A Practical Guide for Using the EZ-Blocker Endobronchial Blocker: Tips and Tricks After 10 Years of Experience.

The EZ-Blocker (EZB) is a "Y-shaped," semirigid endobronchial blocker used for lung isolation and one-lung ventilation during thoracic surgery. Like many medical tools, initial efforts to use this endobronchial blocker may prove challenging for the uninitiated. However, some tips and tricks can be applied fairly rapidly to aid the clinician in properly placing the device, and, furthermore, may help the clinician get the most out of this innovative device. This article focuses on some of the technical aspects of its placement that the authors have developed over time. Additionally, other facets and potential pitfalls are discussed that relate to intraprocedural issues that may sometimes arise when using this device. The following aspects of the EZB as a lung-isolation device are discussed: standard positioning techniques, alternative positioning techniques, use in pediatric patients, approaches to achieving exceptional lung isolation, advanced uses, and limitations and potential issues. Although some information was taken from the authors' rather extensive experience with using this endobronchial blocker, some of the relevant literature are also reviewed, with the goal of being to improve the reader's knowledge of the device and improve the likelihood of its successful placement. The underlying design of the EZB remains unique among commercially available bronchial blockers in improving positional stability. The Y-shaped conformation, however, can lead to challenges when positioning the device in some patients. Therefore, some very practical tips and tricks are provided to assist the clinician in correctly positioning the device and other hints to improve the quality of lung isolation and surgical conditions.

One lung ventilation management in a patient with Reinke's edema.

INTRODUCTION: Reinke's edema (RE) is a benign laryngeal disease. We describe the case of a patient with history of bilateral RE requiring surgical treatment, that came to our attention for a lung lobectomy due to adenocarcinoma. In consideration of the possible complications at the time of extubation and of the probable difficult control of the airways, the patient underwent intervention of microflap surgery for the RE at the same time of lobectomy. We opted for Bronchial Blocker (BB) using a Viva-sight™ Single Lumen Tube (SLT) Internal Diameter (ID) 7.0 mm (Ambu A/S, Baltorpbakken 13, DK-2750 Ballerup, Denmark) with integrated high-resolution camera. PRESENTATION OF CASE: The patient (female, 67 years old, BMI 28) was a candidate for lung lobectomy. She reported a RE requiring surgical treatment. An armoured Endo Tracheal Tube (ETT) ID 5.0 mm was positioned and microflap surgery was performed. Once this surgery ended, the armoured ETT was removed after placing an airway guide wire exchanger and a SLT ID 7.0 mm was placed. ​VivaSight-endoblocher™ (EB) was positioned in the right bronchus. DISCUSSION: We opted for double intervention, the risk that could result from the delay persuaded the patient to perform surgery for the RE. Postponing the lobectomy was dangerous for the oncological situation. The Viva-Sight SLT represented the right compromise. CONCLUSION: Even after the microflap, the space available for the ETT was reduced and, in order not to traumatize a tissue already stressed by surgery and to facilitate the tracheal intubation, we opted for BB using a Viva-sight™.

Erector spine plane block as postoperative rescue analgesia in thoracic surgery.

OBJECTIVE: Erector spine plane block (ESPB) is a newly defined regional anesthesia technique performed by injection of local anesthetic beneath the erector spine muscle. We tested ESPB as a regional rescue analgesia bedside technique to be performed in the thoracic surgical ward, reporting a 7-patient case series. METHODS: We report our experience in rescue analgesia after thoracic surgery. During the postoperative stay, numeric rating scale (NRS) score >3 and inability to perform physiotherapy or effective cough due to postoperative pain represented the criteria for proposing rescue analgesia with ESPB. NRS at rest and during movements was recorded; blood gas analysis and spirometry were performed to evaluate PaO2/FiO2 (P/F), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) before ESPB execution. After performing the ESPB, static and dynamic NRS, P/F, and FVC and FEV1 were recorded at 40 minutes and 80 minutes. RESULTS: NRS had a reduction at rest and in dynamic assessment. The P/F did not improve but spirometric measures improved. FVC had a relevant improvement only after 80 minutes; FEV1 was increased after 40 minutes. CONCLUSION: The use of ESPB as postoperative rescue analgesia can offer several advantages due to effective rescue analgesia and safety that makes it easy to perform in the thoracic surgical ward or in an outpatient clinic setting.

Effectiveness of home-based preoperative pulmonary rehabilitation in COPD patients undergoing lung cancer resection.

