Nonintubated versus Intubated Lung Volume Reduction Surgery in Patients with End-Stage Lung Emphysema and Hypercapnia.

Lung volume reduction surgery (LVRS) represents an important treatment option in carefully selected patients with end-stage lung emphysema. The aim of this study was to assess the efficacy and safety of nonintubated LVRS compared to intubated LVRS in patients with preoperative hypercapnia and lung emphysema. Between April 2019 and February 2021, n = 92 patients with end-stage lung emphysema and preoperative hypercapnia undergoing unilateral video-assisted thoracoscopic LVRS (VATS-LVRS) performed in epidural anesthesia and mild sedation (nonintubated, group 1) or conventional general anesthesia (intubated, control, group 2) were prospectively enrolled in this study. Data were retrospectively analyzed. In all patients, low-flow veno-venous extracorporeal lung support (low-flow VV ECLS) was applied as a bridge through LVRS. Ninety-day mortality was considered as the primary outcome. Secondary endpoints included: chest tube duration, hospital stay, intubation and conversion to general anesthesia. Intergroup analysis showed no significant difference between the baseline data and patients' demographics. N = 36 patients underwent nonintubated surgery. VATS-LVRS under general anesthesia was performed in n = 56 patients. The mean duration of postoperative VV ECLS support was 3 ± 1 day in group 1 compared to 4 ± 1 in group 2. The 90-day mortality rate was 3% in group 1 compared to 7% in group 2. In group 1, all chest tubes were removed 5 ± 1 day (range 4-32 days) and 8 ± 1 day (range 4-44 days) in the control group after the surgery (p < 0.02). Prolonged chest tube therapy (>8 days) was observed in n = 3 patients in group 1 and n = 11 patients in the control group. The mean ICU stay was 4 ± 1 days in group 1 compared to 8 ± 2 days in the control group (p = 0.04). The mean hospital stay was significantly shorter in the nonintubated group 1 (6 ± 2 days vs. 10 ± 4 days, p = 0.01). Conversion to general anesthesia was necessary in one patient due to severe pleural adhesions. Nonintubated VATS-LVRS in patients with end-stage lung emphysema and hypercapnia is effective and well tolerated. Compared to general anesthesia, a reduction in mortality, chest tube duration, ICU and hospital stay and lower rate of prolonged air leak was observed. VV ECLS increases intraoperative safety and mitigates postoperative complications in such "high-risk" patients.

Lung Volume Reduction Surgery Reduces Pulmonary Arterial Hypertension Associated With Severe Lung Emphysema and Hypercapnia.

Lung volume reduction surgery (LVRS) represents a standard surgical approach for patients with severe pulmonary emphysema. One of the relevant risk factors for LVRS is the presence of pulmonary arterial hypertension (PAH). The aim of this study is to assess the postoperative changes in pulmonary arterial pressure (PAP) after LVRS for patients with severe pulmonary emphysema compared with preoperative measures. N = 61 consecutive patients with severe pulmonary emphysema and preoperative evidence for PAH (pulmonary arterial systolic pressure [PASP] ≥ 35 mmHg) were prospectively included into this study. In all patients, thoracoscopic LVRS was performed. PASP was assessed by echocardiography before surgery, early postoperatively, and 3 months after surgery. Data were prospectively recorded and analyzed retrospectively. Primary end points were the postoperative changes in PASP as well as the 90 day mortality rate. Secondary endpoints included: pulmonary function test, exercise capacity, quality of life, and dyspnea symptoms (Borg scale). Early after surgery, a significant reduction in PASP was observed at the day of discharge and at 3 month follow-up. In n = 34 patients, no tricuspid valve regurgitation was detectable anymore suggesting normal PAP. In n = 3 patients, venovenous extracorporeal lung support (VV ECLS) was already implemented preoperatively. In the remaining cases, VV ECLS was applied intraoperatively and continued postoperatively. Mean duration of postoperative ECLS support was 2 days. Four patients died due to acute right heart failure, two patients from sepsis with multiorgan failure, and one patient from acute pulmonary embolism. Ninety day mortality was 11.5 %. A significant improvement was postoperatively observed regarding the performance status, dyspnea scale, as well as quality of life. This study suggests a beneficial effect of LVRS on PAP, which may ultimately help to protect and stabilize right ventricular function. Further studies, implementing pre- and postoperative right heart catheterizations including invasive PAP evaluation, are necessary to support the findings in this study in greater detail.

