A Comparative Evaluation of Unilateral and Bilateral Sequential Lung Isolation for Vertebral Body Tethering: A Retrospective Propensity Matched Analysis.

BACKGROUND: Vertebral body tethering (VBT) requires a thoracoscopic approach to visualize the vertebral bodies. Lung collapse and re-expansion have the potential to cause acute lung injury, resulting in increased oxygen and ventilation requirements. AIMS: We compared the intraoperative ventilator management, intra- and postoperative blood gas determinations, and hospital stay information between adolescents undergoing unilateral versus bilateral lung isolation for vertebral body tethering. METHODS:  A study cohort of 132 propensity-matched cases (66 unilateral and 66 bilateral) was derived from 351 consecutive VBT cases. Patient demographic information, case information, fluid administration, ventilatory settings data, blood gas parameters, and complete blood count and differential data were entered into a datasheet. Derived parameters included values calculated from the alveolar gas equation to develop an oxygen cascade and measures of inflammatory response. Chi-square was used for categorical data, and independent samples and t-tests were used for continuous data. RESULTS: The double lung isolation group required higher peak inspiratory pressures (SL 29±5 vs. DL 31±5, p=0.026), resulting in higher tidal volume (SL 246±63 vs. DL 334±101, p<0.001) and tidal volume per kg (SL 5.6±1.4 vs. DL 6.9±2, p<0.001) as compared to the single lung group. The double lung group required a higher partial pressure of inspired and alveolar oxygen as well as a higher alveolar to arterial oxygen tension gradient (SL 417±126 vs. DL 485±96, p=0.001) to achieve optimal arterial oxygen tension. Patients with double lung isolation had similar intensive care lengths of stay but a longer hospital stay than single lung isolation patients. CONCLUSION: Patients undergoing double lung isolation required greater ventilatory support and had more evidence of acute lung injury, as evidenced by a higher postoperative alveolar to arterial oxygen gradient; however, these healthy adolescents tolerated the procedure well and only differed in the hospital length of stay by a day.

A Novel Use of a Not So "EZ-Blocker" For Lung Isolation During a Direct Transaortic Transcatheter Aortic Valve Replacement.

Alternate access transcatheter aortic valve replacement presents unique challenges for anesthesiologists, including the possible need for lung isolation while working with space constraints around the patient's airway. Troubleshooting lung isolation in these cases can be challenging, requiring quick thinking and adaptability while maintaining patient safety. We present a case of direct transaortic transcatheter aortic valve replacement with an endobronchial blocker ("EZ-blocker") used for lung isolation that required a novel use of the "EZ-blocker" to achieve adequate lung isolation.

Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review.

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

Protecting the non-operative lobe/s of the operative lung can reduce the pneumonia incidence after thoracoscopic lobectomy: a randomised controlled trial.

Lung isolation usually refers to the isolation of the operative from the non-operative lung without isolating the non-operative lobe(s) of the operative lung. We aimed to evaluate whether protecting the non-operative lobe of the operative lung using a double-bronchial blocker (DBB) with continuous positive airway pressure (CPAP) could reduce the incidence of postoperative pneumonia. Eighty patients were randomly divided into two groups (n = 40 each): the DBB with CPAP (Group DBB) and routine bronchial blocker (Group BB) groups. In Group DBB, a 7-Fr BB was placed in the middle bronchus of the right lung for right lung surgery and in the inferior lobar bronchus of the left lung for left lung surgery. Further, a 9-Fr BB was placed in the main bronchus of the operative lung. In Group BB, routine BB placement was performed on the main bronchus on the surgical side. The primary endpoint was the postoperative pneumonia incidence. Compared with Group BB, Group DBB had a significantly lower postoperative pneumonia incidence in the operative (27.5% vs 5%, P = 0.013) and non-operative lung (40% vs 15%) on postoperative day 1. Compared with routine BB use for thoracoscopic lobectomy, using the DBB technique to isolate the operative lobe from the non-operative lobe(s) of the operative lung and providing CPAP to the non-operative lobe(s) through a BB can reduce the incidence of postoperative pneumonia in the operative and non-operative lungs.

Role of simulation-based training in thoracic anaesthesia.

