Preventive skin analgesia with lidocaine patch for management of post-thoracotomy pain: Results of a randomized, double blind, placebo controlled study.

BACKGROUND: To evaluate whether pre-emptive skin analgesia using a lidocaine patch 5% would improve the effects of systemic morphine analgesia for controlling acute post-thoracotomy pain. METHODS: This was a double-blind, placebo controlled, prospective study. Patients were randomly assigned to receive lidocaine 5% patch (lidocaine group) or a placebo (placebo group) three days before thoracotomy. Postoperative analgesia was induced in all cases with intravenous morphine analgesia. The intergroup differences were assessed in order to evaluate whether the lidocaine patch 5% would have effects on pain intensity when at rest and after coughing (primary end-point) on morphine consumption, on the recovery of respiratory function, and on peripheral painful pathways measured with N2 and P2 laser-evoked potential (secondary end-points). RESULTS: A total of 90 patients were randomized, of whom 45 were allocated to the lidocaine group and 45 to the placebo group. Lidocaine compared with the placebo group showed a significant reduction in pain intensity both at rest (P = 0.013) and after coughing (P = 0.015), and in total morphine consumption (P = 0.001); and also showed a better recovery of flow expiratory volume in one second (P = 0.025) and of forced vital capacity (P = 0.037). The placebo group compared with the lidocaine group presented a reduction in amplitude of N2 (P = 0.001) and P2 (P = 0.03), and an increase in the latency of N2 (P = 0.023) and P2 (P = 0.025) laser-evoked potential. CONCLUSIONS: The preventive skin analgesia with lidocaine patch 5% seems to be a valid adjunct to intravenous morphine analgesia for controlling post-thoracotomy pain. However, our initial results should be corroborated/confirmed by larger studies.

Three-dimensional (3D) Printed Model to Plan the Endoscopic Treatment of Upper Airway Stenosis.

BACKGROUND: Endoscopic management of tracheal stenosis may be challenging, especially in the case of complex stenosis placed near the vocal folds, and needing stent placement. Herein, we evaluated the utility of the three-dimensional (3D) airway model for procedural planning in a consecutive series of patients with complex airway stenosis and scheduled for endoscopic treatment. METHODS: This strategy was applied to 7 consecutive patients with tracheal stenosis unfit for surgery. The model was printed in a rubber-like material, and almost 7 hours were needed to create it. All patients presented respiratory failure with a mean value of 3.4±0.4 Medical Research Council (MRC) dyspnea scale, 47±3.9 forced expiratory volume in 1 second (FEV1%), and an impairment in the 6-minute walking test (6MWT) (mean value, 175±53 m). The mean length of the stenosis was 19±3.4 mm; 3 of the 7 (43%) patients presented a subglottic stenosis. In 4/7 (57%) patients the stenosis was >5 mm, but its treatment required the placement of a stent because of the presence of tracheal cartilage injury. RESULTS: The mean operation time was 22.7±6.6 minutes. No complications were observed during and after the procedure. A significant increase of MRC (3.4±0.4 vs. 1.6±0.5; P=0.003), of FEV1% (47±3.9 vs. 77±9.7; P=0.001), and of 6MWT (175±53 vs. 423±101; P=0.0002) was observed after the procedure (mean follow-up, 11.1±8.8 mo). CONCLUSION: Our 3D airway model in the management of airway stenosis is useful for procedural planning, rehearsal, and education. The fidelity level of the 3D model remains the main concern for its wider use in patient care. Thus, our impressions should be confirmed by future prospective studies.

Endoscopic treatment with fibrin glue of post-intubation tracheal laceration.

Post-intubation tracheal laceration (PITL) is a rare and potential life-threatening condition requiring prompt diagnosis and treatment. A conservative treatment is indicated in patients with laceration <2 cm in length while surgery is the treatment of choice for laceration >4 cm. For laceration between 2-4 cm, the best treatment is debate; some authors recommend surgery while others do not definitely exclude endoscopic treatment. Herein, we reported the endoscopic treatment with fibrin glue of PITL. The procedure is performed using a standard video-bronchoscopy in operating room; the patient is in spontaneous breathing and deep sedation. After identification of tracheal laceration, the fibrin glue is injected through a dedicated double lumen catheter into the lesion. After mixing both components of fibrin glue, polymerization of fibrin occurs resulting in an elastic and opaque clot that closes the lesion. The key success of the procedure is based on accurate patient selection. Patients are eligible if (I) they are clinically stable and in spontaneous respiration; (II) with a small and superficial tracheal laceration (≤4 cm in length and without oesophageal injury); (III) localized at level of the upper or middle trachea; and (IV) without clinical and/or radiological signs of mediastinal collection, of emphysema or pneumomediastinum progression, and of infection.

Bronchoscopic lung volume reduction with endobronchial valves for heterogeneous emphysema: long-term results.

BACKGROUND: Bronchoscopic lung volume reduction (BLVR) with implant of one-way endobronchial valves (EBV) is a feasible treatment for management of heterogeneous emphysema (HE) with clinical benefits in the early follow-up. We aimed to evaluate the long-terms results and safety of this procedure in a consecutive series of patients with HE. METHODS: It was a retrospective single center study including all consecutive patients with HE undergoing EBV treatment and completing at least 5 years of long-term follow-up. Patients were splitted into Collapse and No-Collapse Group if a lobar collapse or not were obtained after valves implant. The difference of functional data and quality of life (QoL) before and after the procedure (measured at 3, 6, 9, 12 months from the valve implantation, and then annually up to a maximum of 5 years) were statistically evaluated to show the long-term benefits of the procedure (primary endpoint). Yet, morbidity, mortality and survival rates were also recorded to show the safe of the treatment (secondary endpoint). RESULTS: Thirty-three patients were included in the study. Of these, three patients underwent a bilateral treatment. Collapse Group patients (n=27) presented a significant improvement in FEV1% (+17%; P=0.001); in FVC% (+18%; P=0.002); in RV% (-39%; P=0.003); in 6MWT (P=0.001) and in SGRQ (P=0.001) in the early 12 months of follow-up and no significant decline was seen later. Conversely, No-Collapse Group (n=9) did not have significant benefits. No major complications and death related to the procedure were observed. The 1-,2-,3-,4- and 5-year survival rates were 100%, 90%, 78%, 71% and 71%, respectively. Collapse Group had a better survival than No-Collapse Group (45 vs. 24 months; P=0.001). CONCLUSIONS: Our study confirmed that the lobar collapse is the key success of EBV treatment and the early improvements of respiratory function could be maintained up to five years from the valves implant.