reliance on surgically or intraoperatively placed paravertebral catheters as the primary analgesic modality, and suggests the need for future studies assessing the optimal method of catheter insertion and perioperative management. It also gives some insight into the current opinion and practice of the respondents with regard to formalised enhanced recovery after surgery pathways, acute pain services, opioid-free anaesthesia, and current medication selection.

Anästhesie bei einer thoraxchirurgischen Patientin mit kongenitaler Muskeldystrophie Typ Ullrich

Die kongenitale Muskeldystrophie Typ Ullrich (UCMD) ist eine seltene Erkrankung. Weltweit wurden bislang 50 Fälle genetisch gesichert. Autosomal-dominante und rezessive Mutationen des COL6A1/COL6A2 im Chromosom 21q22.3 oder des COL6A3 im Chromosom 2q37.3 führen zu einem Mangel an Kollagen VI. Typische Merkmale der UCMD sind Muskelschwäche von Körperstamm und Extremitäten, Hyperflexibilität der distalen und Kontrakturen der proximalen Gelenke, Rollstuhlpflichtigkeit im Alter von 9 bis 11 Jahren, Versteifung und Skoliose der Wirbelsäule und eine progrediente restriktive Ventilationsstörung. Etwa 50 % der Kinder benötigen im Alter von 11 bis 12 Jahren eine nichtinvasive Ventilation (NIV), wozu auch eine gestörte Funktion des Diaphragmas beiträgt. Es wird über die Narkose bei einer 21-jährigen Patientin mit einer UCMD berichtet, die seit dem 6. Lebensjahr rollstuhlpflichtig war und bei der seit 2018 eine lebenserhaltene NIV erfolgte. Wegen einer subpleuralen Einblutung in den linken Lungenunterlappen nach Entlastung eines Pneumothorax wurde eine videoassistierte thorakoskopische Chirurgie (VATS) vorgenommen. Die spezifischen Anforderungen durch die UCMD, das Atemwegsmanagement für die Einlungenventilation sowie Aspekte zur Auswahl der Anästhetika werden diskutiert. Nach erfolgreicher VATS konnte die Patientin am 7. postoperativen Tag in die Häuslichkeit entlassen werden.

[Anaesthetic Management of Non-intubated Video-assisted Thoracic Surgery]

Non-intubated thoracic surgery is currently gaining popularity. In select patients and in experienced centres, non-intubated approaches may enable patients to safely undergo thoracic surgical procedures, who would otherwise be considered at high risk from general anaesthesia. While non-intubated techniques have been widely adopted for minor surgical procedures, its role in major thoracic surgery is a topic of controversial debate.This article discusses disadvantages of intubated anaesthetic approaches and advantages of non-intubated thoracic surgery as well as the anaesthetic management. This includes surgical and anaesthetic criteria for patient selection, suitable regional anaesthetic techniques, concepts for sedation and maintenance of airway patency as well as the management of perioperative complications.Non-intubated thoracic surgery has the potential to reduce postoperative morbidity and hospital length of stay. Successful non-intubated management depends on a standardised and well-trained interdisciplinary approach, especially regarding patient selection and perioperative complications.

[Current approaches to anesthetic management in thoracic surgery-An evaluation from the German Thoracic Registry]

BACKGROUND

While many hospitals in Germany perform thoracic surgery, anesthetic techniques and methods that are actually used are usually only known for individual departments. This study describes the general anesthetic management of three typical thoracic surgical procedures across multiple institutions.

MATERIAL AND METHODS

The German Thoracic Registry recorded 4614 patients in 5 institutions between 2016 and 2019. Hospitals with a minimum number of more than 50 thoracic procedures per year are eligible for inclusion in the registry. To analyze the anesthetic management, a matching process yielded three comparable patient groups (n = 1506) that differed solely in the surgical procedure. Three surgical procedures with varying degrees of invasiveness were selected: Group A = video-assisted thoracoscopic surgery (VATS) with wedge resection, group B = VATS with lobectomy, group C = open thoracotomy. Statistical analysis was performed descriptively using relative and absolute frequencies. Dichotomous variables were compared using the χ²-test.

