Anesthetic considerations in interventional pulmonology.

PURPOSE OF REVIEW: In this review, we highlight the important anesthetic consideration that relate to interventional bronchoscopic procedures for the management of central airway obstruction due to anterior mediastinal masses, endoluminal endobronchial obstruction, peripheral bronchoscopy for diagnosis and treatment of lung nodules, bronchoscopic lung volume reduction and medical pleuroscopy for diagnosis and management of pleural diseases. RECENT FINDINGS: The advent of the field of Interventional Pulmonology has allowed for minimally invasive options for patients with a wide range of lung diseases which at times have replaced more invasive surgical procedures. Ongoing research has shed light on advancement in anesthetic techniques and management strategies that have increased the safety during peri-operative management during these complex procedures. Current evidence focusing on the anesthetic techniques is presented here. SUMMARY: The field of Interventional Pulmonology requires a tailored anesthetic approach. Recent advancements and ongoing research have focused on expanding the partnership between the anesthesiologist and interventional pulmonologists which has led to improved outcomes for patients undergoing these procedures.

Discharge From the Postanesthesia Care Unit With Motor Blockade After Spinal Anesthesia Safely Optimizes Fast Track Recovery in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Post anesthesia care units (PACU) await return of motor function in lower extremities, prior to discharge for patients undergoing spinal anesthesia. The purpose of this study was to assess the impact of a newly utilized recovery protocol that facilitated early discharges of patients undergoing total hip and knee arthroplasties (THA/TKA) to the floor before full motor recovery from spinal anesthesia is achieved. METHODS: A total of 647 patients undergoing spinal anesthesia for primary THA (n = 190) and TKA (n = 457) were divided into 2 groups: (1) Early PACU discharge group: patients with partial or full motor blockade at discharge. (2) Control PACU discharge group: patients with full motor recovery at discharge. Readiness for discharge was assessed using a modified Aldrete Score system. The primary outcome was incidences of hypotension or rapid responses post-operatively. RESULTS: There was no significant difference in the incidence of hypotension between the two groups (1.4 versus 1.39%, P = 1.0) and zero rapid responses were noted. Early discharge shortened mean PACU LOS time from 86.50 minutes to 70.27 minutes (P < .01). There was no difference in the incidence of nausea (0.55 versus 0%; P = .51) ordizziness (2.22 versus 0.35%; P = .09). CONCLUSION: In this retrospective observational study, we found that early PACU discharge did not result in an increase in hemodynamic consequences on the surgical floor. Thus, discharge from PACU can be safely and more expeditiously performed without waiting for return of motor function in patients receiving spinal anesthesia for THA/TKA using a modified Aldrete Score recovery protocol.

Anesthetic Considerations in a Patient With LVAD and COVID-19 Undergoing Video-Assisted Thoracic Surgery.

Increased survival with left ventricular assist devices (LVAD) has led to a large number of patients with LVADs presenting for noncardiac surgeries (NCS). With studies showing that a trained noncardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries. This is even more relevant during the current pandemic in which these complex cardiopulmonary interactions may be even more challenging in patients with coronavirus disease 2019 (COVID-19). The authors describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion and briefly discuss unique challenges presented and their management.

Pulmonary Hypertension due to Radiofrequency Catheter Ablation (RFCA) for Atrial Fibrillation: The Lungs, the Atrium or the Ventricle?

Atrial fibrillation is the most common heart rhythm disorder in United States, characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response. While rate and rhythm control using pharmacological regimens remain the primary management strategies in these patients, radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative modality of treatment. Increase in the incidence of RFCA has shed light on complications associated with this procedure. Pulmonary hypertension (PH) is one of the long-term complications that has been observed postcatheter ablation. There have been multiple mechanisms which have been proposed to explain these elevated pulmonary pressures. These include the involvement of the lungs due to pulmonary vein stenosis, pulmonary vein occlusion and, rarely, pulmonary embolism. Radiofrequency catheter ablation can also lead to scarring of the atrium which can cause left atrial diastolic dysfunction leading to elevated pulmonary pressures. Recently, it was also proposed that elevated pulmonary pressure was related to the unmasking of left ventricular diastolic dysfunction occurring after this procedure. In this article, we review all the mechanisms that are associated with the development of pulmonary hypertension in patients undergoing RCFA for atrial fibrillation and the approach to diagnosis and management of such patients.