Simulation-based training (SBT) aims to acquire technical and non-technical skills in a simulated fashion without harming the patient. Simulation helps the anaesthesiologist acquire procedural competence and non-technical abilities. In thoracic anaesthesia, various simulators are available with varying degrees of fidelity and costs. Apart from improving bronchoscopy-related skills, other potential applications of SBT include the practice of lung isolation in normal and difficult airway scenarios, troubleshooting complications during surgeries, and certification of the proficiency of anaesthesiologists. A pragmatic approach is required for choosing the simulator based on its availability, cost, and benefits. Although the literature supports SBT to improve procedural skills, retention of the skills and their translation into improving clinical outcomes remain largely unproven. Randomised, controlled studies targeting the effect of SBT on the improvement of clinical outcomes of patients are needed to prove their worth.

Facilitating Lung Collapse for Thoracoscopic Surgery Utilizing Endobronchial Airway Occlusion Preceded by Pleurotomy and One-minute Suspension of Two-lung Ventilation.

OBJECTIVES: To assess when and whether clamping the double-lumen endobronchial tube (DLT) limb of the non-ventilated lung is more conducive to a rapid and effective lung deflation than simply allowing the open limb of the DLT to communicate with the atmosphere. DESIGN: This was a single-center, single-blind, randomized, controlled trial. SETTING: The trial was performed in a single institutional setting. PARTICIPANTS: The participants were 60 patients undergoing elective video-assisted thoracoscopic surgery. INTERVENTIONS: Patients were randomized to the open-clamp airway technique (OCAT group) or control group. Patients in the control group had one-lung ventilation initiated upon being placed in the lateral decubitus position. The OCAT group had two-lung ventilation maintained until the pleural cavity was opened with the introduction of a planned thoracoscopic access port to allow the operated lung to fall away from the chest wall. Thereafter, ventilation was suspended (temporarily ceased) for 1 minute before the DLT lumen of the isolated lung was clamped. The primary outcome of the trial was the time to complete lung collapse scored as determined from video clips taken during surgery. The secondary outcomes were (1) lung collapse score at 30 minutes after pleural incision, (2) surgeon satisfaction with surgery, and (3) intraoperative hypoxemia. MEASUREMENTS AND MAIN RESULTS: The median time to reach complete lung collapse in the OCAT group was 10 minutes (odds ratio 10.0, 95% CI 6.3-13.7), which was much shorter than that of the control group (25 minutes [odds ratio 25.0, 95% CI 13.6-36.4]). The difference in complete lung collapse at 30 minutes between the 2 groups was significant (p < 0.001). The surgeon's satisfaction with surgery was higher in the OCAT group than in the control group (8.5 ± 0.2 vs 6.8 ± 0.2; p < 0.001). There was no difference regarding intraoperative hypoxemia. CONCLUSIONS: Suspending ventilation of both DLT limbs for 1 minute after pleural cavity opening and then clamping the DLT lumen of the isolated lung resulted in a more rapid deflation of the surgical lung. This open-clamp airway technique is an effective technique for rapid surgical lung collapse during thoracoscopic surgery.

Lung isolation-a personalized and clinically adapted approach to control bronchoscopy-associated acute massive airway hemorrhage.

BACKGROUND: The current concept of bronchoscopy-associated massive airway hemorrhage is not accurate enough, and the amount of bleeding as the only evaluation criterion cannot comprehensively evaluate magnitude of the effects and the severity. OBJECTIVE: To propose the concept of bronchoscopy-associated acute massive airway hemorrhage, analyze its impact on patients and highlight the treatment approach of acute massive airway hemorrhage without ECMO support. DESIGNS: A retrospective cohort study. SETTING: Include all patients who received bronchoscopy intervention therapy at Interventional Pulmonology Center of Emergency General Hospital from 2004 to December 2021. PATIENTS: 223 patients met the inclusion criteria. INTERVENTION: Patients were divided into two groups: acute massive airway hemorrhage group (n = 29) and non-acute massive airway hemorrhage group (n = 194). MAIN OUTCOME MEASURES: Perioperative adverse events between two groups were the main outcome. Secondary outcome was the impact of lung isolation on patient in group Acute. RESULTS: The incidence of acute massive airway hemorrhage was 0.11%, and the incidence of non-acute massive airway hemorrhage was 0.76% in this study. There were significant differences in the incidence of intraoperative hypoxemia, lowest SpO2, hemorrhagic shock, cardiopulmonary resuscitation, intraoperative mortality, and transfer to ICU between acute group and non-acute group (P<0.05, respectively). Lung isolation was used in 12 patients with acute massive airway hemorrhage, and only 2 patients died during the operation. CONCLUSION: Bronchoscopy-associated acute massive airway hemorrhage had more serious impact on patients due to rapid bleeding, blurred vision of bronchoscopy, inability to stop bleeding quickly, blood filling alveoli, and serious impact on oxygenation of the lung lobes. Polyvinyl chloride single-lumen endotracheal intubation for lung isolation, with its characteristics of low difficulty, wide applicability and available in most hospitals, may reduce the intraoperative mortality of patients with bronchoscopy-associated acute massive airway hemorrhage. TRIAL REGISTRATION: Chinese Clinical Trial Registry on 13/03/2022. REGISTRATION NUMBER: ChiCTR2200057470.