RESULTS

The study enrolled patients with a median age of 65.6 years. The mean value of the American Society of Anesthesiologists (ASA) classification was 2.8. One lung ventilation was most commonly performed (group A = 98.2%, group B = 99.4%, group C = 98.0%) with double lumen tubes (DLT). Bronchial blockers (group A = 0.2%, group B = 0.4%, group C = 0%) were rarely used. Primary bronchoscopy was used to control double lumen tubes after insertion in the majority of cases (group A = 77.5%, group B = 73.1%, group C= 79.7%). Continuous positive airway pressure (CPAP, group A = 1.2%, group B = 1.4%, group C = 5.1%) and jet ventilation (group A = 1.6%, group B = 1.6%, group C = 1.4%) were rarely used intraoperatively. In group C, the administration of a vasopressor was also more frequently required (group A = 59.9%, group B = 77.8%, group C = 86%). A central venous catheter was established in 30.1% of all patients in group A, 39.8% in group B and 73.3% in group C. Patients in group A received an arterial catheter less frequently (71.7%) when compared to groups B (96.4%) and C (95.2%). Total intravenous anesthesia with propofol was used in most patients (group A = 67.7%, group B 61.6%, group C 75.7%). Propofol supplemented by volatile anesthetics was used less frequently (group A = 28.5%, group B = 35.5%, group C = 23.7%). With increasing invasiveness of the surgical procedure, placement of an epidural catheter was preferred (group A = 18.9%, group B = 29.5%, group C = 64.1%). Paravertebral catheters (group A = 7.6%, group B = 4.4%, group C = 4.8%) or a single infiltration of the paravertebral space were performed less frequently (group A = 7.8%, group B = 17.7%, group C = 11.6%). Postoperatively, some patients (3.4-25.7%) were transferred to the general ward. The largest proportion of patients transferred to a general ward underwent less invasive thoracic procedures (group A). When the extent of resection was greater (group B and group C) patients were mostly transferred to an intermediate care unit (IMC) or an intensive care unit (ICU). The insertion of invasive catheters was neither associated with the patients' ASA classification nor preoperative pathologic pulmonary function.

CONCLUSION

Our data indicate that less invasive thoracic operations are associated with a reduction of invasive anesthetic procedures. As the presented data are descriptive, further studies are required to determine the impact of invasive anesthetic procedures on patient-related outcomes. This evaluation of the anesthetic management in experienced thoracic anesthesiology departments represents the next step towards establishing national quality standards and promoting structural quality in thoracic anesthesia.

Comparison of left double lumen tube and y-shaped and double-ended bronchial blocker for one lung ventilation in thoracic surgery—a randomised controlled clinical trial

Background

Double lumen tube (DLT) intubation is the most commonly used technique for one lung ventilation. Bronchial blockers (BB) are an alternative, especially for difficult airways. The EZ-bronchial blocker (EZB) is an innovative y-shaped and double-ended device of the BB family.

Methods

A randomised, controlled trial was conducted in 80 patients undergoing elective thoracic surgery using DLT or EZB for one lung ventilation (German Clinical Trial Register DRKS00014816). The objective of the study was to compare the clinical performance of EZB with DLT. Primary endpoint was total time to obtain successful one lung ventilation. Secondary endpoints were time subsections, quality of lung collapse, difficulty of intubation, any complications during the procedure, incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms.

Results

74 patients were included, DLT group (n = 38), EZB group (n = 36). Median total time to obtain one lung ventilation [IQR] in the DLT group was 234 s [207 to 294] versus 298 s [243 to 369] in the EZB group (P = 0.007). Median total time was relevantly influenced by different preparation times. Quality of lung collapse was equal in both groups, DLT group 89.5% were excellent vs. 83.3% in the EZB group (P = 0.444). Inadequate lung collapse in five patients of the EZB group resulted in unsuccessful repositioning attempts and secondary DLT placement. Endoscopic examinations revealed significantly more carina trauma (P = 0.047) and subglottic haemorrhage (P = 0.047) in the DLT group. Postoperative subjective symptoms (sore throat, hoarseness) were more common in the DLT group, as were speech problems.

Conclusions

Using EZB prima facie results in prolonged time to obtain one lung ventilation with equal quality of lung collapse for the thoracic surgeon. If preparation times are omitted in the analysis, the time difference is statistically and clinically not relevant. Our data showed only little evidence for reducing objective airway trauma as well as subjective complaints. In summary both procedures were comparable in terms of times and clinical applicability. Therefore decisions for DLT or EZB should depend more on individual experience, in-house equipment and the individual patient, than on any times that are neither clinically significant nor relevant.

