One-lung Ventilation Research Articles

Advancements in Respiratory Surgery Anesthesia: A Collaborative Approach to Perioperative Management and Recovery

Thoracic surgery is a highly complex field requiring collaboration between surgeons, anesthesiologists, pulmonologists, and other specialists. Successful outcomes depend on thorough preoperative evaluations that consider the patient’s overall health, lifestyle habits, and surgical risks. Key elements include proper intraoperative anesthesia management, postoperative pain control, and the integration of enhanced recovery after surgery (ERAS) protocols to optimize recovery. Double-lumen tubes (DLTs) are essential for one-lung ventilation during thoracic procedures, although they can be invasive. Recent advancements, such as video-assisted laryngoscopes, have improved the success of DLTs and reduced the invasiveness of DLT intubation and extubation. Postoperative pain management is crucial for minimizing complications and enhancing recovery. Techniques like epidural analgesia, nerve blocks, and patient-controlled analgesia improve patient outcomes by allowing early mobility and deep breathing. Dexmedetomidine (DEX), a sedative with minimal respiratory impact, has shown promise in reducing delirium and aiding recovery. This review highlights the importance of teamwork, pain management, and emerging technologies in improving thoracic surgery outcomes. Advances in these areas, particularly within ERAS protocols, continue to enhance patient care and overall surgical success.

Anesthetic Considerations for Repair of Thoracoabdominal Aortic Aneurysms.

Anesthetic management of open thoracoabdominal aneurysm (TAAA) repair poses a number of challenges for even the most experienced of cardiovascular anesthesiologists. This procedure encompasses a large number of unique anesthetic techniques, including one-lung ventilation, invasive hemodynamic monitoring, left-heart bypass, massive transfusion, selective renal and visceral perfusion, and central nervous system monitoring with CSF drainage. In this article, we aim to describe the anesthetic management for thoracoabdominal aortic aneurysm repair, including preoperative workup, intraoperative management, as well as postoperative concerns in the intensive care unit.

Preoperative Multivariable Model for Risk Stratification of Hypoxemia During One-Lung Ventilation

BACKGROUND: Hypoxemia occurs with relative frequency during one-lung ventilation (OLV) despite advances in airway management. Lung perfusion scans are thought to be one of the most accurate methods to predict hypoxemia during OLV, but their complexity and costs are well-known limitations. There is a lack of preoperative stratification models to estimate the risk of intraoperative hypoxemia among patients undergoing thoracic surgery. Our primary objective was to develop a risk stratification model for hypoxemia during OLV based on preoperative clinical variables. METHODS: This is a single-center, retrospective cohort study including 3228 patients who underwent lung resections with OLV from 2017 to 2022, at a tertiary academic health care center in the United States. Vital signs and ventilator settings were retrieved minute by minute. Intraoperative hypoxemia was defined as an episode of oxygen desaturation (Spo 2 <90%) for at least 5 minutes. Demographic and clinical characteristics were included in a stepwise logistic regression, which was used for the selection of predictors of the risk score model. All patients included in this cohort underwent elective lung surgery in lateral decubitus position, with double lumen tube and placement confirmation with fiberoptic bronchoscopy. Our model was validated internally using area under the receiver operating curves (AUC) with bootstrapping correction. RESULTS: The incidence of hypoxemia during OLV was 8.9% (95% confidence interval [CI], 8.0–10.0). Multivariable logistic regression identified 9 risk factors with their corresponding scoring: preoperative Spo 2 <92% (15 points), hemoglobin <10 g/dL (6 points), age >60 years old (4 points), male sex (4 points), body mass index >30 kg/m2 (8 points), diabetes mellitus (4 points), congestive heart failure (7 points), hypertension (3 points), and right-sided surgery (3 points). The AUC of the model after bootstrap correction was 0.708 (95% CI, 0.676–0.74). Based on the highest Youden index, the optimal score for predicting intraoperative hypoxemia was 13. The risk of hypoxemia increased from 4.7% in the first quartile of scores (0–13 points), to 32% in the third quartile (27–39 points), and 83.3% in the fourth quartile (>39 points). At scores of 20 or greater, the specificity of the model exceeded 90% and reached a positive predictive value of 80%. CONCLUSIONS: The risk of hypoxemia during OLV can be stratified preoperatively using accessible clinical variables. Our risk model is well calibrated but showed moderate discrimination for predicting intraoperative hypoxemia. The accuracy of preoperative models for risk stratification of hypoxemia during OLV should be explored in prospective studies.