Blood purification therapy in patients with severe COVID-19 requiring veno-venous ECMO therapy: A retrospective study.

OBJECTIVE: Patients with severe manifestations of COVID-19 might exhibit characteristics of a sepsis-like syndrome that can progress to multiple organ failure and ultimately death. Underlying mechanism have been explored and suggest a profound dysregulation of the immune system associated with hyperinflammation, hemodynamic instability and respiratory failure. Besides standard intensive care treatment, approaches modulating the dysregulated immune response, such as CytoSorb hemoadsorption, have been used. However, data of ECMO-dependent patients in comparison to a control cohort remain scarce. METHODS: Included were 26 critically ill COVID-19 patients requiring high-flow veno-venous extracorporeal membrane oxygenation (high-flow VV ECMO) therapy due to severe acute respiratory distress syndrome (ARDS), of whom 16 were additionally treated with an extracorporeal hemoadsorption device, and compared to a control group of 10 patients. Assessed were levels of inflammatory markers, vasopressor requirements, oxygenation parameters, as well as clinically relevant outcome variables. Data were prospectively recorded and retrospectively analyzed. RESULTS: Treatment with the applied multimodal therapy approach resulted in a stabilization in hemodynamics, a control of the hyperinflammatory response as evidenced by a significant reduction in inflammatory mediators, as well as a marked improvement in lung function. No device related adverse events were observed while treatment appeared safe and feasible. CONCLUSION: Treatment of a critically ill COVID-19 ARDS patients with combined VV ECMO support and hemoadsorption therapy led to a rapid and sustained hemodynamic stabilization, a control of the uncontrolled inflammatory response and an improvement in oxygenation. Given these signals pointing toward a patient-oriented benefit of extracorporeal hemoadsorption therapy in those patients, future controlled, randomized studies should focus on the investigation of the appropriate timing and dosing of this promising treatment modality.

Multidisciplinary management of pleural infection after ventricular assist device implantation.

BACKGROUND: Postsurgical pleural infection is a life-threatening complication after implantation of artificial devices such as ventricular assist devices (VADs). The treatment can be challenging and the evidence in the literature is very limited. Here we report our multidisciplinary approach of the management of pleural infection after VAD implantation. METHODS: Between March 2014 and December 2019, 33 patients developed postoperative pleural infection after VAD implantation and underwent thoracic surgical intervention at our institution. All patients were prospectively enrolled in this analysis. Data were retrospectively analyzed. Primary outcome was the 90-day mortality rate. Length of ICU stay related to pleural infection, chest tube duration, re-thoracotomy rate and length of ventilatory support represented secondary outcomes. RESULTS: The 90-day mortality rate was 6% (2 patients). The mean ICU stay related to the pleural infection was 6 days (2-24 days). Video-assisted thoracoscopic surgery (VATS) was performed in all patients. Conversion to thoracotomy was necessary in 12 cases. Decortication and parietal pleurectomy in addition to hematoma and empyema removal was performed in all patients. Due to diffuse bleeding, packing of the thoracic cavity with temporary thoracic closure was necessary in 10 patients. Depacking was performed after a mean of 3 days (3-7 days). Recurrent empyema or bleeding after definitive chest closure was not observed. Lung resection was performed in 3 patients. CONCLUSIONS: Thoracic surgical management of pleural infection in patients after VAD implantation is challenging and complicated due to the inevitable anticoagulative therapy. A perioperative multidisciplinary management which includes the early involvement of thoracic surgical expertise helps to improve survival in this very complex patient cohort.

Outcome Prediction in Patients with Severe COVID-19 Requiring Extracorporeal Membrane Oxygenation-A Retrospective International Multicenter Study.