Anesthetic considerations for medical pleuroscopy.

Pleuroscopy, also known as medical thoracoscopy or local anesthesia thoracoscopy, is a commonly utilized procedure in the growing field of interventional pulmonology and considered a required procedure as part of the interventional pulmonology fellowship curriculum. Pleuroscopy is mainly utilized for parietal pleural biopsies in patients with undiagnosed pleural effusions, with a comparable diagnostic yield to video-assisted thoracoscopy (VATS) (>92%). Pleuroscopy is also performed for talc insufflation for pleurodesis, indwelling pleural catheter insertion, and rarely for decortication in patients with stage 2 empyema. Though these procedures can be done under local anesthesia with moderate sedation, an increasing number of cases are being performed with the presence of the anesthesiologist providing monitored anesthesia care (MAC). Given that a significant number of patients undergoing pleuroscopy will have significant co-morbidities, proceduralists and anesthesiologists must be prepared to manage these cases in a non-OR setup. In this article, we discuss some of the technical aspects of pleuroscopy, and highlight the peri-operative considerations for proceduralists and anesthesiologists in managing these patients including the role of ultrashort sedatives and intraoperative procedural and anesthetic considerations. We also discuss the upcoming adjunctive role of local and regional anesthesia techniques in management of these patients. In addition, we summarize the current data regarding various regional anesthesia techniques and discuss avenues for further research.

Analgesic Trends in the Management of Pain Following Total Knee Arthroplasty: A Comparison of Peri-Articular Infiltration, Adductor Canal Block, and Adjuvant Treatment for Posterior Knee Pain.

The rising number of total knee arthroplasties (TKA's) in the United States increases demand for perioperative pain modalities, which can promote early mobilization and discharge. Over the decades, a focus has shifted from opioid-dominant regimens to motor-sparing multimodal protocols, which have not only improved pain scores and reduced opioid consumption but also improved overall patient outcomes. In this article, we briefly review the evolution of post-operative pain management in patients undergoing TKA and summarize the literature on the most popular modalities currently used including periarticular injections, adductor canal blocks, distal selective nerve blocks, as well as liposomal bupivacaine as part of a multimodal approach.

A 68-Year-Old Man With Dyspnea on Exertion and Cough.

A 68-year-old man with a history of chronic lymphocytic leukemia well controlled on ibrutinib, hypertension, obesity, and a remote history of smoking (10 pack-years) presented with increasing dyspnea on exertion and cough. He had previously finished two courses of oral antibiotics for his symptoms without significant improvement. On presentation, he had no fevers or sputum production.

Inflammatory myofibroblastic tumor of the lung.

Inflammatory myofibroblastic tumors (IMT) of the lung, first reported in 1939, are considered a subset of inflammatory pseudo -tumors. They are a distinctive lesions composed of myofibroblastic spindle cells accompanied by an inflammatory infiltrate of plasma cells, lymphocytes, and eosinophils. IMTs may be benign, invade surrounding structures, undergo malignant transformation, recur or may even metastasize. They can occur due to a genetic mutation or can occur secondary to infectious or autoimmune diseases. Patients may be asymptomatic, or present with cough, hemoptysis, dyspnea, pleuritic pain, constitutional symptoms or pneumonia. In this article we review the pathophysiology, genetics, clinical presentation, imaging findings of IMT of the lung. We also discuss the various surgical and non-surgical treatment options and the prognosis associated with this disease.

Aorto-Atrial Fistulas: A Contemporary Review.