Resolvin E1 and Inhibition of BLT2 Signaling Attenuate the Inflammatory Response and Improve One-Lung Ventilation-Induced Lung Injury

ABSTRACT Introduction One-lung ventilation (OLV) is a prevalently used technique to sustain intraoperative pulmonary function. Resolvin E1 (RvE1), a specialized pro-resolving lipid mediator, accelerates the resolution of inflammation in the lungs. However, its therapeutic effects on OLV-induced lung injury remain unclear. Methods We initially developed an OLV rat model and treated it with RvE1. Subsequently, we assessed the wet/dry ratio of the lung tissue, performed hematoxylin and eosin staining, and calculated the ratio of polymorphonuclear cells to white blood cells in the bronchoalveolar lavage fluid. Additionally, we assessed apoptosis, inflammatory factor levels, and lung permeability in the rat lung tissues in the RvE1 treated and untreated groups and explored the molecular mechanisms mediated by RvE1. Results Our results indicated that RvE1 alleviated lung injury and inflammation and improved lung tissue apoptosis and permeability in OLV rats. Moreover, RvE1 suppressed the expression of the BLT1/2 signaling pathway and its ligands. The use of BLT2 and BLT1 inhibitors (LY255283 and U-75302, respectively) enhanced RvE1’s anti-inflammatory effects and reduced lung injury. Furthermore, synergistic treatment with the BLT2 inhibitor and RvE1 provided grater benefits by more effectively inhibiting the NF-kB, p38 MAPK, and ERK pathways. Discussion RvE1 and the inhibition of BLT2 signalling reduce the inflammatory response and mitigate OLV-induced lung injury. These findings suggest a novel therapeutic pathway for managing OLV-related complications.

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: A Blinded Observational Feasibility Study.

Minimally invasive thoracic surgical techniques require effective lung isolation using one-lung ventilation (OLV). Verification of lung isolation may be confirmed by auscultation, visual confirmation using fiberoptic bronchoscopy (FOB), or more recently, point-of-care ultrasound (POCUS). The aim of this study was to prospectively compare lung ultrasound with clinical auscultation to confirm OLV before thoracic surgery in pediatric patients. This prospectively blinded feasibility study included 40 patients ranging in age from 0 to 20 years. After confirmation of lung separation by the primary anesthesia team using FOB, the sonographer and the auscultator, both blinded to the laterality of surgery and lung separation, entered the operating room. The sonographer evaluated for pleural lung sliding and the auscultator listened for breath sounds. Successful lung separation was definitively confirmed by direct visualization of lung collapse during the operation. In confirming effective single-lung ventilation, lung ultrasound had a diagnostic accuracy of 95% (95% confidence interval [CI], 82.7%-98.5%). In contrast, auscultation could only reliably confirm lung isolation with 68% accuracy (95% CI, 51.5%-80.4%). The McNemar test showed a statistically significant difference between the use of lung ultrasound and auscultation (P < .001). The median time to perform ultrasonography was 67 seconds (interquartile range [IQR], 46-142) and the median time to perform auscultation was 21 seconds (IQR, 10-32). Based on the initial results of our feasibility trial, lung ultrasound proved to be a fast and reliable method to verify single-lung ventilation in pediatric patients presenting for thoracic surgery with a high degree of diagnostic accuracy.

Management of the Expected Difficult Airway with Planned One-Lung Ventilation: A Retrospective Analysis of 44 Cases.

Difficult airway management is essential in anesthesia practice. Particular challenges are posed to patients who require intraoperative one-lung ventilation. Specific guidelines for these scenarios have been lacking. The recent update of German guidelines incorporates recommendations for securing the airway in anticipated difficult airway scenarios in patients requiring one-lung ventilation. However, scientific data on this specific topic is rare. A retrospective analysis was conducted on adult patients undergoing thoracic surgery with one-lung ventilation from 2016 to 2021. During these years, the standard of practice has been in line with the now published guidelines. Patients with anticipated difficult airways were identified, and airway management strategies were analyzed. Among 3,197 anesthetic procedures, 44 cases involved anticipated difficult airways, primarily due to prior head and neck tumor treatment. Nasal bronchoscopic awake intubation followed by oral reintubation under videolaryngoscopic inspection and the use of bronchial blockers was the standard procedure. No severe complications were recorded, and one-lung ventilation was maintained successfully in all cases. The study highlights the challenges of managing difficult airways during thoracic surgery. Recommendations align with recent guidelines, emphasizing the importance of tailored approaches. The use of single-lumen tubes with bronchial blockers appears favorable over double-lumen tubes, offering comparable ventilation quality with reduced risks. Despite limitations, the study underscores the safety and efficacy of tailored airway management strategies during one-lung ventilation in patients with anticipated difficult airways. The presented approach offers patient safety and practicability. Further multicenter studies are warranted to validate these findings and refine clinical approaches.