The role of veno-venous extracorporeal membrane oxygenation therapy (V-V ECMO) in severe COVID-19 acute respiratory distress syndrome (ARDS) is still under debate and conclusive data from large cohorts are scarce. Furthermore, criteria for the selection of patients that benefit most from this highly invasive and resource-demanding therapy are yet to be defined. In this study, we assess survival in an international multicenter cohort of COVID-19 patients treated with V-V ECMO and evaluate the performance of several clinical scores to predict 30-day survival. METHODS: This is an investigator-initiated retrospective non-interventional international multicenter registry study (NCT04405973, first registered 28 May 2020). In 127 patients treated with V-V ECMO at 15 centers in Germany, Switzerland, Italy, Belgium, and the United States, we calculated the Sequential Organ Failure Assessment (SOFA) Score, Simplified Acute Physiology Score II (SAPS II), Acute Physiology And Chronic Health Evaluation II (APACHE II) Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score, Predicting Death for Severe ARDS on V­V ECMO (PRESERVE) Score, and 30-day survival. RESULTS: In our study cohort which enrolled 127 patients, overall 30-day survival was 54%. Median SOFA, SAPS II, APACHE II, RESP, and PRESERVE were 9, 36, 17, 1, and 4, respectively. The prognostic accuracy for all these scores (area under the receiver operating characteristic-AUROC) ranged between 0.548 and 0.605. CONCLUSIONS: The use of scores for the prediction of mortality cannot be recommended for treatment decisions in severe COVID-19 ARDS undergoing V-V ECMO; nevertheless, scoring results below or above a specific cut-off value may be considered as an additional tool in the evaluation of prognosis. Survival rates in this cohort of COVID-19 patients treated with V­V ECMO were slightly lower than those reported in non-COVID-19 ARDS patients treated with V-V ECMO.

Combined Use of CytoSorb and ECMO in Patients with Severe Pneumogenic Sepsis.

BACKGROUND: High morbidity and mortality are frequently reported in intensive care patients suffering from severe sepsis with systemic inflammation. With the development of severe respiratory failure, extracorporeal membrane oxygenation (ECMO) is often required. In this study, cytokine adsorption therapy in combination with ECMO is applied in patients with acute respiratory distress syndrome (ARDS) due to severe pneumogenic sepsis. The efficacy of this therapy is evaluated compared with a historical cohort without hemoadsorption therapy. METHODS: Between January and May 2018, combined high-flow venovenous ECMO and CytoSorb therapy (CytoSorb filter connected to ECMO circuit) was applied in patients (n = 13) with pneumogenic sepsis and ARDS. These patients were prospectively included (CytoSorb group). Data from patients (n = 7) with pneumogenic sepsis and ECMO therapy were retrospectively analyzed (control group). RESULTS: All patients survived in the CytoSorb group, where the 30-day mortality rate reached 57% in the control group. After CytoSorb therapy, we instantly observed a significant reduction in procalcitonin (PCT) and C-reactive protein (CRP) levels compared with the control group. Within 48 hours, the initial high doses of catecholamine could be weaned off only in the CytoSorb group. CONCLUSIONS: Our results indicate that CytoSorb in combination with ECMO is an effective therapy to prevent escalation of sepsis with rapid weaning off high-dose catecholamine infusions and quick reduction in PCT and CRP levels. Optimal timing of immunomodulatory therapy and impact on ECMO-related inflammation still need to be furtherly investigated.

Veno-Venous Extracorporeal Lung Support as a Bridge to or Through Lung Volume Reduction Surgery in Patients with Severe Hypercapnia.

Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Rationale of Hemoadsorption during Extracorporeal Membrane Oxygenation Support.

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support are increasingly used for treating various forms of shock, lung failure, protected interventions and life support including resuscitation. Most patients on ECMO are affected by a systemic inflammatory response caused by the underlying disease as well as the ECMO support itself, which contributes to vasoplegia, multi-organ failure, deterioration and death. Unfortunately, effective strategies for control of inflammation and related organ failure and shock on ECMO are lacking. Recently, a new polystyrene-based device for hemoadsorption, which aims to reduce excessive levels of inflammatory molecules such as interleukins, cytokines as well as damage- and pathogen-associated molecular patterns, has become available. Here we summarize the rationale, available data and technical aspects of polystyrene-based hemoadsorption during ECMO support, and give recommendations based on existing experience.

Rib osteosynthesis is a safe and effective treatment and leads to a significant reduction of trauma associated pain.