Trial registration

German Clinical Trial Register DRKS00014816, prospectively registered on 07.06.2018

Difficult lung separation. An insight into the challenges faced during COVID-19 pandemic

Difficult lung isolation or separation in patients undergoing thoracic surgery using one-lung ventilation might be attributed to upper airway difficulty or abnormal anatomy of the lower airway. Additionally, adequate deflation of the surgical lung can impair surgical exposure. The coronavirus disease 2019 (COVID-19) has a harmful consequence for both patients and anesthesiologists. Management of patients with difficult lung isolation can be challenging during the COVID-19 pandemic. Careful planning and preparation, preoperative routine testing, protective personal equipment, standard safety measures, proper preoxygenation, and individualize the patients care are required for successful lung separation. A systematic approach for management of difficult lung separation is centered around securing the airway and providing adequate ventilation using either a blocker or double-lumen tube. Several measures are described to expedite lung collapse.

Current practice of thoracic anaesthesia in Europe - a survey by the European Society of Anaesthesiology Part I - airway management and regional anaesthesia techniques

Background

The scientific working group for “Anaesthesia in thoracic surgery” of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) has performed an online survey to assess the current standards of care and structural properties of anaesthesia workstations in thoracic surgery.

Methods

All members of the European Society of Anaesthesiology (ESA) were invited to participate in the study.

Results

Thoracic anaesthesia was most commonly performed by specialists/board-certified anaesthetists and/or senior/attending physicians. Across Europe, the double lumen tube (DLT) was most commonly chosen as the primary device for lung separation (461/ 97.3%). Bronchial blockers were chosen less frequently (9/ 1.9%).

Throughout Europe, bronchoscopy was not consistently used to confirm correct double lumen tube positioning. Respondents from Eastern Europe (32/ 57.1%) frequently stated that there were not enough bronchoscopes available for every intrathoracic operation. A specific algorithm for difficult airway management in thoracic anaesthesia was available to only 18.6% (n = 88) of the respondents. Thoracic epidural analgesia (TEA) is the most commonly used form of regional analgesia for thoracic surgery in Europe. Ultrasonography was widely available 93,8% (n = 412) throughout Europe and was predominantly used for central line placement and lung diagnostics.

Conclusions

While certain „gold standards “are widely met, there are also aspects of care requiring substantial improvement in thoracic anaesthesia throughout Europe.

Our data suggest that algorithms and standard operating procedures for difficult airway management in thoracic anaesthesia need to be established. A European recommendation for the basic requirements of an anaesthesia workstation for thoracic anaesthesia is expedient and desirable, to improve structural quality and patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01480-w.

To tube or not to tube: a skeptic's guide to nonintubated thoracic surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department.

RECENT FINDINGS

Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise.

SUMMARY

In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.

[Videoassisted Thoracoscopy with Preserved Spontaneous Breathing - an Anaesthesiological Perspective]

INTRODUCTION

Video-assisted thoracoscopic procedures with preserved spontaneous breathing (NI-VATS = conscious video-assisted thoracic surgery) have enjoyed a revival in recent years. However, there have been few reports on proper patient selection, as well as surgical or anaesthesiologic management for these procedures in Germany. Therefore, we present our experience with NI-VATS procedures in the form of a case study and discuss the results with a current survey and the current literature.

METHOD

Retrospective evaluation of all NI-VATS procedures at our local institution.

RESULTS

From June 2018 to January 2020 n = 17 (9 male and 8 female) patients underwent NI-VATS at our institution. Median age of patients was 68 [61 - 79] years. Fourteen patients suffered from progressive cancer as the underlying disease, leading to thoracic surgery. All patients had a number of comorbidities and were classified according to the ASA categories III (n = 9) or IV (n = 8). Surgical procedures were of short duration (in median 18 [15 - 27] min) and included 82% pleural procedures (pleurectomy, decortication or insertion of pleural drainage). All patients tolerated the surgical procedures under local anaesthesia and conscious sedation very well. Eleven patients could therefore be transferred to the normal ward after surgery, while the remaining patients underwent prolonged and intensified postoperative monitoring. Five of the 17 patients died within the hospital, in median 8 [3.0 - 33.5] days after surgery, in context of the underlying disease. None of the deaths could be associated with the surgical procedures.

DISCUSSION

In a well selected patient cohort and with our local experience, NI-VATS is a safe and practicable alternative to standard thoracotomy in general anaesthesia and one-lung ventilation. In our local institution, multimorbid patients with interventions of short duration and reasonable extent underwent successful NI-VATS and emerged as good candidates for this procedure. Careful patient selection and knowledge of the procedure and its side effects present important milestones for successful NI-VATS.