Impact of intravenous infusion of lidocaine on intrapulmonary shunt and postoperative cognitive function in patients undergoing one-lung ventilation.

Intravenous infusion of lidocaine as an anesthesia adjuvant can improve patient outcomes, but its impact on intrapulmonary shunt during one-lung ventilation (OLV) has not been clarified. To determine the effect of intravenous lidocaine infusion on intrapulmonary shunt during OLV and postoperative cognitive function in video-assisted thoracoscopic surgery (VATS). Sixty patients who underwent OLV for thoracic surgery were randomized to receive intravenous infusion of lidocaine (lidocaine group, n = 30) or normal saline (control group, n = 30) for anesthesia induction. Arterial and venous blood gases were measured during two-lung ventilation and at 15 and 30 min after OLV (OLV + 15 and OLV + 30). The Mini-Mental State Examination was administered before the surgery and at postoperative 12 months to assess patient cognitive function. No significant difference was found in intrapulmonary shunt fraction (Qs/Qt) between the lidocaine group and the control group at OLV + 15 (p = 0.493) and OLV + 30 (p = 0.754). The lidocaine group used significantly lower doses of propofol and remifentanil compared to the control group (both p < 0.001). Furthermore, no significant difference was observed in the incidence of postoperative cognitive dysfunction between the lidocaine group and the control group at 1 year post-operation (3.3% vs 6.7%, p = 0.554). Intravenous lidocaine administered in VATS had no significant impact on intrapulmonary shunt during OLV or postoperative cognitive function. However, it significantly reduced the doses of anesthetics used during the surgery.

The effects of thoracic epidural blockade on ventilation-perfusion matching during one-lung ventilation: An exploratory study

ObjectiveElectrical impedance tomography (EIT) enables continuous image acquisition, facilitating real-time measurements of ventilation and perfusion at the clinical bedside. Experimental and clinical studies on controversial effects of thoracic epidural blockade (TEB) with local anesthetics on ventilation-perfusion(V/Q) matching and hypoxia during one lung ventilation (OLV) are rare. The aim of this study was to use EIT to investigate the effects of TEB combined with general anesthesia on pulmonary perfusion distribution and V/Q matching during one-lung ventilation. DesignSingle-centered, prospective, unblinded, randomized, parallel-group clinical trial. SettingSurgical suite of a university-affiliated teaching hospital. PatientsThirty patients prepared for thoracic surgery were randomly assigned to either the control group or the TEB group, which received a combination of thoracic epidural blockade and general anesthesia. MeasurementsEIT measurements and blood gas analysis were conducted in the lateral position during two-lung ventilation(T0), 15 min after OLV(T1), and 15 min after administration of 0.25 % ropivacaine or 0.9 % saline via epidural delivery during OLV(T2). Hemodynamic and respiratory parameters were recorded, and Dead Space%, Shunt%, and V/Q Match% were calculated based on blood gas analysis and EIT images. ResultsMean arterial pressure (p < 0.05) significantly decreased 15 min after TEB, while there were no significant changes in heart rate among the 30 patients (p = 0.547). OLV resulted in a significant decrease in arterial oxygen partial pressure/inspired oxygen fraction (PaO2/FiO2) from T0 to T1 in both groups. The PaO2/FiO2 in the TEB group was significantly lower after epidural administration of the local anesthetic (p < 0.05). Shunt- ABG (%) was significantly higher in the TEB group compared to the control group at T2 (p < 0.05). TEB increased non-ventilated perfusion distribution(p < 0.05), and Shunt-EIT % (p < 0.05) and reduced Matched Region % (p < 0.05), while Dead Space-EIT % remained (p = 0.499). ConclusionsBased on the contrast-enhanced EIT evaluation of pulmonary perfusion and ventilation, TEB appears to induce a V/Q mismatch in patients undergoing OLV in the lateral position for thoracic surgery.Trial registration: ClinicalTrials.gov, NCT04730089. Registration on January 25th, 2021.