OBJECTIVE: To investigate the effectiveness of a home-based preoperative rehabilitation program for improving preoperative lung function and surgical outcome of patients with chronic obstructive pulmonary disease (COPD) undergoing lobectomy for cancer. METHODS: This was a prospective, observational, single-center study including 59 patients with mild COPD who underwent lobectomy for lung cancer. All patients attended a home-based preoperative rehabilitation program including a minimum of 3 sessions each week for 4 weeks. Each session included aerobic and anaerobic exercises. Participants recorded the frequency and the duration of exercise performed in a diary. The primary end point was to evaluate changes in lung function including predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1), 6-minute walking distance test (6MWD), PPO diffusing capacity for carbon monoxide (DLCO) %, and blood gas analysis values before and after the rehabilitation program. Postoperative pulmonary complications were recorded and multivariable analysis was used to identify independent prognostic factors (secondary end point). RESULTS: All patients completed the 4-week rehabilitation program. Thirteen of 59 (22%) patients (Group A) performed <3 sessions per week (mean sessions per week: 2.3±1.3); 46 of 59 (78%) patients (Group B) performed ⩾3 sessions per week (mean sessions per week: 3.5±1.6). The comparison of PPO FEV1% and 6MWD before and after rehabilitation showed a significant improvement only in Group B. No significant changes in PPO DLCO% or in blood gas analysis values were seen. Nine patients presented postoperative pulmonary complications, including atelectasis (n = 6), pneumonia (n = 1), respiratory failure (n = 1), and pulmonary embolism (n = 1). Group A presented higher number of postoperative pulmonary complications than Group B (6 vs 3; p = 0.0005). Multivariate analysis showed that the number of weekly rehabilitation sessions was the only independent predictive factor (p = 0.001). CONCLUSIONS: Our simple and low-cost rehabilitation program could improve preoperative clinical function in patients with mild to moderate COPD undergoing lobectomy and reduce postoperative pulmonary complications. All patients should be motivated to complete at least 3 rehabilitation sessions per week in order to obtain significant clinical benefits. Our preliminary results should be confirmed by larger prospective studies.

Intratracheal Thyroid: A Different Approach.

During embryonic development, the abnormal migration of thyroid tissue may cause ectopic localization of the gland in the intralaryngotracheal space. This case report describes the management of a young patient with a recent diagnosis of asthma. During bronchoscopy, a large mass occupying the tracheal lumen was discovered. After tracheotomy to protect the airway, an incisional biopsy was performed and revealed an intratracheal ectopic thyroid. The deep incisions through the tracheotomy to the base of the lesion allowed colloidal content to leak out of the mass until complete resolution of airway obstruction. Fifteen days later the patient was released totally rehabilitated.

Preoperative optimization with levosimendan in heart failure patient undergoing thoracic surgery.

INTRODUCTION: We present the case of a patient with dilatative cardiomyopathy waiting for heart transplantation with pleural effusion to be subjected to pleural biopsy, treated with preoperative infusion of levosimendan to improve heart performances. PRESENTATION OF CASE: A 56-year-old man (BMI 22,49) with dilatative cardiomyopathy (EF 18%) presented right pleural effusion. The levosimendan treatment protocol consisted of 24h continuous infusion (0,1ug/kg/min), without bolus. The patient was under continuous hemodynamic monitoring prior, during and after levosimendan administration. The surgery for pleural biopsy was performed with uniportal Video Assisted Thoracoscopic approach (VATS). DISCUSSION: A significant increase of Cardiac Index (CI) and Stroke Volume Index (SVI) were observed at 4h after infusion initiation and was sustained during the next 24h after the end of infusion. Levosimendan administration was safe. CONCLUSION: In this case the prophylactic preoperative levosimendan administration is safe and effective in cardiac failure patient undergoing thoracic surgery, but prophylactic preoperative levosimendan treatment in these patients merits further study.

Intraoperative Extracorporeal Carbon Dioxide Removal During Apneic Oxygenation with an EZ-Blocker in Tracheal Surgery.

Tracheal surgery requires continued innovation to manage the anesthetic during an open airway phase. A common approach is apneic oxygenation with continuous oxygen flow, but the lack of effective ventilation causes hypercapnia, with respiratory acidosis. We used extracorporeal carbon dioxide removal for intraoperative decapneization during apneic oxygenation in a 64-year-old woman who was scheduled for tracheal surgery because of tracheal stenosis caused by long-term intubation. Our findings demonstrate that even after 40 minutes of total apnea, using an EZ-blocker for oxygenation and external decapneization, hemodynamic and gas exchange variables never demonstrated any dangerous alterations.

Major thoracic surgery in Jehovah's witness: A multidisciplinary approach case report.

INTRODUCTION: A bloodless surgery can be desirable also for non Jehovah's witnesses patients, but requires a team approach from the very first assessment to ensure adequate planning. PRESENTATION OF THE CASE: Our patient, a Jehovah's witnesses, was scheduled for right lower lobectomy due to pulmonary adenocarcinoma. Her firm denies to receive any kind of transfusions, forced clinicians to a bloodless management of the case. DISCUSSION: Before surgery a meticulous coagulopathy research and hemodynamic optimization are useful to prepare patient to operation. During surgery, controlled hypotension can help to obtain effective hemostasis. After surgery, clinicians monitored any possible active bleeding, using continuous noninvasive hemoglobin monitoring, limiting the blood loss due to serial in vitro testing. The optimization of cardiac index and delivery of oxygen were continued to grant a fast recovery. CONCLUSION: Bloodless surgery is likely to gain popularity, and become standard practice for all patients. The need for transfusion should be targeted on individual case, avoiding strictly fixed limit often leading to unnecessary transfusion.