Aorto-atrial fistulas (AAFs) are a relatively rare, but potentially life-threatening condition, where an anomalous connection forms between the aortic structures and the cardiac atria. AAFs are most often the result of an underlying condition concerning the cardiac structures. It may be congenital, secondary to conditions such as aortic dissection, infective endocarditis, or valve replacement, or iatrogenic in nature. Secondary causes incite local deterioration of cardiac wall integrity leading to formation of fistulous connections, whereas iatrogenic causes are more traumatic in nature. Signs and symptoms include those of volume overload and heart failure, with patients often presenting with fever, regurgitative murmurs, cardiac chamber dilation, and pedal edema. The diagnosis of AAFs requires a high degree of clinical suspicion necessitating imaging techniques such as echocardiography, computer tomography, and more invasive procedures. Management is dependent on underlying conditions and include the use of antibiotics, percutaneous closure, and in many cases, open heart surgery. It is important for physicians to be aware of this pathological condition to aid in timely management and favorable outcomes. This review attempts to summarize the various causes and clinical presentations of AAFs over the past decades.

Nationwide trends in inpatient admissions of pulmonary hypertension in the United States from 2000 to 2013.

INTRODUCTION: Pulmonary hypertension (PH) is a disorder of the pulmonary vasculature with high mortality and bears a large economic burden on the healthcare system. We conducted a review of the largest inpatient database in the United States and analyzed the trends in hospitalizations due to PH from the turn of the century (2000) to 2013 to evaluate the rate of hospitalizations and determine the cost and mortality associated with PH. MATERIAL AND METHODS: We analyzed the National Inpatient Sample Database (NIS) for all patients in which PH (Primary or Secondary) or cor pulmonale was the primary discharge diagnosis (ICD-9: 416.0, 416.8 and 416.9) from 2000 to 2013. The NIS is the largest all-payer inpatient database in the United States and contains data from approximately 8 million hospital stays each year. The statistical significance of the difference in the number of hospital discharges, lengths of stays and associated hospital costs over the study period was calculated. RESULTS: In 2000, there were 12,066 hospital admissions with the principal discharge diagnosis of pulmonary hypertension, which increased to 13,605 admissions in 2013 (p < 0.001). The mean length of stay for PH increased from 5.89 days to 6.67 days during this period (p = 0.04). During the same period, the hospital charges increase by 174.5% from US$ 24,973 in 2000 to US$ 68,545 in 2013 (Adjusted for inflation). The aggregate cost of hospital visits of a patient increased by 209.5% from US$ 301,324,218 in 2000 to US$ 932,554,725 in 2013. CONCLUSIONS: The number of inpatient discharges related to PH has increased even though the number of inpatient discharges with PAH has been reported to be lower in literature. The mean length of stay has also shown a mild increase. This increase is associated with a significant increase in the mean and aggregate cost. These inpatient costs associated with PH contribute significantly to the total healthcare burden. Further research on cost-effective evaluation and management of PH is required.

Pulmonary hypertension associated with antiphospholipid antibody: Call for a screening tool?

Antiphospholipid (aPL) antibodies are antibodies specific for anionic phospholipids. They are immunoglobulins that attack phospholipids, phospholipid-binding proteins, or phospholipid-protein complexes and are detected in anticardiolipin and lupus anticoagulant assays. aPL antibodies are often associated with antiphospholipid syndrome (APS) which can be idiopathic or from secondary causes such as systemic lupus erythematosus (SLE), infection or drugs. They have also been shown to be associated with Pulmonary Hypertension. We conducted a review of the literature that included all articles on PubMed with keywords 'antiphospholipid antibody' and 'pulmonary hypertension' between January 1980 and July 2017 and identified 217 articles. A total of 47 articles were found to be relevant to the topic and included as references. We ascertained that aPL antibodies have been implicated in the development of both idiopathic pulmonary arterial hypertension (PAH) and PAH associated with connective tissue disease (CTD). aPL antibodies were also noted to be associated with left-sided valvular heart disease that can lead to pulmonary venous hypertension (PVH). Patients with anitiphospholipid antibody syndrome (Diagnostic criteria incudes +aPL antibodies) were noted to have a high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). A recent study also found a positive association of aPL antibodies with ILD and PH in patients with systemic sclerosis. While association between autoimmune thyroid disease and PH (Group V PH), and autoimmune thyroid disease and aPL antibodies is established, no studies linked these three phenomena together. Thus, aPL antibodies had an association with all WHO groups of Pulmonary hypertension (PH). In this review article, we study the association and discuss the need for screening for PH in patients with positive aPL antibodies.

