Effects of bronchial blockers on one-lung ventilation in general anesthesia: A randomized controlled trail

Comparison of ICG-Guided Near-Infrared Fluorescence Imaging and Modified Inflation-Deflation Method in Identifying the Intersegmental Plane During Lung Segmentectomy of Infants

BACKGROUND

The identification of the intersegmental plane (ISP) is a crucial step in segmentectomy for children with congenital pulmonary airway malformation (CPAM) due to complex anatomical variations. However, there is very limited literature available on this aspect specifically for infant. In this study, we compared the intravenous indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) imaging method with the modified inflation-deflation method in terms of their perioperative characteristics and summarized our experience.

METHODS

From June 2021 to November 2022, the data of 83 patients with CPAM who underwent segmentectomy by video-assisted thoracoscopic surgery were retrospectively reviewed. Twenty-eight patients underwent ICG-guided NIRF method, and 56 patients underwent the modified inflation-deflation method, characteristics and clinical outcomes were compared.

RESULTS

The median age of the patients was 4.99 months (4.99 ± 1.51) with a mean body weight of 7.54 kg (7.54 ± 1.99). Both methods could accurately identify the ISP. The time taken to clearly display the ISP was shorter in ICG group than in the modified inflation-deflation group (0.18 ± 0.08 vs. 6.49 ± 1.67 min; P < 0.001), and the surgical duration (61.32 ± 14.28 vs. 88.18 ± 8.03 min; P < 0.001) were significantly shorter in the ICG group too. The two groups exhibited differences in the length of chest tube drainage (1.75 ± 1.24 vs. 2.36 ± 1.54 days; P = 0.072) and the length of hospital stay (4.61 ± 1.75 vs. 5.20 ± 3.07 days; P = 0.078), however, the differences were not statistically significant. There were no significant differences between the two groups in the blood lost and postoperative complications. At a follow-up of more than 1 year after operation, all patients had recovered well without recurrence.

CONCLUSIONS

According to our experience, the ICG-guided NIRF method was safe and feasible for infants during thoracoscopic segmentectomy, it can quickly display the ISP and shorten the surgical duration compared with the modified inflation-deflation method.

Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study

BACKGROUND

Postoperative pneumonia is one of the common complications after video-assisted thoracoscopic surgery. There is no related study on the effect of lung isolation with different airway devices on postoperative pneumonia. Therefore, in this study, the propensity score matching method was used to retrospectively explore the effects of different lung isolation methods on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery.

METHODS

This is A single-center, retrospective, propensity score-matched study. The information of patients who underwent VATS in Weifang People 's Hospital from January 2020 to January 2021 was retrospectively included. The patients were divided into three groups according to the airway device used in thoracoscopic surgery: laryngeal mask combined with bronchial blocker group (LM + BB group), tracheal tube combined with bronchial blocker group (TT + BB group) and double-lumen endobronchial tube group (DLT group). The main outcome was the incidence of pneumonia within 7 days after surgery; the secondary outcome were hospitalization time and hospitalization expenses. Patients in the three groups were matched using propensity score matching (PSM) analysis.

RESULTS

After propensity score matching analysis, there was no significant difference in the incidence of postoperative pneumonia and hospitalization time among the three groups (P > 0.05), but there was significant difference in hospitalization expenses among the three groups (P < 0.05).

CONCLUSIONS

There was no significant difference in the effect of different intubation lung isolation methods on postoperative pneumonia in patients undergoing thoracoscopic surgery.

One-lung ventilation with a bronchial blocker in thoracic patients

BACKGROUND

Lung isolation is a technique used in a multitude of surgeries to ensure single-lung ventilation with collapse of the contralateral lung, as to achieve improved access and visualization of relevant anatomical structures. Despite being accepted and having favorable outcomes, bronchial blockers (BBs) are not to this day the main device of choice among anaesthesiologists.

METHODS

In this retrospective and descriptive study, we analyzed the safety and efficacy of a BB in all types of thoracic surgeries in our centre between 2015 and 2022, excluding patients with massive hemoptysis or empyema, or who had undergone a prior pneumonectomy.