A novel approach to calculate the required volume of air for bronchial blockers in young children.

Bronchial blocker balloons inflated with small volumes of air increase balloon pressure, involving a risk of airway injury especially in young children. However, there are no established guidelines regarding the appropriate volumes of air required to provide safe bronchial occlusion. This study aimed to introduce a novel method for calculating the amount of air required for safe bronchial blocker balloon occlusion for one lung anesthesia in young children. We included 79 pediatric patients who underwent video-assisted thoracoscopic surgery at our hospital. Preoperatively, the balloon pressure and corresponding diameter of 5F bronchial blockers inflated with different volumes of air were measured. Intraoperatively, bronchial diameters measured by computerized tomographic scans were matched to the exvivo measured balloon diameters. The quality of lung isolation, incidence of balloon repositioning, and airway injury were documented. Postoperatively, airway injury was evaluated through fiberoptic bronchoscopy. Balloon pressure and balloon diameter showed linear and nonlinear correlations with volume, respectively. The median lengths of the right and left mainstem bronchi were median (interquartile range) range: 5.3 mm (4.5-6.3) 2.7-8.15 and 21.8 (19.6-23.4) 14-29, respectively. Occluding the left mainstem bronchus required <1 mL of air, with a balloon pressure of 27 cm H2O. The isolation quality was high with no case of mucosal injury or displacement. Occluding the right mainstem bronchus required a median air volume of 1.3 mL, with a median balloon pressure of 44 cm H2O. One patient had poor lung isolation due to a tracheal bronchus and another developed mild and transient airway injury. The bronchial blocker cuff should be regarded as a high-pressure balloon. We introduced a new concept for safe bronchial blocker balloon occlusion for one-lung ventilation in small children.

Infant bronchial tree simulator: Success of a built-from-scratch model for single lung isolation

BackgroundOne-lung ventilation in infants is a high-risk procedure. Complications include endotracheal tube occlusion, with grave consequences. Although there are commercially available bronchoscopy simulators, there are no realistic models of infant patients. This limits access to training opportunities that would ensure safe and efficient lung isolation. To bridge this gap, we developesd a realistic infant bronchial tree model for single lung intubation and evaluated preliminary validity evidence of its features and clinicians’ ability to perform critical skills associated with pediatric one-lung ventilation. MethodsUsing computed tomography imaging, a stereolithography file of an infant airway was generated to 3D print a model. This model was inserted into a commercially available airway trainer to allow lung isolation using standard bronchoscopy techniques. Ten experienced pediatric anesthesiologists independently evaluated the simulator’s physical attributes, realism, value, and relevance using a 29-item paper survey and rated using 4-point rating scales (4 = highest). Participants’ ability to complete 5 critical tasks was self-reported using 5-point rating scales (5 = too easy). Item and domain mean ratings were calculated, and comments reviewed. ResultsOverall, reviews were positive, with mean scores indicating adequate realism and high value. Specific challenges were associated with right mainstem bronchus and upper lobe takeoff. Performance scores indicated that most tasks were “somewhat easy to perform,” suggesting that the model’s anatomy did not hinder physicians’ ability to perform one-lung ventilation. ConclusionPreliminary findings indicate that the novel simulator holds promise for training in lung isolation techniques after refinement. Future research will target refinement, expanding evaluation, and developing a comprehensive curriculum and competency assessment program.

Goal-Directed Fluid Therapy Using Pulse Pressure Variation in Thoracic Surgery Requiring One-Lung Ventilation: A Randomized Controlled Trial.

Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters.