The Comparison Between Bronchial Occlusion and Artificial Pneumothorax for Thoracoscopic Lobectomy in Infants

OBJECTIVE

To compare the difference between single-lung ventilation with bronchial occlusion and double-lung ventilation with carbon dioxide artificial pneumothorax for thoracoscopic lobectomy in infants.

DESIGN

This was a retrospective study.

SETTING

It was done in a teaching hospital.

PARTICIPANTS

Between March 2017 and April 2020, a total of 72 infants underwent thoracoscopic lobectomy in the authors' hospital.

INTERVENTIONS

Twenty-one patients received single-lung ventilation with bronchial occlusion, and 51 patients received carbon dioxide (CO₂) artificial pneumothorax.

MEASUREMENTS

The patient data included the endotracheal tube length, surgical exposure, intraoperative blood loss, and surgery duration. The mean arterial pressure (MAP), central venous pressure (CVP) and peak inspiratory pressure (Ppeak), partial pressure of oxygen in arterial blood (PaO₂), and partial pressure of carbon dioxide in arterial blood (PaCO₂) were measured at four points: time of bilateral lung ventilation before the thoracic surgery (T0), 10 minutes after the surgery started (T1), 30 minutes after the surgery started (T2), 60 minutes after the surgery started (T3), and 10 minutes after the surgery was over (T4).

MAIN RESULTS

Compared to artificial pneumothorax, the bronchial occlusion group has the following advantages: the surgical exposure was better, the surgery duration was shorter, there was less intraoperative bleeding, and the duration of tracheal intubation was shorter (p < 0.05); bronchial occlusion resulted in a lower MAP but a higher CVP in infants at T1, T2, and T3 (p < 0.05) than the artificial pneumothorax group and resulted in a lower PaCO₂ and higher PaO₂ at T2, T3, and T4 (p < 0.05). There was no significant difference in Ppeak between the two groups (p > 0.05).

CONCLUSION

Compared with CO₂ artificial pneumothorax, bronchial occlusion is more favorable for thoracoscopic lobectomy in infants.

A Survey of the Practice of Thoracic Anesthesia in India

OBJECTIVE

The aim of the survey was to understand the contemporary thoracic anesthesia practice in India.

DESIGN

A prospective questionnaire-based survey.

SETTINGS

The survey was conducted at the Annual Conference of the Indian Association of Cardiovascular and Thoracic Anesthesiologists 2018 (IACTACON-2018). After the conference, the questionnaire was distributed again to the conference participants electronically to increase the response rate.

PARTICIPANTS

Anesthesiologists from India attending IACTACON-2018.

INTERVENTIONS

Hard copies of a validated questionnaire (n = 430) were distributed among Indian anesthesiologists attending IACTACON 2018. The questionnaire included 17 questions pertaining to preanesthesia checkup, lung isolation devices, intraoperative management, postoperative analgesia, and infrastructure available at their institutions. Following the conference, the survey was continued online by sending the link of the online survey to all registered participants (n = 421) from India, taking care to avoid duplication of responses. Collected data were analyzed using frequency distributions and chi-square tests.

MEASUREMENTS AND MAIN RESULTS

Total responses were 166 (110 hardcopies and 56 online responses) of 430, with the response rate being 38.6%. A double-lumen tube (DLT) was the most commonly preferred for lung isolation (160/166: 96.4%). Nearly 55% of anesthesiologists preferred auscultation for confirmation of DLT, as 38% of anesthesiologists reported unavailability of the pediatric bronchoscope. Nearly 80% of anesthesiologists were compliant with the principles of protective one-lung ventilation. Preference for inhalation anesthetic agents during one-lung ventilation, use of restrictive intravenous fluids, and regional blocks for postoperative analgesia commonly were followed by the Indian anesthesiologists.

CONCLUSION

Despite the challenges offered by limited resources, the practice of thoracic anesthesia in India is at par with the standards followed across the world.

Videolaryngoscopy versus direct laryngoscopy for double-lumen endotracheal tube intubation in thoracic surgery - a randomised controlled clinical trial

Background

Double-lumen tube (DLT) intubation is necessary for thoracic surgery and other operations with the need for lung separation. However, DLT insertion is complex and might result in airway trauma. A new videolaryngoscopy (GVL) with a thin blade might improve the intubation time and reduce complexity as well as iatrogenic airway complications compared to conventional direct laryngoscopy (DL) for DLT intubation.

Methods

A randomised, controlled trial was conducted in 70 patients undergoing elective thoracic surgery using DLT for lung separation. Primary endpoint was time to successful intubation. The secondary endpoints of this study were number of intubation attempts, the assessment of difficulty, any complications during DLT intubation and the incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms.

