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Pfitzner J. One-lung Ventilation Techniques to Facilitate Thoracoscopic Surgery: Time for Some Different Studies? J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00284-2. [PMID: 38890082 DOI: 10.1053/j.jvca.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 06/20/2024]
Affiliation(s)
- John Pfitzner
- The Queen Elizabeth Hospital, Discipline of Surgery, University of Adelaide, South Australia, Australia
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Abstract
'Apnoeic oxygenation' describes the diffusion of oxygen across the alveolar-capillary interface in the absence of tidal respiration. Apnoeic oxygenation requires a patent airway, the diffusion of oxygen to the alveoli, and cardiopulmonary circulation. Apnoeic oxygenation has varied applications in adult medicine including facilitating tubeless anaesthesia or improving oxygenation when a difficult airway is known or anticipated. In the paediatric population, apnoeic oxygenation prolongs the time to oxygen desaturation, facilitating intubation. This application has gained attention in neonatal intensive care where intubation remains a challenging procedure. Difficulties are related to the infant's size and decreased respiratory reserve. In addition, policy changes have led to limited opportunities for operators to gain proficiency. Until recently, evidence of benefit of apnoeic oxygenation in the neonatal population came from a small number of infants recruited to paediatric studies. Evidence specific to neonates is emerging and suggests apnoeic oxygenation may increase intubation success and limit physiological instability during the procedure. The best way to deliver oxygen to facilitate apnoeic oxygenation remains an important question.
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Affiliation(s)
- Elizabeth K Baker
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia.
| | - Peter G Davis
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Kate A Hodgson
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia.
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Pfitzner J. Reasons for using nitrous oxide in one-lung ventilation, especially for thoracoscopic surgery. Anaesth Intensive Care 2019; 47:478-479. [PMID: 31648529 DOI: 10.1177/0310057x19877657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John Pfitzner
- 48 Knox Terrace, Skye, 5072, Adelaide, South Australia, Australia
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One-lung ventilation duration-dependent stress response in thoracotomies and the effect of a low-volume, high-frequency differentiated ventilation strategy on this response. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 27:336-342. [PMID: 32082881 DOI: 10.5606/tgkdc.dergisi.2019.16826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 12/23/2018] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the effect of ventilation of the non-ventilated lung in patients undergoing one-lung ventilation by a separate low-tidal-volume (1 mL/kg) ventilator at high frequency (30/min) on preventing the effect of one-lung ventilation-associated oxidative damage. Methods The study included 45 patients (24 males, 21 females; mean age 54.6±7.7 years; range, 18 to 65 years) with an American Society of Anesthesiologists risk group of 1 to 2 and scheduled for elective thoracotomy. Patients were randomly divided into three groups as those due for thoracotomy without one-lung ventilation (group 1, n=15), those due for thoracotomy with one-lung ventilation (group 2, n=15), and those due for thoracotomy in whom both lungs were ventilated (group 3, n=15). Blood specimens were collected for ischemia-modified albumin, malondialdehyde, and lactate measurements one minute before one-lung ventilation (t0), 30 minutes after one-lung ventilation (t1), 60 minutes after one-lung ventilation (t2), and at postoperative 24th hour (t3). For group 1, t0 was defined as the time at which the thorax was opened. Results A statistically significant increase in ischemia-modified albumin, malondialdehyde, and lactate levels occurred in group 2 as the duration of one-lung ventilation increased (p<0.01). Plasma ischemia-modified albumin and malondialdehyde levels in group 3 were statistically significantly lower at t1, t2, and t3 compared with group 2 (p<0.01). Plasma lactate levels were significantly lower in group 3 at t1 (p<0.05) and t3 compared with group 2 (p<0.01). Conclusion Separate ventilation of the non-ventilated lung with low tidal volume and high frequency reduces the response to one-lung ventilation-associated oxidative stress in thoracic surgery.
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Pfitzner J, Fowlie JA, Kishore M, Michael AS, Lance DG. Arterial Oxygen Desaturation during only one of two Similar Thoracoscopic Procedures on the Same Patient. Anaesth Intensive Care 2019; 33:805-7. [PMID: 16398389 DOI: 10.1177/0310057x0503300617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The present report describes two similar thoracoscopic procedures performed on the same 81-year-old male patient. Because acute hypoxia had developed during one-lung ventilation on the first occasion, serial blood gases were taken during the second. Also, whereas on the first occasion the non-ventilated lung had been left open to air when one-lung ventilation was initiated, on the second it was connected to an ambient pressure oxygen source with the object of theoretically enabling apnoeic oxygenation during lung collapse. It is argued that this fundamental difference in anaesthetic practice may have contributed to the improved oxygenation that was recorded during the second thoracoscopy.