Emergency Operable Traumatic Pulmonary Injury at a Level 1 Trauma Center: A Retrospective Descriptive Study

ABSTRACT Introduction Despite the use of body armor, emergency operable pulmonary trauma (EOPT) remains a major cause of battlefield morbidity and mortality. While EOPT during military conflicts has some features that distinguish it from EOPT in civilian settings, the 2 occurrences demonstrate overall parallel findings related to presentation, management, and outcome. The goals of the present study were to provide a descriptive analysis of the nature of EOPT and its management at a level 1 trauma center and to determine the associations between EOPT patient demographics and/or patient management and outcome in order to better understand battlefield EOPT. Materials and Methods This is a retrospective, descriptive analysis of EOPT at a level 1 trauma center during a recent 9-year period (2012–2020). The Oregon Health &amp; Science University Trauma Registry was searched, and 106 patients met inclusion criteria for the study. Patients with primary cardiac trauma were excluded. Individual electronic medical records were reviewed to obtain descriptive data, and associations were evaluated for statistical significance. Results In-hospital mortality in this cohort was 17.0%. The most common pulmonary injury associated with EOPT was unilateral diaphragmatic laceration (62.3%), and the most common single operation performed for EOPT was a laparotomy (71.7%) often involving diaphragmatic repair. In the remaining instances of EOPT, a thoracotomy (11.3%), a thoracotomy and a laparotomy (10.4%), or another surgery (6.6%) occurred. The primary indication for EOPT surgery was uncontrolled hemorrhage, and one-third of patients received massive transfusion. One-lung ventilation (OLV) was infrequently employed (8.5%). When OLV was used, it was equally likely to involve a single-lumen endotracheal tube (SLETT) with mainstem bronchus insertion, a SLETT with a bronchial blocker, or a double-lumen endotracheal tube. Time from EOPT to operating room arrival was inversely related to in-hospital mortality. Also, both initial in-hospital endotracheal intubation and low injury severity score were strongly associated with survival in the population studied. Conclusions The most common indication for EOPT surgery was uncontrolled hemorrhage. The most frequent operation performed for this EOPT cohort was a laparotomy for diaphragmatic repair. A total of 91.5% of EOPT surgery was performed without OLV, an unexpected finding. When OLV occurred, it was equally likely to involve an SLETT with mainstem bronchus insertion, an SLETT with bronchial blocker, or a double-lumen endotracheal tube. The most common indication for OLV was surgical exposure. More extensive injury (expressed as an injury severity score), preadmission endotracheal intubation, and a shorter time from EOPT to operating room arrival were associated with increased odds ratios for mortality. A better understanding of the nature of EOPT at a civilian level 1 trauma center can serve to identify conditions that are associated with more favorable outcomes for EOPT under battlefield conditions and thereby assist in both management decisions and to help prognosticate and triage severely injured patients in that setting.

Effects of Dexmedetomidine in Improving Oxygenation and Reducing Pulmonary Shunt in High-Risk Pediatric Patients Undergoing One-Lung Ventilation for Thoracic Surgery: A Double-Blind Randomized Controlled Trial.

Background and objectives Pediatric thoracic surgery has unique considerations due to the immaturity of the respiratory system anatomically and physiologically, which presents technical and pharmacological considerations, including the very common technique of one-lung ventilation (OLV), which causes serious complications in children. Therefore, we investigated the effects of dexmedetomidine on oxygenation and pulmonary shunt fraction (Qs/Qt) in high-risk pediatric patients undergoing OLV for thoracic surgery. This randomized controlled trial aimed to investigate dexmedetomidine's effect on the partial pressure of arterial oxygen (PaO2) and pulmonary shunt fraction (Qs/Qt). Methods A total of 63 children underwent thoracic surgery with OLV and were divided into two groups. The dexmedetomidine group (group Dex, n = 32) received dexmedetomidine (0.4 μg/kg/hour), and the placebo group (group placebo, n = 31) received normal saline. Two arterial and central venous blood samples were taken for arterial and venous blood gas analysis at four time points: T1 (10 minutes after mechanical ventilation of total lung ventilation), T2 (10 minutes after OLV), T3 (60 minutes after OLV), and T4 (20 minutes after the end of OLV). At these intervals, the following parameters were measured: PaO2, Qs/Qt, mean arterial pressure (MAP), heart rate (HR), and peak inspiratory pressure (PIP). Results The two groups had no significant differences in FEV1/FVC and baseline pulmonary shunt fraction (Qs/Qt). Dexmedetomidine significantly improved PaO2 compared with placebo during OLV (T2 and T3). There was a significant decrease in Qs/Qt compared with placebo during OLV (T2, T3, and T4). There was a decrease in PIP compared with placebo during OLV (T2 and T3). No statistically significant differences in MAP or HR were observed between the groups. Conclusion Infusion of dexmedetomidine during OLV in high-risk pediatric thoracic surgery reduces shunt and pulmonary shunt fraction Qs/Qt, improves PaO2 and body oxygenation, reduces PIP and pressure load, and maintains hemodynamic stability (MAP, HR).