RESULTS

One hundred and thirty-four patients were intervened due to lung cancer (67.9%), respiratory disease (23.9%), and non-respiratory disease (8.2%) undergoing lung surgeries (65.7%), pleural and mediastinal surgeries (29.9%), chest wall surgeries (3.0%) and other surgeries (1.5%). In most cases, lung collapse was considered excellent (63.9%) or good (33.1%) with only 4 cases (3.0%) of poor lung collapse. More than 90% of patients did not present intraoperative or immediate postoperative complications. No statistically significant differences were found between lung collapse and the demographic, clinical or BB-related variables (p > 0.05). However, we found a significatively higher proportion of excellent lung collapses in VATS surgeries and lateral decubitus positioning, as well as a significatively less proportion of poor lung collapses (p < 0.05). Moreover, there was a significantly higher proportion of excellent lung collapses when the BB was placed in the left bronchus (p < 0.05).

CONCLUSIONS

With these results, in our experience BBs constitute an effective alternative, capable of achieving pulmonary collapse in all kinds of thoracic procedures with satisfactory safety rates due to their minimal complications.

Efficacy of rigid-angle bronchial blockers for uniportal video-assisted thoracoscopic tumor resection

Background

For uniportal video-assisted thoracoscopic surgery (VATS), which is greatly dependent on satisfactory lung collapse without lung compression from another port, few reports have elucidated the intraoperative efficacy of bronchial blockers (BBs). We hypothesized that operation time would be prolonged if BBs required more intraoperative repositioning during surgical manipulation. We compared the operation times of different surgical procedures performed using BBs with double-lumen tubes (DLTs) in uniportal VATS.

Materials and Methods

Patients who underwent intubated uniportal VATS were enrolled retrospectively from March to May 2019. Data on the patient, anesthetic, and surgical factors were collected. Regression analyses were performed to determine the effect of various factors on operation time.

Results

317 patients who underwent uniportal VATS were included. Wedge resection constituted 70.7%, and anatomic resection constituted 29.3% of procedures. BBs were applied for left- and right-side wedge resection (85.6% and 78.7%, respectively) and left- and right-side anatomic resection (74.1% and 56.4%, respectively). The surgical factors significantly affecting operation time were operation procedures (P < .01), number of lymph nodes sampled (P < .001), and size of tumors (P < .01).

Conclusions

The efficacy of BBs was comparable to that of DLTs for uniportal VATS wedge resection. With significantly less preference for right-side anatomic resection, the efficacy of DLTs was comparable with that of BBs, which were applied in more than half of right-side uniportal anatomic VATS. We conclude that even in uniportal VATSs, rigid-angled BBs demonstrate comparable efficacy with feasible alternatives.

The association between double-lumen tube versus bronchial blocker and postoperative pulmonary complications in patients after lung cancer surgery

Background

Both double-lumen tube (DLT) and bronchial blocker (BB) are used for lung isolation in patients undergoing lung cancer surgery. However, the effects of different devices for lung isolation remain inconclusive. Present study was designed to investigate the association between the choice of the two devices and postoperative pulmonary complications (PPCs) in patients with lung cancer.

Methods

In this retrospective cohort study, patients who underwent lung cancer surgery between January 1, 2020 and October 31, 2020 were screened. Patients were divided into two groups according to different devices for lung isolation: DLT group and BB group. Primary outcome was the incidence of a composite of PPCs during postoperative in-hospital stay.

Results

A total of 1721 were enrolled for analysis, of them, 868 received DLT and 853 BB. A composite of PPCs was less common in patients with BB (25.1%, [214/853]) than those received DLT (37.9% [329/868] OR 0.582 95% CI 0.461-0.735 P < 0.001). Respiratory infection was less common in BB group (14.4%, [123/853]) than DLT group (30.3%, [263/868], P<0.001). The incidence of non-PPCs complications was not statistically significant between the 2 groups.

Conclusions

For patients undergoing surgery for lung cancer, the use of BB for lung isolation was associated with a reduced risk of PPCs when compared with DLT.

Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis

BACKGROUND

Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure.

METHODS

The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups.

RESULTS

A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32 months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15 months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups.

CONCLUSIONS

Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.

A Comparison Between Selective Lobar Bronchial Blockade and Main Bronchial Blockade in Pediatric Thoracoscopic Surgery: A Retrospective Cohort Study

OBJECTIVE

The primary objective of this study was to assess the effect of selective lobar blockade on the risk of hypoxemia during one-lung ventilation in pediatric patients undergoing thoracoscopic surgery.

DESIGN

This was a retrospective matched case-control cohort study.

SETTING

The study was performed in a teaching hospital.

PARTICIPANTS

A total of 60 pediatric patients who underwent thoracoscopic surgery in the authors' hospital from March 2020 to March 2021 were analyzed.