PURPOSE: The usefulness of chest wall stabilization after blunt chest wall trauma with unstable rib fractures has recently been intensely discussed. Thereby, the surgical approach seems to influence outcome, mortality and the long-term complication rate including chronic chest pain, thoracic deformity and quality of life. Here, we present the outcome after surgical stabilization of unstable rib fractures using intramedullary splints and plate osteosynthesis. METHODS: n = 50 patients were enrolled in this trial. Surgical stabilization was performed using intramedullary splints and/or plate osteosynthesis. Video-assisted thoracoscopy was performed in all patients for the inspection of the thoracic cavity and to exactly localize the fractured ribs. The pre- and postoperative pain course was documented using the visual analog scale. RESULTS: A total of n = 50 patients (10 females, mean age 63 years) were included into the analysis. All patients presented with traumatic serial rib fractures with a mean of 3 fractured ribs (range 2-8 ribs) and an unstable thorax wall. Rib osteosynthesis was performed using intramedullary splints (n = 17 patients), locking plates (n = 17 patients), or a combined use of both procedures (n = 16 patients). Mean operating time was 80 min (31-161 min). No major complications were seen intra- and postoperatively. Mean hospital stay was 8 ± 2 days (2-21 days). In all patients, excellent chest wall stability was achieved. Moreover, a significant reduction of pain was observed (2.6 ± 0.3 postoperatively vs. 8 ± 1.15 preoperatively, p < 0.0001) already during the hospital stay. CONCLUSIONS: Rib osteosynthesis is a safe and effective treatment option for patients with unstable rib fractures after blunt chest wall trauma. It leads to a significant reduction of the trauma-associated pain caused by the rib fractures and supports a quick recovery of the patients.

[Extracorporeal Membrane Oxygenation in Thoracic Surgery: the Anesthesiologist's Perspective]. / Extrakorporale Membranoxygenierung in der Thoraxchirurgie: die Sicht des Anästhesisten.

"Enhanced Recovery after Surgery" programs have been developed for thoracic surgery over the last couple of years. Besides minimally invasive surgical techniques, there are a number of anaesthesiological aspects like the choice of short acting anaesthetics, the use of regional analgesia, a balanced intraoperative fluid therapy, the avoidance of postoperative nausea and vomiting and, most importantly, protective ventilation, that need to be considered. In patients undergoing thoracic surgery procedures with preexisting severe limitations in pulmonary function, protective ventilation under the conditions of one lung ventilation often leads to severe dysfunction of pulmonary gas exchange. In this situation, establishing veno-venous membrane oxygenation (vvECMO) is a sufficient and safe method to facilitate perioperative treatment of these patients. Postoperatively, patients benefit from the continuation of the conscious vvECMO by augmentation of necessary therapeutic procedures such as physical and respiratory therapy or early mobilisation as well as healing of air leakage of the operated lung. To avoid bleeding complications, ECMO can be operated without anticoagulation intraoperatively with heparin-coating of the tube system. Postoperatively, heparin, argatroban or bivalirudin are options for anticoagulation. New techniques like minimally-invasive thoracic surgery under regional anaesthesia and sedation can potentially be developed further using vvECMO support in the future.

Single-Site Cannulation Venovenous Extracorporeal CO2 Removal as Bridge to Lung Volume Reduction Surgery in End-Stage Lung Emphysema.

Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we first describe the application of low-flow venovenous extracorporeal CO2 removal (LFVV-ECCO2R) as bridge to LVRS in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute failure of the breathing pump. Between March and October 2015, n = 4 patients received single-site LFVV-ECCO2R as bridge to LVRS. Indication for extracorporeal lung support was severe hypercapnia with respiratory acidosis and acute breathing pump failure. Two patients required continuous mechanical ventilation over a temporary tracheostomy and were bed ridden. The other two patients were nearly immobile because of severe dyspnea at rest. Length of preoperative ECCO2R was 14 (1-42) days. All patients underwent unilateral LVRS. Anatomical resection of the right (n = 3) or left (n = 1) upper lobe was performed. Postoperatively, both patients with previous mechanical ventilatory support were successfully weaned. ECCO2R in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute breathing pump failure is a safe and effective bridging tool to LVRS. In such patients, radical surgery leads to a significant improvement of the performance status and furthermore facilitates respiratory weaning from mechanical ventilation.