Impact of staged goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing McKeown esophagectomy: a randomized controlled trial

BackgroundOur aim was to evaluate the influence of staged goal directed therapy (GDT) on postoperative pulmonary complications (PPCs), intraoperative hemodynamics and oxygenation in patients undergoing Mckeown esophagectomy.MethodsPatients were randomly divided into three groups, staged GDT group (group A, n = 56): stroke volume variation (SVV) was set at 8–10% during the one lung ventilation (OLV) stage and 8–12% during the two lung ventilation (TLV) stage, GDT group (group B, n = 56): received GDT with a target SVV of 8–12% During the entire surgical procedure, and control group (group C, n = 56): conventional fluid therapy was administered by mean arterial pressure (MAP), central venous pressure (CVP), and urine volume. The primary outcome was the incidence of postoperative pulmonary complications within Postoperative days (POD) 7. The secondary outcomes were postoperative lung ultrasound (LUS) B-lines artefacts (BLA) scoring, incidence of other complications, the length of hospital stay, intraoperative hemodynamic and oxygenation indicators included mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), cardiac output (CO), oxygenation index (OI), respiratory indices (RI), alveolar-arterial oxygen difference (Aa-DO2).ResultsPatients in group A and group B had a lower incidence of PPCs (7/56 vs. 17/56 and 9/56 vs. 17/56, p < 0.05), and a fewer B-lines score on postoperative ultrasound (4.61 ± 0.51 vs. 6.15 ± 0.74 and 4.75 ± 0.62 vs. 6.15 ± 0.74, p < 0.05) compared to group C. The CI, CO, MAP, and OI were higher in group A compared to group B and group C in the stage of thoracic operation. During the abdominal operation stage, patients in group A and group B had a better hemodynamic and oxygenation indicators than group C.ConclusionsIn comparison to conventional fluid therapy, intraoperative staged GDT can significantly reduce the incidence of postoperative pulmonary complications in patients undergoing McKeown esophagectomy, facilitating patient recovery. Compared to GDT, it can improve intraoperative oxygenation and stabilize intraoperative hemodynamics in patients.Trial registrationThis study was registered in the Chinese Clinical Trial Registry on 24/11/2021 (ChiCTR2100053598).

Bronchial Blocker Versus Endobronchial Intubation in Young Children Undergoing One-Lung Ventilation: A Multicenter Retrospective Cohort Study.

Thoracic surgery and one-lung ventilation in young children carry significant risks. Approaches to one-lung ventilation in young children include endobronchial intubation (mainstem intubation) and use of a bronchial blocker. We hypothesized that endobronchial intubation is associated with a greater prevalence of airway complications compared to use of a bronchial blocker. The Multicenter Perioperative Outcomes Group database was queried from 2004 to 2022 for one-lung ventilation cases in children, 2 months to 3 years of age, inclusive. Airway notes and free-text comments were manually reviewed for airway complications. Documented airway complications were considered the primary outcome and were divided into "Moderate" and "Critical." Moderate airway complications were bronchial blocker or endotracheal tube movement leading to loss of isolation, hypoxemia requiring ventilatory intervention, bronchial blocker migration into the trachea, significant impairment of ventilation, and other. Critical complications included reintubation or airway replacement intraoperatively, complete endotracheal tube occlusion, cardiac arrest or airway-related bradycardia, and procedure aborted due to an airway issue. An adjusted propensity score-matched analysis was then used to assess the impact of a bronchial blocker on the outcomes of moderate and critical complications. After exclusions, 704 patients were included in the primary analysis. In unadjusted analyses, no statistically significant difference was observed in moderate airway complications between endobronchial intubation and bronchial blocker cohorts: 37 of 444 (8.3%; 95% confidence interval [CI], 5.9%-11.3%) vs 28 of 260 (10.8%; 95% CI, 7.3%-15.2%) with P = .281. In the unadjusted analysis, the prevalence of critical airway complications was significantly higher in the endobronchial intubation cohort compared to the bronchial blocker cohort: 28 of 444 (6.3%; 95% CI, 4.2%-9.0%) vs 5 of 260 (1.9%; 95% CI, 0.6%-4.4%) with P = .008. In the propensity-matched cohort analysis, endobronchial intubation was associated with a slightly increased risk of critical complications compared to use of a bronchial blocker: 14 of 243 (5.8%; 95% CI, 2.8%-8.7%) vs 5 of 243 (2.1%; 95% CI, 0.3%-3.8%) with P = .035. Endobronchial intubation might be associated with a slightly increased risk of critical airway complications compared to use of a bronchial blocker in young children undergoing thoracic surgery and one-lung ventilation. Further, prospective studies are needed before a definitive change in practice is recommended.