Results

65 patients were included (DL group [n  =  31], GVL group [n  =  34]). Median intubation time (25th–75th percentiles) in GVL group was 93 s (63–160) versus 74 (58–94) in DL group [p = 0.044]. GVL resulted in significantly improved visualisation of the larynx (Cormack and Lehane grade of 1 in GVL group was 97% vs. 74% in DL Group [p = 0.008]). Endoscopic examinations revealed significant differences in GVL group compared to DL group showing less red-blooded vocal cord [p = 0.004], vocal cord haematoma [p = 0.022] and vocal cord haemorrhage [p = 0.002]. No significant differences regarding the postoperative subjective symptoms of airway were found.

Conclusions

Videolaryngoscopy using the GlideScope®-Titanium shortly prolongs DLT intubation duration compared to direct laryngoscopy but improves the view. Objective intubation trauma but not subjective complaints are reduced.

Trial registration

German Clinical Trial Register DRKS00020978, retrospectively registered on 09. March 2020.

Implementation of strategies to prevent and treat postoperative delirium in the post-anesthesia caring unit : A German survey of current practice

Postoperative delirium is associated with worse outcome. The aim of this study was to understand present strategies for delirium screening and therapy in German Post-Anesthesia-Caring-Units (PACU). We designed a German-wide web-based questionnaire which was sent to 922 chairmen of anesthesiologic departments and to 726 anesthetists working in ambulatory surgery. The response rate was 30% for hospital anesthesiologists. 10% (95%-confidence interval: 8–12) of the anesthesiologists applied a standardised screening for delirium. Even though not on a regular basis, in 44% (41–47) of the hospitals, a recommended and validated screening was used, the Nursing Delirium Screening Scale (NuDesc) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). If delirium was likely to occur, 46% (43–50) of the patients were examined using a delirium tool. 20% (17–23) of the patients were screened in intensive care units. For the treatment of delirium, alpha-2-agonists (83%, 80–85) were used most frequently for vegetative symptoms, benzodiazepines for anxiety in 71% (68–74), typical neuroleptics in 77% (71–82%) of patients with psychotic symptoms and in 20% (15–25) in patients with hypoactive delirium. 45% (39–51) of the respondents suggested no therapy for this entity. Monitoring of delirium is not established as a standard procedure in German PACUs. However, symptom-oriented therapy for postoperative delirium corresponds with current guidelines.

Dimensional Variations of Left-Sided Double-Lumen Endobronchial Tubes

Background

Tube size selection is critical in ventilating patients' lungs using double-lumen endobronchial tubes (DLTs). Little information about relevant parameters is readily available from manufacturers. The aim of this study is to provide reference data for relevant dimensions of conventionally available DLTs.

Methods

In this study in a benchmark in vitro setup, several dimensional parameters of four sizes of left-sided double-lumen endobronchial tubes from six different manufacturers were assessed, such as distances and diameters of tube shaft, cuff lengths, and diameters as well the angle at the tip.

Results

Endobronchial tubes of ostensibly the same size revealed wide variation in measured parameters between brands from different manufacturers. In some parameters, there was an overlap between different sizes from the same manufacturer, i.e., diameters and distances did not increase with increasing nominal endobronchial tube size. The information about dimensions of endobronchial tubes provided by manufacturers' leaflets is insufficient.

Conclusions

Endobronchial tube size selection carries unnecessary uncertainty because clinically relevant parameters are unknown and vary considerably between different manufacturers.

Airway management in anesthesia for thoracic surgery: a "real life" observational study

Background

One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs.

Methods

A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway.

Results

Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted.

Conclusions

DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.

Anaesthesia management for bronchoscopic and surgical lung volume reduction

Optimizing the patient's condition before the lung volume reduction (LVR) according to recommendations by American College of Cardiology/American Heart Association (ACC/AHA) guideline on perioperative cardiovascular evaluation is mandatory. Implementation of a multimodal analgesia concept and the use short-acting anaesthetics enhances recovery and avoids postoperative pulmonary complications. Normovolemia, normothermia, lung protective ventilation and an evidence-based concept of airway management (i.e., double-lumen tube, bronchus blocker) are suggested for intraoperative management of surgical lung volume reduction (SLVR). General anaesthesia (using remifentanil, propofol and mivacurium) with an i-gel^® supraglottic airway device should be used for bronchoscopic lung volume reduction (BLVR). Jet ventilation through rigid bronchoscopy or with a jet catheter may be an alternative concept. Experienced consultants should perform anaesthesia for LVR.