Single-Site Low-Flow Veno-Venous Extracorporeal Lung Support Does Not Influence Hemodynamic Monitoring by Transpulmonary Thermodilution.

The application of extracorporeal lung support (ECLS) in patients with acute respiratory distress syndrome is a well-established concept. In patients receiving ECLS therapy, hemodynamic monitoring is often required. However, less is known about the effect of ECLS on hemodynamic measurements. In the present work, the influence of single-site low-flow veno-venous ECLS (LFVV-ECLS) on hemodynamic monitoring by transpulmonary thermodilution (TPTD) was prospectively investigated. Five consecutive patients undergoing single-site LFVV-ECLS for severe hypercapnic respiratory failure were included in this study. For single-site LFVV-ECLS, a 22 Fr twin-port double-lumen cannula was inserted percutaneously into the right jugular vein. Hemodynamic monitoring was performed using the Pulse index Continuous Cardiac Output system. Before ECLS initiation, baseline measurements of cardiac index, systemic vascular resistance, mean arterial pressure, and extravascular lung water (EVLW) were performed. During the first 3 days of ECLS therapy, repeated hemodynamic measurements at different ECLS flow rates were performed. No significant differences were seen in hemodynamic measurements. With respect to EVLW, a significant decrease over the duration of ECLS therapy was observed. This study demonstrates that LFVV-ECLS does not interfere with TPTD. It needs to be further studied if these findings also apply to other ECLS modes.

Intermittent versus continuous sciatic block combined with femoral block for patients undergoing knee arthroplasty. A randomized controlled trial.

PURPOSE: Many institutions perform peripheral femoral and/or sciatic nerve blocks for analgesia after total knee arthroplasty. The aim of the present investigation was to compare the analgesic effect of an intermittent sciatic block (boluses on demand only) with a continuous infusion. METHODS: One hundred and forty patients receiving a femoral and a sciatic nerve block (SNB) by catheter were assessed. The femoral catheter was infused continuously in both groups. In the continuous group (n = 70), the sciatic catheter was used continuously as well. In the intermittent group (n = 70), after a single injection of 20 ml ropivacaine 0.75 %, injections into the sciatic catheter were performed on demand only. Frequency of injections, ventral and dorsal numerical pain scores (NRSs) of the knee, functional outcome (degree of flexion/extension) and additional opioid requirements were assessed during the post-operative period. RESULTS: In both groups, dorsal and ventral NRSs were below 3 at rest and below 5 during mobilisation over the complete period of assessment. Differences between the groups could not be observed. The cumulative number of supplemental injections into the sciatic catheter was higher in the intermittent group (52) compared with the continuous group (24; p < 0.05). Groups did not differ from each other with regard to functional outcome and opioid consumption. CONCLUSIONS: The use of a sciatic block performed as intermittent bolus injection on demand only did not affect post-operative outcome parameters with regard to pain scores, functional outcome or opioid requirements. This approach might therefore be considered as an alternative to a continuous infusion concept. ClinicalTrials.gov Identifier: NCT01843153.

Intraoperative veno-venous extracorporeal lung support in thoracic surgery: a single-centre experience.

