Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia.

OBJECTIVES: In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia (TEA) regarding pain control and enhanced recovery. METHODS: A retrospective multicentre analysis with single-centre propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either TEA or intercostal nerve block. The primary outcome was a proportion of pain scores ≥4 (scale 0-10) until postoperative day (POD) 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate. RESULTS: In 218 patients, TEA was compared to intercostal nerve block and showed no difference in the proportion of pain scores ≥4 {14.3% [interquartile range (IQR) 0.0-33.3] vs 11.1% (IQR 0.0-27.3) respectively, P = 0.24}, more frequently needed additional opioids on the day of surgery (18% vs 48%) and first POD (20% vs 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] vs 3.0 days [IQR 2.8-4.0]) and were significantly more mobile until POD 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in the course whereas TEA had higher late (rebound) pain scores. CONCLUSIONS: In a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to TEA and is linked to improved mobility. Results require randomized confirmation.

CD8⁺ T cells with an intraepithelial phenotype upregulate cytotoxic function upon influenza infection in human lung.

The human lung T cell compartment contains many CD8⁺ T cells specific for respiratory viruses, suggesting that the lung is protected from recurring respiratory infections by a resident T cell pool. The entry site for respiratory viruses is the epithelium, in which a subset of lung CD8⁺ T cells expressing CD103 (αE integrin) resides. Here, we determined the specificity and function of CD103⁺CD8⁺ T cells in protecting human lung against viral infection. Mononuclear cells were isolated from human blood and lung resection samples. Variable numbers of CD103⁺CD8⁺ T cells were retrieved from the lung tissue. Interestingly, expression of CD103 was seen only in lung CD8⁺ T cells specific for influenza but not in those specific for EBV or CMV. CD103⁺ and influenza-reactive cells preferentially expressed NKG2A, an inhibitor of CD8⁺ T cell cytotoxic function. In contrast to CD103⁻CD8⁺ T cells, most CD103⁺CD8⁺ cells did not contain perforin or granzyme B. However, they could quickly upregulate these cytotoxic mediators when exposed to a type I IFN milieu or via contact with their specific antigen. This mechanism may provide a rapid and efficient response to influenza infection, without inducing cytotoxic damage to the delicate epithelial barrier.