Research and development of the sOLVe Tube™ dual lumen endobronchial tube: from concept to construct.

Introduction: Dual lumen endobronchial tubes (DLTs) are frequently used for lung isolation and one lung ventilation in thoracic surgery and other specialized clinical scenarios. Modern DLTs are large and rigid, and account for half of all tracheobronchial injuries. Their 70 year old design has numerous flaws which limit their safety and clinical utility. Our research team set out to design a new and improved DLT to mitigate these shortcomings, and then test the proposed device to ensure proper function. Methods: Using published airway anatomy data and computed tomography imaging from 195 thoracic surgery patients, we designed a new DLT with a single size/configuration that would fit into adult surgery patients. This single "Universal design" was intended to replace both left and right sided 35Fr-41Fr DLTs (8 total products), while remaining small in diameter (35Fr). Other design goals included: 1) making intubation easier and safer, 2) allowing full sized therapeutic bronchoscopes to fit into this tube, 3) making the DLT more resistant to dislodgement. After design process completion the proposed dimensions were tested against 195 patients' left and right mainstem bronchi for radiographic fit. Once production prototypes were manufactured, they were tested in large adult Yorkshire pigs and fresh human cadavers for anatomic fit and performance. Results: The proposed design passed the radiographic fit test in all 195 patients for both left and right mainstem endobronchial placement. Intubation was successful and deemed atraumatic in all pigs and cadavers, and the device appropriately fit in both the right and left mainstem bronchi. Lung isolation was successfully achieved and the device proved resistant to axial force dislodgement. Conclusion: We propose a new design for a novel DLT meant to replace 8 currently supplied adult configurations with a single, one size/configuration fits all product that allows for large bore bronchoscopy and resists axial force dislodgement.

Left-Sided Double-Lumen Tube vs EZ-Blocker for One-Lung Ventilation in Thoracic Surgery: A Systematic Review and Meta-Analysis.

Background. The EZ-Blocker is the newest generation of bronchial blocker and offers a potential alternative to left-sided double lumen tubes for lung isolation and one-lung ventilation during thoracic surgery. Methods. Databases were searched for randomized controlled trials comparing left-sided double lumen tube to the EZ-Blocker for one-lung ventilation during thoracic surgery. The time for placement, incidence of intraoperative displacement, and surgeons' rating of lung collapse quality were designated as coprimary outcomes. The safety profiles of the two devices, including the incidence of airway trauma and post-extubation discomfort were also examined. Results. Six randomized controlled trials (495 patients) were analyzed. Compared to the EZ-Blocker, the left-sided double lumen tube was faster to place by a weighted mean difference of [95% CI] of -61.24 seconds [-102.48, -20.00] (P = .004) and was much less likely to become displaced during lung isolation with an odds ratio [95% CI] of .56 [.34, .91] (P = .02). The left-sided double lumen tube and the EZ-Blocker provided similar surgeon-rated quality of lung isolation. Although the left-sided double lumen tube caused a greater degree of post-extubation sore throat, there was a similar incidence of carinal trauma and post-extubation hoarseness compared to the EZ-Blocker. Conclusion. Our analysis suggests that the left-sided double lumen tube can be placed more quickly and is less prone to intraoperative displacement compared to the EZ-Blocker; the quality of lung collapse is similar. Thus, evidence appears to support the continued utilization of the left-sided double lumen tube for routine thoracic surgery requiring one-lung ventilation.

A single-arm prospective interventional study to assess the efficacy of continuous bronchial cuff pressure monitoring to detect the displacement of lung isolation devices in elective thoracic surgeries.