OBJECTIVES: Intraoperative extracorporeal lung support (ECLS) during thoracic surgical procedures is a modern concept that is gaining increasing acceptance. So far, cardiopulmonary bypass (CPB), veno-arterial extracorporeal membrane oxygenation (v-a-ECMO) or pumpless arterio-venous interventional lung assist (iLA) were utilized for intraoperative support. Only a few case reports have described the use of veno-venous ECMO for intraoperative ECLS. Here, we report our experience with intraoperative ECLS using different veno-venous low-flow and high-flow settings adapted to the individual patient requirements. METHODS: Between April 2014 and April 2015, 9 patients underwent pulmonary resections under ECLS. In 6 patients, a twin-port double-lumen cannula was inserted percutaneously into the right femoral vein for low-flow ECLS. In 3 patients, high-flow ECLS was achieved either by femoro-atrial (n = 1) or femoro-jugular cannulation. RESULTS: Indications for ECLS were severely impaired lung function (n = 3), previous pulmonary resections including contralateral pneumonectomy (n = 4), previous single-lung transplantation (sLTX) (n = 1) and extended carinal pneumonectomy (n = 1). Procedures included segmentectomy (n = 3), extended lobectomy with bronchial and vascular anastomoses (n = 1), VATS lobectomy (n = 2), extended left-sided carinal pneumonectomy (n = 1) as well as extended metastasectomy (n = 2). Low-flow ECLS allowed for apnoea up to 45 min in patients with previous pneumonectomy (n = 3) and facilitated protective single-lung ventilation in patients (n = 3) with severely impaired pulmonary function. During trans-sternal carinal pneumonectomy (n = 1), high-flow ECLS achieved by femoro-atrial cannulation allowed for apnoea for 40 min, avoiding cross-field ventilation. In 2 patients requiring extended metastasectomy after previous lobectomy of the contralateral lower lobe (n = 1) or pulmonary metastases in the graft after sLTX for end-stage fibrosis (n = 1), high-flow ECLS by percutaneous femoro-jugular cannulation allowed for extensive metastasectomy under optimal atelectasis of the lung. CONCLUSIONS: For intraoperative ECLS, different modes may be applied depending on the intended procedures and required mechanical ventilation. In our experience, different settings of veno-venous ECLS provide sufficient partial or complete lung support, avoiding possible complications associated with other forms of extracorporeal support such as CPB or v-a-ECMO.

Single site cannulation veno-venous extracorporeal lung support during pulmonary resection in patients with severely compromised pulmonary function.

The intraoperative application of extracorporeal lung support devices during thoracic surgical procedures represents a modern concept with promising results. So far, pumpless extracorporeal interventional lung assist and veno-venous or veno-arterial extracorporeal membrane oxygenation via dual cannulation were utilized for complete or partial lung support throughout the surgical procedure. We report the initial intraoperative application of low-flow singular double-lumen veno-venous-extracorporeal membrane oxygenation for extracorporeal lung support during lung resections in patients with severely impaired preoperative pulmonary function. In our hands, this novel concept contributed to the safe performance of complex surgery in pulmonary compromised patients avoiding the possible complications of other forms of extracorporeal support.

Randomized evaluation of the size 2 laryngeal tube and classical laryngeal mask airway in different head and neck positions in children under positive pressure ventilation.

PURPOSE: The aim of this study was to evaluate the applicability of the laryngeal tube (LT) size 2 and the classical laryngeal mask airway (LMA) size 2 in different head-neck positions under positive pressure ventilation in children by measuring leak pressures, peak pressures and the achievable tidal volumes under positive pressure ventilation. METHODS: Forty children were randomized to receive airway management by either the LT or LMA as the primary device. Leak pressures, peak pressures and tidal volumes under positive pressure ventilation were measured in the neutral, anteflection, retroversion, left-rotation and right-rotation head-neck positions. RESULTS: In all head-neck positions, the leak pressures were significantly higher for the LT than for the LMA (neutral 25.9 ± 7.0 vs. 19.1 ± 5.7 cmH2O; anteflection 29.7 ± 7.1 vs. 24.2 ± 8.9 cmH2O; retroversion 24.1 ± 7.6 vs. 17.2 ± 6.9 cmH2O). In both devices, the peak ventilation pressures were higher in the anteflection position (LT 27.1 ± 6.3 cmH2O; LMA 17.8 ± 6.7 cmH2O) than in the retroversion position (LT 13.7 ± 3.9 cmH2O; LMA 12.7 ± 3.6 cmH2O). Compared to the respirator settings, lower tidal volumes were achieved in the anteflection position (LT 65 ± 48 vs. 129 ± 38 ml, LMA 100 ± 21 vs. 125 ± 29 ml) as compared to the other positions. CONCLUSION: Based on our results, we suggest that in anaesthetized children, the size 2 LT, compared to the size 2 LMA, may be more suitable for positive pressure ventilation due to favorable leak and peak pressures. Both devices can be safely used in head-neck positions other than neutral. Most disadvantageous with regards to the measured parameters was the anteflection position, especially for the LT.