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Grott M, Eichhorn M, Eichhorn F, Schmidt W, Kreuter M, Winter H. Thoracic surgery in the non-intubated spontaneously breathing patient. Respir Res 2022; 23:379. [PMID: 36575519 PMCID: PMC9793515 DOI: 10.1186/s12931-022-02250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 11/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The interest in non-intubated video-assisted thoracic surgery (NIVATS) has risen over the last decade and numerous terms have been used to describe this technique. They all have in common, that the surgical procedure is performed in a spontaneously breathing patient under locoregional anaesthesia in combination with intravenous sedation but have also been performed on awake patients without sedation. Evidence has been generated favouring NIVATS compared to one-lung-ventilation under general anaesthesia. MAIN BODY We want to give an overview of how NIVATS is performed, and which different techniques are possible. We discuss advantages such as shorter length of hospital stay or (relative) contraindications like airway difficulties. Technical aspects, for instance intraoperative handling of the vagus nerve, are considered from a thoracic surgeon's point of view. Furthermore, special attention is paid to the cohort of patients with interstitial lung diseases, who seem to benefit from NIVATS due to the avoidance of positive pressure ventilation. Whenever a new technique is introduced, it must prove noninferiority to the state of the art. Under this aspect current literature on NIVATS for lung cancer surgery has been reviewed. CONCLUSION NIVATS technique may safely be applied to minor, moderate, and major thoracic procedures and is appropriate for a selected group of patients, especially in interstitial lung disease. However, prospective studies are urgently needed.
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Affiliation(s)
- Matthias Grott
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Martin Eichhorn
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Florian Eichhorn
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Werner Schmidt
- grid.5253.10000 0001 0328 4908Department of Anaesthesiology and Intensive Care Medicine, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Michael Kreuter
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Center for Interstitial and Rare Lung Diseases, Pneumology Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Hauke Winter
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
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Kim KK, Krause M, Brandes IF, Khanna AK, Bartels K. Transesophageal echocardiography for perioperative management in thoracic surgery. Curr Opin Anaesthesiol 2021; 34:7-12. [PMID: 33315644 DOI: 10.1097/aco.0000000000000947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. RECENT FINDINGS Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. SUMMARY Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.
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Affiliation(s)
- Kevin K Kim
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Martin Krause
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ivo F Brandes
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Son SL, Kim WS, Kwon M, Moon YJ. Airway obstruction during pneumonectomy using a single lumen tube: A case report. Medicine (Baltimore) 2020; 99:e19736. [PMID: 32311966 PMCID: PMC7220147 DOI: 10.1097/md.0000000000019736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Endotracheal intubation is an essential step for airway management during general anesthesia. When surgeons carry out thoracic surgery such as pneumonectomy, they usually request lung isolation to secure a clear surgical view. A double lumen endotracheal tube is used for lung isolation in routine thoracic surgeries. PATIENT CONCERNS A 56-year-old man was previously diagnosed with left Aspergilloma, a tuberculosis destroyed lung, and diabetes mellitus. According to his chest x-ray and chest computed tomography, his left lung was nearly collapsed, and the result of a pulmonary function test was severely restricted. The patient's diffusing capacity for carbon monoxide was 63% and predicted postoperative forced expiratory volume in 1 second was 23.5% DIAGNOSES:: Due to his previous history, radiologic findings and laboratory test results, he was diagnosed with left Aspergilloma and tuberculosis destroyed lung. INTERVENTIONS Due to recurrence of Aspergilloma in his left lung, the patient was scheduled for a left pneumonectomy. Since the patient's partial oxygen concentration was adequate despite his left lung being nearly totally collapsed, we thought that we would be capable of performing the pneumonectomy using a single lumen tube (SLT). For a better surgical view, we planned lung isolation via insertion of a SLT deep into the bronchus. OUTCOMES During pneumonectomy, after tracheal suction was performed, we tried a lung recruitment maneuver. Suddenly end-tidal carbon dioxide did not show on the monitor. The patient's blood pressure dropped and heart rate was decreasing. We thought that cardiopulmonary resuscitation was needed and an approximately 2 cm sized hematoma was removed from the endotracheal tube after vigorous suctioning. After getting rid of the hematoma, we changed the single tube to a double lumen tube (DLT). LESSONS This case led us to the conclusion that a DLT should be used for safety when carrying out thoracic surgery. We report a rare case of an airway obstruction using a SLT during pneumonectomy.
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Affiliation(s)
| | - Woo-Shik Kim
- Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, Korea
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Hackett S, Jones R, Kapila R. Anaesthesia for pneumonectomy. BJA Educ 2019; 19:297-304. [PMID: 33456906 DOI: 10.1016/j.bjae.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2019] [Indexed: 12/25/2022] Open
Affiliation(s)
- S Hackett
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R Jones
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R Kapila
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Kidane B, Peel JK, Seely A, Malthaner RA, Finley C, Grondin S, Louie BE, Srinathan S, Darling GE. National practice variation in pneumonectomy perioperative care among Canadian thoracic surgeons†. Interact Cardiovasc Thorac Surg 2017; 25:872-876. [DOI: 10.1093/icvts/ivx252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/02/2017] [Indexed: 12/25/2022] Open
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Zhao Y, Liu S. Acute Cardiac Herniation After Left Intrapericardial Pneumonectomy. J Cardiothorac Vasc Anesth 2017; 31:270-273. [DOI: 10.1053/j.jvca.2016.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Indexed: 12/29/2022]
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Imaging in Thoracic Surgery. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Inhaled nitric oxide in cardiac surgery: Evidence or tradition? Nitric Oxide 2015; 49:67-79. [PMID: 26186889 DOI: 10.1016/j.niox.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/08/2015] [Accepted: 06/25/2015] [Indexed: 12/15/2022]
Abstract
Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.