Background and Aims: During proximal or distal migration of lung isolation device (LID), the bronchial cuff would move into a wider or narrower portion of the bronchus, leading to a decrease or increase in the cuff pressure, respectively. To test this hypothesis, we conducted a study to find out the efficacy of continuous bronchial cuff pressure (BCP) monitoring for detecting the displacement of LID. Methods: A single-arm interventional study was conducted including hundred adult patients undergoing elective thoracic surgeries using a left-sided LID. BCP was monitored in a continuous manner using a pressure transducer connected to the bronchial cuff of the LID. The position of the LID was assessed using a paediatric bronchoscope. Changes in the BCP were noted when the LID was moved intentionally in the left main bronchus (part 1) and during the surgery (part 2). Bronchoscopic confirmation was performed at the end of the surgery to note any uncaptured movement of the LID (part 3). Results: During part 1 of the study, BCP consistently decreased on the proximal movement and increased on the distal movement of the LID, although the magnitude of change was not constant. During part 2 of the study, sensitivity, specificity, positive predictive value, negative predictive value and accuracy of continuous BCP monitoring to detect the dislodgement of LIDs (n = 41) during the surgery were 97.6%, 40%, 76.9%, 88.9% and 78.7%, respectively. Conclusion: Continuous BCP monitoring is a useful and sensitive method for monitoring the position of left-sided LIDs in limited-resource settings.

Tracheoesophageal Fistula: Airway Management and Temporization in a Community Hospital Setting.

A tracheoesophageal fistula (TEF) is a rare anatomical abnormality that can present significant challenges for the anesthesia provider. TEFs, depending on location and size, can result in aspiration, hypoxia, and difficulty with ventilation in the intensive-care unit (ICU) and operating room (OR) settings. Though usually seen and most commonly described as a congenital abnormality, it can also be an acquired condition in adults. Early recognition and diagnosis of TEF are of paramount importance to avoid respiratory complications. The rapid isolation of the TEF is key to management and different methods can be used to temporize the clinical situation until definitive surgical or endoscopic procedures can be accomplished. We discuss methods of temporization of the clinical situation, especially in a community hospital setting with limited access to immediate and sophisticated treatment.

Anesthetic Management of Patients With Kartagener Syndrome: A Systematic Review of 99 Cases.

KARTAGENER SYNDROME (KS) is characterized by the triad of chronic sinusitis, bronchiectasis, and situs inversus. The mirrored anatomy and respiratory infections in patients with KS patients pose great challenges for anesthetic management. The aim of this review is to summarize published cases with the hope of helping anesthesiologists perform anesthesia in patients with KS more safely. A comprehensive literature search for all cases of anesthetic management of KS patients was performed in Pubmed, EMBASE, CNKI, and Wanfang Database. The extracted data included age, sex, type of surgery, preoperative treatment, type of anesthesia, anesthetic agents, airway management, central venous catheterization, transesophageal echocardiogram, reversal of neuromuscular blockade, adverse events during the surgery, and postoperative complications. The study authors included 82 single-case reports, 3 case series, and 1 case cohort, with a total number of 99 patients. The most common surgical procedures were thoracic surgery (51.5%), which was followed by ear, nose, and throat surgery (16.5%), and general surgery (14.5%). The preoperative treatment of the patients was reported in only 20 patients, and included antibiotics, bronchodilators, steroids, chest physiotherapy, and postural drainage. General anesthesia was performed for 85.4% of the surgeries, and regional anesthesia was performed in 14.6% of the cases. For nonthoracic surgery, an endotracheal tube was the most commonly used airway device. For thoracic surgery, a double-lumen tube was the most commonly used airway device. The intraoperative process was uneventful in most patients, and most patients recovered smoothly in the postoperative course.

Effectiveness of Simulation- Versus Didactic Video-Based Learning to Teach Advanced Lung Isolation Techniques.

