Comparing the effectiveness of single-lumen high-frequency positive pressure ventilation with double-lumen endobronchial tube for the anesthesia management of endoscopic thoracic sympathetic blockade surgery.

OBJECTIVES: In this trial, we aimed to compare anesthetic effectiveness of single lumen tube (SLT) for tracheal intubation with high-frequency positive pressure ventilation (HFPPV) versus classic double lumen tube (DLT) for tracheal intubation in endoscopic thoracic sympathetic blockade surgery. DESIGN: This was a prospective randomized controlled clinical study. SETTING: The study was single-centered and conducted in a university hospital. PARTICIPANTS: There were 135 endoscopic thoracic sympathetic blockade patients in this study. INTERVENTIONS: The patients were randomly allocated either to DLT (n = 67) or SLT (n = 68) groups. In SLT group, the ventilator setting was kept with frequencies that range from 1 to 1.8 Hz (60-110/min). Data regarding anesthesia duration, surgery duration, difficult intraoperative lung deflation, postoperative atelectasis, postoperative pain, postoperative pneumothorax were recorded and compared. All patients were operated by a single experienced surgeon under general anesthesia provided by the same anesthesia team. MEASUREMENTS AND MAIN RESULTS: Both groups were age and gender matched. Among all recorded variables, only anesthesia time was found to be close to statistical significance (P = .059, favoring single lumen). All other parameters were found to be similar between groups. (P < .05). CONCLUSION: We reported that DLT and single lumen tracheal intubation were equally effective for lung deflation during surgery, and SLT with HFPPV ventilation mode during endoscopic thoracic sympathetic blockade surgery provided the surgeon with an adequate and clean workspace with shorter onset of anesthesia. We may suggest the HFPPV technique for uncomplicated surgery groups or where sufficient conditions for DLT cannot be provided in the operating room.

Surgical Anatomy of the Posterior Intermuscular Approach to the Brachial Plexus.

Background: First rib resection and scalenectomy is a well-established treatment option for thoracic outlet syndrome. The posterior approach is rarely used due to extensive muscle sacrifice resulting in significant procedural morbidity. In this paper, we report the surgical anatomy of modified and less-invasive muscle-sparing posterior approach. Methods: Eleven human cadavers were used in this study. With specific care to preserve muscles' integrity, the brachial plexus was exposed by dissecting through the posterior neck musculature. A muscular triangle was found under the trapezius muscle, which provided direct access to deeper structures. Four anatomical reference points were identified to denote a 3-dimensional space enclosing proximal brachial plexus. Results: A muscular triangle was found under the trapezius muscle in all cadavers. It was bordered infero-medially by rhomboid minor, supero-medially by splenius capitis, and laterally by levator scapula muscles. The inferomedial border (rhomboid) was 55 mm (48-80), superomedial border (splenius capitis) was 60.5 mm (42-89), and the lateral border (levator scapulae) was 99 mm (60-130). A consistent vein was present inside the triangle and could be used as an anatomical landmark. The 4 reference points were C5, T1 intervertebral foramina, transverse tubercle, and scalene tubercle of the first rib. Removal of the first rib could be performed without brachial plexus retraction. The latter was exposed from neural foramina to lateral border of the first rib. Conclusions: The posterior approach provides ample space to for exposure and manipulation with the first rib and proximal brachial plexus.