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Affiliation(s)
- J Pfitzner
- Department of Anaesthesia and Thoracic Surgery Unit, The Queen Elizabeth Hospital, Woodville, South Australia
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Pfitzner J. Evidence-based medicine: time to upend the pyramid for some clinical situations? Br J Anaesth 2018; 120:1134-1135. [PMID: 29661395 DOI: 10.1016/j.bja.2018.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/12/2018] [Indexed: 11/29/2022] Open
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Apneic oxygen insufflation decreases the incidence of hypoxemia during one-lung ventilation in open and thoracoscopic pulmonary lobectomy: A randomized controlled trial. J Thorac Cardiovasc Surg 2017; 154:360-366. [DOI: 10.1016/j.jtcvs.2017.02.054] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 02/04/2017] [Accepted: 02/19/2017] [Indexed: 12/12/2022]
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The role of an ambient pressure oxygen source during one-lung ventilation for thoracoscopic surgery. Anaesth Intensive Care 2016; 44:20-7. [DOI: 10.1177/0310057x1604400105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Video-assisted thoracoscopic surgery is facilitated by prompt collapse of the non-ventilated (‘operated’) lung, and interrupted and impeded if there is a need for oxygen (O2) delivery by continuous positive airways pressure in order to manage hypoxaemia. It has been proposed that connecting an ambient pressure O2 source to the airway of the non-ventilated lung at the time one-lung ventilation is initiated and before the chest is opened will, by avoiding entrainment of ambient nitrogen, serve to facilitate lung collapse. It has also been proposed that leaving the O2 source connected will enable, not only ongoing apnoeic oxygenation before the chest is opened, but also the thoracoscopic procedure to commence with the operated lung fully pre-oxygenated (with an inspired oxygen fraction of 1), and apnoeic oxygenation to continue throughout the operative procedure in those patients who exhibit a degree of small airways patency at ambient pressure. In reality, several factors can influence the speed of collapse of the operated lung, and very many factors can influence the incidence of hypoxaemia during one-lung ventilation. It therefore appears unlikely that the necessary evidence to support these proposals will be forthcoming from randomised clinical studies on large numbers of patients. Rather, the necessary evidence may only be provided by specifically designed within-patient clinical measurement studies. Nevertheless, it is argued that, in the meantime, there is already sufficient rationale for an ambient pressure O2 source to be connected to the airway of the non-ventilated lung, and for it to remain connected for the duration of one-lung ventilation.
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Granell M, Guijarro R, Hernández MJ, de Andrés JA. Comments to the article: "Endobronchial stent for the treatment of atraumatic rupture of the left bronchial due to a bull horn. Anesthetic implications". REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:172. [PMID: 25146771 DOI: 10.1016/j.redar.2014.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/25/2014] [Accepted: 05/27/2014] [Indexed: 06/03/2023]
Affiliation(s)
- M Granell
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España; Universidad de Valencia, Facultad de Medicina, Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - R Guijarro
- Servicio de Cirugía Torácica, Consorcio Hospital General Universitario de Valencia, Valencia, España; Universidad de Valencia, Facultad de Medicina, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - M J Hernández
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J A de Andrés
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España; Universidad de Valencia, Facultad de Medicina, Consorcio Hospital General Universitario de Valencia, Valencia, España
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Smoking as a risk factor for intraoperative hypoxemia during one lung ventilation. J Anesth 2013; 27:550-6. [DOI: 10.1007/s00540-013-1559-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 01/14/2013] [Indexed: 01/07/2023]
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Wilkey BJ, Alfille P, Weitzel NS, Puskas F. Anesthesia for Tracheobronchial Surgery. Semin Cardiothorac Vasc Anesth 2012; 16:209-19. [DOI: 10.1177/1089253212464715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The airway is a crucial dynamic structure that spans different anatomical zones, including the intrathoracic, extrathoracic, tracheal, bronchial, and alveolar zones. Because of its vital role as the sole oxygen-conducting pathway to the alveoli, and hence to the human body, surgery involving any portion requires careful and specific planning by both the surgeon and the anesthesiologist. The review covers essential management points for proximal and distal tracheal procedures, including a discussion of tracheal stenting and tracheoplasty.
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Affiliation(s)
| | - Paul Alfille
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Singh S, Chaturvedi R, Shukla RN, Saundattikar G, Balaji S. Anaesthetic management of an esophageal stent perforation of the left main bronchus. Med J Armed Forces India 2012; 71:186-8. [PMID: 25859084 DOI: 10.1016/j.mjafi.2012.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 05/18/2012] [Indexed: 10/27/2022] Open
Affiliation(s)
- Shivinder Singh
- Associate Professor, Dept of Anaesthesiology & Critical Care, AFMC, Pune 4110040, India
| | | | | | | | - S Balaji
- Resident, Anaesthesiology, AFMC, Pune 4110040, India
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Faber P, Klein AA. Theoretical and practical aspects of anaesthesia for thoracic surgery. J Perioper Pract 2008; 18:121-2, 124-9. [PMID: 18426131 DOI: 10.1177/175045890801800305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thoracic surgical procedures account for only a small fraction of all surgery undertaken in the NHS. Thoracic surgery is performed in specialist centres as patients often suffer serious co-morbidities and require vigilant care and observation by staff involved in their treatment. Anaesthesia for thoracic surgery challenges the theoretical and practical experience of all involved. This review briefly summarises the anaesthetic skills and knowledge required to deliver a safe and professional service to patients with thoracic pathology.
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Affiliation(s)
- Peter Faber
- Papworth Hospital, Papworth Everard, Cambridge CB23 3RE
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Pfitzner J, Stevens HJ, Lance DG. Identifying Imminent Displacement of a Double-Lumen Tube Caused by Surgical Traction at the Pulmonary Hilum. J Cardiothorac Vasc Anesth 2007; 21:776-7. [PMID: 17905296 DOI: 10.1053/j.jvca.2006.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Indexed: 11/11/2022]
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Pfitzner J, Stevens HJ, Rao V, Close JS, Lance DG. One-lung ventilation in a patient with an organizing empyema and severe idiopathic pulmonary fibrosis. Br J Anaesth 2006; 97:266-8. [PMID: 16831882 DOI: 10.1093/bja/ael167] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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