Repercussions of SARS-CoV-2 infection on intrapulmonary shunt in patients undergoing one-lung ventilation

BackgroundHypoxic pulmonary vasoconstriction is the most important regulatory mechanism by which right-to-left shunts decrease during one-lung ventilation (OLV), but the effects of pulmonary microarterial thrombosis and impaired HPV after SARS-CoV-2 infection on intrapulmonary shunt during OLV remain unknown. The aim of this study was to observe the changes of intrapulmonary shunt in patients undergoing thoracoscopic partial pneumonectomy at different periods after SARS-CoV-2 infection compared with patients without SARS-CoV-2 infection history.MethodsA total of 80 patients who underwent elective thoracoscopic partial lung resection and were classified as American Society of Anaesthesiologists (ASA) grades I-II were selected and divided into 4 groups (n = 20 in each group): patients not infected with SARS-CoV-2 (Group A), patients infected with SARS-CoV-2 for 5–8 weeks (Group B), patients infected with SARS-CoV-2 for 9–12 weeks (Group C), and patients infected with SARS-CoV-2 for 13–16 weeks (Group D). For all patients, the same anaesthesia method was adopted, and anaesthesia was maintained with propofol, remifentanil, and cisatracurium. Radial artery and mixed venous blood gases were measured at 10 min of two-lung ventilation (TLV), 15 min of one-lung ventilation (OLV15), and 30 min of OLV (OLV30) in the lateral recumbent position to calculate the intrapulmonary shunt. Multiple linear regression analysis was employed to investigate the association between intrapulmonary shunt and SARS-CoV-2 infection.ResultsQs/Qt at TLV was significantly higher in Groups B and C than in Group A (P < 0.05), and PaO2 at TLV was significantly lower in Groups B and C than in Group A (P < 0.05). Qs/Qt values at OLV15 and OLV30 were significantly higher in Group B, C or D than in Group A (P < 0.05), and PaO2 values at OLV15 and OLV30 were significantly lower in Groups B, C or D than in Group A (P < 0.05). Multiple linear regression analysis revealed that SARS-CoV-2 infection (95%CI -4.245 to -0.679, P = 0.007) was an independent risk factor for increased intrapulmonary shunt during TLV, while SARS-CoV-2 infection (95%CI 0.124 to 3.661, P = 0.036), exacerbation of COVID-19 clinical classification (95%CI -5.203 to -1.139, P = 0.003), and persistent symptoms (95%CI -12.122 to -5.522, P < 0.001) were independent risk factors for increased intrapulmonary shunt during OLV after SARS-CoV-2 infection.ConclusionSARS-CoV-2 infection increased intrapulmonary shunt and reduced oxygenation. Although oxygenation improved at TLV after 13–16 weeks of infection, intrapulmonary shunt and oxygenation under OLV took longer to recover.Trial registrationChinese Clinical Trial Registry, Retrospectively registered, Full date of first registration: 17/05/2023, Registration number: ChiCTR2300071539.

Pulmonary Artery Endograft Implantation Using a Parallel Stent Grafting Technique to Enable the Treatment of a Bronchial Anastomosis Complication After Lung Transplantation.