INTERVENTIONS

The authors examined their electronic medical records and found 30 patients in whom selective lobar blockade was used. These patients then were matched to 30 other patients in whom routine main bronchial blockade was performed in the authors' center based on age, weight, sex, side of surgery, and type of surgery.

MEASUREMENTS AND MAIN RESULTS

The inclusion criteria were four-fold: (1) pediatric patients with scheduled thoracoscopic resection of the middle and lower lobe lesions; (2) no obvious anesthesia or surgical contraindications; (3) American Society of Anesthesiologists class I to II; and (4) age younger than one year old. The exclusion criteria were as follows: (1) pediatric patients whose trachea was intubated with a size less than 3.0 mm; (2) a difficult airway; (3) changes in ventilation patterns during surgery; and (4) severe pneumonia and respiratory and circulatory system dysfunction. The following patient data were collected: (1) general clinical information; (2) mean arterial blood pressure, heart rate, central venous pressure, airway peak pressure (Ppeak), oxygenation index (PaO₂/F_IO₂ ratio), and alveolar-arterial oxygen differential pressure (AaDO2) at different time points; that is, before one-lung ventilation (OLV) (T1), ten minutes after OLV (T2), and ten minutes after the end of OLV (T3); (3) degree of lung collapse ten minutes after OLV; (4) operative duration; and (5) the prevalence of hypoxemia, the number of adjustments required for intraoperative displacement of the bronchial blocker, and pulmonary atelectasis. A total of 135 patients were selected, and 60 pediatric patients (30 in group S and 30 in group R) were included in this study. There were no significant differences in age, sex, weight, general preoperative data, degree of lung collapse, or operative duration (p > 0.05). The perioperative hemodynamics between the two groups were not statistically significant (p > 0.05). The oxygenation index, AaDO2, and Ppeak were not significantly different between the two groups at the T1 time point (p > 0.05). However, the oxygenation index was higher, and AaDO2 and Ppeak were lower in group S than in group R at the T2 and T3 time points (p < 0.05). The incidence of atelectasis, the prevalence of hypoxemia, and the number of adjustments required for intraoperative displacement of the bronchial blocker in group S were lower than those in group R (p < 0.05).

CONCLUSION

Selective lobar bronchial blockade, using a bronchial blocker in pediatric thoracoscopic surgery, may represent an alternative to excluding the main bronchial blockade for patients undergoing middle and lower lobe procedures, which may improve intraoperative oxygenation and reduce postoperative atelectasis.

Extraluminal Placement of a Bronchial Blocker Compared with Carbon Dioxide Artificial Pneumothorax in Infants Undergoing Video-Assisted Thoracoscopic Surgery

Objective: To investigate the safety and effectiveness of extraluminal placement of a bronchial blocker compared with carbon dioxide (CO₂) artificial pneumothorax in infants undergoing video-assisted thoracoscopic surgery (VATS).

Methods: The study involved 33 infants (group A) who underwent one-lung ventilation (OLV) with extraluminal placement of a bronchial blocker and 35 other infants (group B) who underwent CO₂ artificial pneumothorax. Clinical characteristics, the degree of lung collapse, and complications were compared.

Results: The degree of lung collapse in group A was significantly higher than that in group B at T2 and T3. The mean arterial pressure (MAP) of group B was significantly lower than that of group A at 10 min and 30 min after OLV. The partial pressure of carbon dioxide (PaCO₂) of group B was significantly higher than that of group A at 30 min after OLV. The incidence of hypotension in group B was higher than that in group A.

Conclusion: Compared with CO₂ artificial pneumothorax, extraluminal placement of a bronchial blocker is associated with a better degree of lung collapse, fewer episodes of hypotension, and lower PaCO₂ accumulation during OLV in infants undergoing VATS.

The Year in Thoracic Anesthesia: Selected Highlights From 2020

Selected highlights in thoracic anesthesia in 2020 include updates in the preoperative assessment and prehabilitation of patients undergoing thoracic surgery; updates in one-lung ventilation (OLV) pertaining to the devices used for OLV; the use of dexmedetomidine for lung protection during OLV and protective ventilation, recommendations for the care of thoracic surgical patients with coronavirus disease 2019; a review of recent meta-analyses comparing truncal blocks with paravertebral and thoracic epidural blocks; and a review of outcomes after initiating the enhanced recovery after surgery guidelines for lung and esophageal surgery.

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.

The Year in Thoracic Anesthesia: Selected Highlights from 2019

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.