Nationwide trends of hospitalizations for cystic fibrosis in the United States from 2003 to 2013.

Cystic fibrosis (CF) is a multisystem autosomal recessive genetic disorder with significant advances in early diagnosis and treatment in the last decade. It is important to provide updated information regarding these changing demographics as they also reflect a considerable improvement in survival. We analyzed the National Inpatient Sample Database (NIS) in the United States for all patients in which CF was the primary discharge diagnosis (ICD-9: 277.0-277.09) from 2003 to 2013 to evaluate the rate of hospitalizations and determine the cost and mortality associated with CF along with other epidemiological findings. The statistical significance of the difference in the number of hospital discharges, lengths of stays and associated hospital costs over the study period was calculated. In 2003, there were 8,328 hospital discharges with the principal discharge diagnosis of CF in the United States, which increased to 12,590 discharges in 2013 (p < 0.001). The mean hospital charges increased by 57.64% from US$ 60,051 in 2003 to US$ 94,664 in 2013. The aggregate cost of hospital visits increased by 138.31% from US$ 500,105,727 to US$ 1,191,819,760. In the same time, the mortality decreased by 49.3 %. The number of inpatient discharges related to CF has increased from 2003 to 2013. This is due to increased life expectancy of CF patients, resulting in increased disease prevalence. There has been a significant increase in the mean and aggregate cost associated with CF admissions. Over the last decade, many advances have been made in the diagnosis and treatment of CF, consequentially leading to a significant transformation in the epidemiology and demographics of this chronic disease. Rising hospital costs associated with the care of CF patients necessitates future studies analyzing the diagnostic modalities, algorithms and treatment practices of physician's treating CF patients.

Infective abdominal aortitis due to Campylobacter fetus bacteremia: A case report and review of literature.

Infectious aortitis (IA) is a rare but life-threatening condition, and most commonly affects the abdominal aorta or thoracic aorta. Various microorganisms have been associated with infectious thoracic aortitis, most commonly Staphylococcus, Enterococcus, Streptococcus, and Salmonella species. Campylobacter fetus (C. fetus) has been seen as a cause of infective aortitis only in a few case reports. We report a rare case of infective aortitis of the abdominal aorta caused due to C. fetus bacteremia. While C. fetus infections usually occur in patients with immunosuppression, such as malignancy, or those with diabetes mellitus, but our patient was not immunocompromised. Furthermore, the IA occurred in the absence of an aortic aneurysm, unlike its usual presentation. Thus, it is extremely important to establish an early diagnosis of IA and find out the causative organism for appropriate medical treatment, because this condition is potentially life threatening.

Endocarditis in left ventricular assist device.

Heart failure is one of the leading causes of death in developed nations. End stage heart failure often requires cardiac transplantation for survival. The left ventricular assist device (LVAD) has been one of the biggest evolvements in heart failure management often serving as bridge to transplant or destination therapy in advanced heart failure. Like any other medical device, LVAD is associated with complications with infections being reported in many patients. Endocarditis developing secondary to the placement of LVAD is not a frequent, serious and difficult to treat condition with high morbidity and mortality. Currently, there are few retrospective studies and case reports reporting the same. In our review, we found the most common cause of endocarditis in LVAD was due to bacteria. Both bacterial and fungal endocarditis were associated with high morbidity and mortality. In this review we will be discussing the risk factors, organisms involved, diagnostic tests, management strategies, complications, and outcomes in patients who developed endocarditis secondary to LVAD placement.

Cardiac manifestations of idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, parenchymal disease of the lung with an estimated prevalence of 14-43 per 100,000. Patient usually presents with coughing and exertional dyspnea, which can lead to acute respiratory failure. IPF has been associated with various co-morbidities such as lung cancer, emphysema, obstructive sleep apnea (OSA), GERD and multiple cardiovascular consequences. The cardiovascular manifestations of IPF include pulmonary hypertension, heart failure, coronary artery disease, cardiac arrhythmias & cardiac manifestations of drugs used to treat IPF. This review will outline evidence of the association between IPF and cardiovascular conditions and attempt to provide insights into the underlying pathophysiology. We also discuss the impact of these cardiovascular diseases on patients with IPF including increased morbidity and mortality.