Bronchial stenosis associated with bronchial anastomosis dehiscence after lung transplantation is a catastrophic complication following lung transplantation with a paucity of therapeutic solutions. To describe an adaptation of the parallel stent grafting technique in the pulmonary arterial territory to treat this challenging situation. This is a case report of a 52-year-old patient who presented bronchus stenosis and bronchial anastomosis dehiscence after lung transplantion. Bronchial stenting and lung retransplantation were contraindicated. Therefore, an endovascular approach using pulmonary artery endograft placement to prevent bleeding during repeated right bronchial balloon dilation was propposed. The technique consists of the deployment of an aortic extender endoprosthesis in the right main pulmonary artery and a balloon expandable stent in the upper lobe pulmonary artery (using a parallel graft configuration) through the common femoral and right internal jugular veins, respectively. Intraoperative transesophageal echocardiogram and one-lung ventilatory ventilation are needed. The patient underwent a new bronchoscopy 16 days after the procedure, that showed epithelization at the previous eroded zone, enabling bronchocopic balloon dialtion to be safely performed. A post-operative contrast-enhanced CT scan revealed an adequate positioning of the stent grafts. Despite all eforts, the patient succumbed to ventilator associated pneumonia on postoperative day 108. The technique's advantages include its feasibility even in situations in which other techniques may be contraindicated and its potential use in emergencies. Its limitations include the need for experienced interventionists to perform it, and the potential risk of acute tricuspid regurgitation. This study illustrates the early feasibility of the parallel stent grafting technique applied to the pulmonary artery territory. However, it's safety profile regarding infectious risk was not demontrated.

A Comparison of Conventional Rotating Method and Non-Rotating Method for Double-Lumen Tube Insertion Using a Customized Rigid J-Shaped Stylet for One-Lung Ventilation: A Randomized Controlled Trial.

Background: The conventional double-lumen tube (DLT) insertion method requires a rotatory maneuver that was developed using direct laryngoscopy and may not be optimal for video laryngoscopy. This study compared a new non-rotatory maneuver with the conventional method for DLT insertion using video laryngoscopy. Methods: Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly assigned to either the rotating (R) or non-rotating (NR) method groups. All patients were intubated using a customized rigid J-shaped stylet, a video laryngoscope, and a left-sided silicone DLT. The conventional rotatory maneuver was performed in the R group. In the NR group, the stylet was inserted with its tip oriented anteriorly (12 o'clock direction) while maintaining the bronchial lumen towards the left (9 o'clock direction). After reaching the glottic opening, the tube was inserted using a non-rotatory maneuver, maintaining the initial orientation. The primary endpoint was the intubation time. Secondary endpoints included first-trial success rate, sore throat, hoarseness, and airway injury. Results: Ninety patients (forty-five in each group) were included. The intubation time was significantly shorter in the NR group compared to the R group (22.0 [17.0, 30.0] s vs. 28.0 [22.0, 34.0] s, respectively), with a median difference of 6 s (95% confidence interval [CI], 3-11 s; p = 0.017). The NR group had a higher first-attempt success rate and a lower incidence of sore throats. Conclusions: The non-rotatory technique with video laryngoscopy significantly reduced intubation time and improved first-attempt success rate, offering a viable and potentially superior alternative to the conventional rotatory technique.

Expression of Concern: Dexmedetomidine improves lung injury after one-lung ventilation in esophageal cancer patients by inhibiting inflammatory response and oxidative stress.

Expression of Concern: Dexmedetomidine improves lung injury after one-lung ventilation in esophageal cancer patients by inhibiting inflammatory response and oxidative stress.

Bibliometric and knowledge map analysis of one lung ventilation.

One lung ventilation (OLV) is an essential method of lung isolation to protect the ventilated lung from soiling by the contralateral lung and obtain optimal surgical exposure in thoracic surgery. This study aims to examine the trends and developments in OLV research from 1982 to 2024 through bibliometric analysis. The literature on OLV was systematically searched in the Web of Science Core Collection database for this study. VOSviewer and CiteSpace were utilized to perform comprehensive bibliometric and visual analyses of global publication/trends, countries/institutions, authors/co-cited authors, journals/co-cited journals, co-cited references, and keywords in the field of OLV. A total of 1,682 articles and reviews on OLV research were identified, which showed an overall growing trend from 1982 to 2024. The United States was the leader in this field, accounting for the largest number of publications (n=299). Among all institutions, Yonsei University had the largest number of publications (n=23), but National Taiwan University Hospital had the highest number of cited publications (n=876). The papers related to OLV were mainly published in Journal of Cardiothoracic and Vascular Anesthesia (n=147) and the most productive author was Cheng YJ (n=15). After keywords analysis, "infants", "dexmedetomidine", "inflammation", and "airway management" were newly emergent research hotspots. Through bibliometric and visualization methods, we undertook a comprehensive analysis in the field of OLV. The United States maintained a top position in this field, the emerging hotspots of OLV changed from basic research to clinical research and the further innovation of OLV management. This study provides new ideas for scholars in their future works.