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Kawagoe I, Inada E, Ishikawa S, Matsunaga T, Takamochi K, Oh S, Suzuki K. Perioperative management of carinal pneumonectomy: a retrospective review of 13 patients. J Anesth 2014; 29:446-449. [PMID: 25348684 DOI: 10.1007/s00540-014-1932-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 10/05/2014] [Indexed: 10/24/2022]
Abstract
Carinal pneumonectomy is a challenging procedure because of the difficulties in surgical technique, intraoperative airway management, and postoperative respiratory and anastomotic complications. However, information regarding the anesthetic and intraoperative respiratory management of this procedure is scarce. This report describes our routine anesthetic and respiratory management strategy in patients undergoing carinal pneumonectomy. Medical records of 13 patients who underwent carinal pneumonectomy under combined general and epidural anesthesia between 2008 and 2012 were analyzed retrospectively. Eleven patients underwent right carinal pneumonectomy and two underwent left carinal pneumonectomy. A left double-lumen tube was used in all but one case, in which endobronchial intubation was difficult because of intrabronchial invasion of the tumor. A 6.0-mm-long reinforced endobronchial tube was intubated into the main bronchus of the non-operative side from the surgical field during carinal resection. There were no episodes of severe hypoxemia or hypercapnia during surgery. Twelve patients were extubated immediately after surgery. No patient developed post-thoracotomy acute lung injury or required postoperative reintubation despite poor preoperative respiratory function. The 30-day mortality rate was 0%. Our airway management protocol for carinal pneumonectomy enables positive surgical outcomes.
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Affiliation(s)
- Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-11-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Eiichi Inada
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-11-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Seiji Ishikawa
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Matsunaga
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kazuya Takamochi
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shiaki Oh
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Pedoto A, Amar D. Perioperative Arrhythmias and Acute Right Heart Failure in Noncardiac Thoracic Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0055-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sullivan B, Puskas F, Fernandez-Bustamante A. Transesophageal echocardiography in noncardiac thoracic surgery. Anesthesiol Clin 2013; 30:657-69. [PMID: 23089501 DOI: 10.1016/j.anclin.2012.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In high-risk surgeries with medically complicated patients, transesophageal echocardiography (TEE) adds an additional level of monitoring with which few can disagree. This article presents multiple applications of TEE that can assist both the anesthesiologist and the surgeon through major noncardiac thoracic surgery. It highlights how TEE can be used as an adjuvant to lung resection surgery; TEE as a monitor during lung transplantation; TEE to assess patients for extracorporeal membrane oxygenation; TEE for thoracic aortic surgery; and TEE in the assessment of patients with acute pulmonary hypertension undergoing noncardiac thoracic surgery.
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Affiliation(s)
- Breandan Sullivan
- Department of Anesthesiology and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Evans RG, Ndunge OBA, Naidu B. A novel two-hit rodent model of postoperative acute lung injury: priming the immune system leads to an exaggerated injury after pneumonectomy. Interact Cardiovasc Thorac Surg 2013; 16:844-8. [PMID: 23482375 DOI: 10.1093/icvts/ivt077] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Postoperative acute lung injury (PALI) is a rare, poorly understood, usually fatal condition, accounting for the majority of deaths following lung resection. Its low frequency and unpredictable development make the identification of the mechanisms of injury from clinical studies alone almost impossible. Multiple validated 'two-hit models' exist for ALI secondary to other causes. We describe a novel rodent 'two-hit' model of PALI: a low-grade immune stimulus, such as sepsis, greatly aggravates the injury in the remaining lung observed following pneumonectomy. METHODS Under general anaesthesia, rats received either low-dose intratracheal lipopolysaccharide (IT-LPS) challenge (10 μg for 1 h) followed by left posterolateral thoracotomy, one-lung ventilation (OLV), pneumonectomy and 3 h of ventilation; 500 μl IT 0.9% saline followed by the same surgery or IT-LPS followed by sham surgery and ventilation. All other conditions were constant. Lung injury is heralded by neutrophil accumulation, which was determined by right lung bronchoalveolar lavage cell count. Data are presented as mean ± standard error of the mean. The T-test was used to compare normally distributed groups with correction for multiple comparisons. RESULTS A dose-response curve identified the clinically relevant 'low dose' of LPS to be used in further studies. Ventilatory parameters were standardized to reflect clinical practice (volume-control, tidal volume of 6 ml/kg, positive end-expiratory pressure of 2 cmH2O, maximum airway pressure of <15 cmH2O). There was a degree of adaptation to obtain a consistent and robust model with retest validity. OLV and pneumonectomy alone produced a small lung injury (65.1 ± 5), as did 10 µg intratracheal LPS alone (50.7 ± 6.9). However, when OLV, pneumonectomy and 10 µg LPS were combined, an exaggerated injury occurred (161.4 ± 10.3), P = 0.007. CONCLUSIONS Early results show that a two-hit model of PALI is viable and that sepsis aggravates the response to pneumonectomy. The model is now being further characterized. Once established, this model will offer the chance to better understand PALI and to develop and test novel therapies and risk reduction strategies for the condition.
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Affiliation(s)
- Robert G Evans
- Department of Thoracic Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
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Analysis of how an aspiration catheter is included in the bronchial suture during lung resection surgery. Arch Bronconeumol 2012; 48:342-3. [PMID: 22521761 DOI: 10.1016/j.arbres.2012.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 02/18/2012] [Indexed: 11/22/2022]
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Moitra VK. Thoracic Surgery. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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