OBJECTIVES: Mastery of lung isolation is crucial for optimal cardiothoracic anesthesia education. The authors tested the hypothesis that simulation- is more effective than didactic video-based learning (cognitive, affective, and psychomotor) to teach anesthesiology fellows advanced lung isolation techniques. DESIGN: A prospective randomized study. SETTING: At a single academic heart center, simulation laboratory. PARTICIPANTS: Thirty anesthesiology fellows with equivalent prior experience in basic lung isolation techniques. INTERVENTIONS: Randomized participants received 1 of 2 structured educational interventions of equivalent duration designed to teach advanced lung isolation skills, a simulation workshop, or a video-based didactic session. MEASUREMENTS AND MAIN RESULTS: To assess Bloom's taxonomy domains, performance measurements included pre- and postintervention cognitive tests and affective surveys and a postintervention psychomotor task (time to complete lung isolation). Changes in test and survey scores and time to completion were compared using the Mann-Whitney U test; p values < 0.05 were considered significant. Improvements in lung isolation learning assessments were greater in the simulation group, but significant differences only existed in the affective domain. Specifically, affective survey score increases were greater in the simulation group (simulation- versus video-based didactic: +19.0 v +4.0; p ≤ 0.001), whereas there was no significant difference in cognitive pre- to posttest scores (simulation- versus video-based: +28.6 v +19.1, p = 0.23), and time to achieve lung isolation (simulation- versus video-based: 32 v 36 seconds, p = 0.46). CONCLUSIONS: Although greater affective learning of advanced lung isolation skills occurred with simulation-based compared to didactic video-based education, the authors found no differences between the teaching approaches in cognitive and psychomotor learning among anesthesiology fellows.

Tracheal Bronchus and Successful Right-Sided Isolation With a Bronchial Blocker.

The presence of a tracheal bronchus, which is often incidentally discovered, complicates endotracheal intubation and lung isolation during thoracic surgery. Prior reports of successful right-sided lung isolation in the presence of tracheal bronchus required utilization of a double lumen tube. Although right-sided lung isolation was required in our case, due to other patient factors, it was determined that a double lumen tube of a suitable size would be unlikely to be placed safely and successfully. We describe the successful use of a Rüsch EZ-Blocker bronchial blocker in obtaining right-sided isolation in a patient with a difficult airway and tracheal bronchus.

Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review.

Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.

The association between double-lumen tube versus bronchial blocker and postoperative pulmonary complications in patients after lung cancer surgery.

Background: Both double-lumen tube (DLT) and bronchial blocker (BB) are used for lung isolation in patients undergoing lung cancer surgery. However, the effects of different devices for lung isolation remain inconclusive. Present study was designed to investigate the association between the choice of the two devices and postoperative pulmonary complications (PPCs) in patients with lung cancer. Methods: In this retrospective cohort study, patients who underwent lung cancer surgery between January 1, 2020 and October 31, 2020 were screened. Patients were divided into two groups according to different devices for lung isolation: DLT group and BB group. Primary outcome was the incidence of a composite of PPCs during postoperative in-hospital stay. Results: A total of 1721 were enrolled for analysis, of them, 868 received DLT and 853 BB. A composite of PPCs was less common in patients with BB (25.1%, [214/853]) than those received DLT (37.9% [329/868] OR 0.582 95% CI 0.461-0.735 P < 0.001). Respiratory infection was less common in BB group (14.4%, [123/853]) than DLT group (30.3%, [263/868], P<0.001). The incidence of non-PPCs complications was not statistically significant between the 2 groups. Conclusions: For patients undergoing surgery for lung cancer, the use of BB for lung isolation was associated with a reduced risk of PPCs when compared with DLT.

Intubation with vivasight double-lumen tube versus conventional double-lumen tube in adult patients undergoing lung resection: A retrospective analysis.

Objectives: The present study was designed to compare outcomes in patients undergoing thoracic surgery using the VivaSight double-lumen tube (VDLT) or the conventional double-lumen tube (cDLT). Design: A retrospective analysis of 100 patients scheduled for lung resection recruited over 21 consecutive months (January 2018-September 2019). Setting: Single-center university teaching hospital investigation. Participants: A randomized sample of 100 patients who underwent lung resection during this period were selected for the purpose to compare 50 patients in the VDLT group and 50 in the cDLT group. Interventions: After institutional review board approval, patients were chosen according to inclusion and exclusion criteria and we created a general database. The 100 patients have been chosen through a random process with the Microsoft Excel program (Microsoft 2018, Version 16.16.16). Measurements and Main Results: The primary endpoint of the study was to analyze the need to use fiberoptic bronchoscopy to confirm the correct positioning of VDLT or the cDLT used for lung isolation. Secondary endpoints were respiratory parameters, admission to the intensive care unit, length of hospitalization, postoperative complications, readmission, and 30-day mortality rate. The use of fiberoptic bronchoscopy was lower in the VDLT group, and the size of the tube was smaller. The intraoperative respiratory and hemodynamics parameters were optimal. There were no other preoperative, intraoperative, or postoperative differences between both groups. Conclusions: The VDLT reduces the need for fiberoptic bronchoscopy, and it seems that a smaller size is needed. Finally, VDLT is cost-effective using disposable fiberscopes.