Pulmonary hypertension in thoracic surgical patients.

PURPOSE OF REVIEW: Literature about thoracic surgery in patients with pulmonary hypertension is scarce. Perceived high risk has appropriately discouraged any unnecessary operation. However, the medical therapy for pulmonary hypertension has made great advances during the last decade. It is likely that future advances in survival and possibly the need for diagnostic procedures will increase the anesthesiologist's exposure to such patients. Understanding the unique physiology as well as new therapeutic agents will facilitate safe care for these challenging patients. RECENT FINDINGS: Since 1998, there have been three World Heath Organization symposiums on pulmonary hypertension. The most recent meeting in 2008 at Dana Point included revisions of the classification scheme and updates on new trials and therapies. New drugs have been utilized in cardiac, lung, or liver transplant operations to treat pulmonary hypertension. It is also recognized that one-lung ventilation presents unique problems for the patient with pulmonary hypertension. Inhalation use of the new pulmonary vasodilator drugs represents a new frontier for intraoperative pharmacology. SUMMARY: Here, the various types of pulmonary hypertension, physiologic changes, and new drug therapies are reviewed. Clinical experience with patients with pulmonary hypertension undergoing both nonthoracic and thoracic procedures is also reviewed. By identifying potential problem areas and application of new pharmacology, an approach to the patient with pulmonary hypertension is synthesized.

Technique, utility, and safety of awake tracheoplasty using combined laser and balloon dilation.

OBJECTIVES: Laryngotracheostenosis (LTS) is a condition in which the airway is narrowed between the vocal cords and the carina. We seek to examine whether flexible bronchoscopy with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser incision and balloon dilation tracheoplasty is a practical choice in the management of patients with subglottic or tracheal stenosis. METHODS: A retrospective chart review was performed at a tertiary care hospital. All subjects with laryngotracheostenosis treated between January 1, 2000, and April 2005 who underwent endoscopic Nd:YAG laser incision and balloon dilation tracheoplasty performed using topical anesthesia and intravenous sedation were included. RESULTS: A total of 18 patients comprised the study and 36 procedures were performed without complication. Only one procedure was required by eight subjects, while five subjects required two procedures, three subjects had three procedures, one subject had four procedures, and one subject had five procedures until an adequate stable airway was obtained. The average follow-up was 22 months (range 3-55 months). The average body mass index (BMI) was 32.0 kg/m (range = 20.8-42.2 kg/m) and 11 of the 18 subjects (61.1%) were categorized as obese or morbidly obese by BMI criteria. CONCLUSION: Combined Nd:YAG laser incision and balloon dilation in an awake, spontaneously breathing patient is a safe and effective management tool in the treatment of laryngotracheostenosis. This technique may be particularly beneficial in patients who are at increased risk for general anesthesia such as those with morbid obesity or who have had a history of airway problems during anesthesia.

Management of obstructing pulmonary broncholithiasis with three-dimensional imaging and holmium laser lithotripsy.

Major airway obstruction due to broncholithiasis produces significant morbidity, and management is difficult. Many of the patients are elderly and are not good candidates for surgical removal. Bronchoscopic removal may be limited due to anatomic considerations, skill of the bronchoscopist, and exposure of the patient to additional procedural risks. Preprocedural planning with three-dimensional (3D) multidetector CT (MDCT) imaging enhances the bronchoscopist's knowledge of the relationships of the target lesions with critical structures, and improves the efficiency of the application of specific endobronchial therapies. Here we report our experience treating obstructing broncholithiasis in two patients utilizing pretreatment planning with 3D MDCT imaging, followed by bronchoscopically delivered holmium laser fragmentation of the stones.

Predictive performance of three multivariate difficult tracheal intubation models: a double-blind, case-controlled study.

We performed a case-controlled, double-blind study to examine the performance of three multivariate clinical models (Wilson, Arné, and Naguib models) in the prediction of unanticipated difficult intubation. The study group consisted of 97 patients in whom an unanticipated difficult intubation had occurred. For each difficult intubation patient, a matched control patient was selected in whom tracheal intubation had been easily accomplished. Postoperatively, a blinded investigator evaluated both patients. The clinical assessment included the patient's weight, height, age, Mallampati score, interincisor gap, thyromental distance, thyrosternal distance, neck circumference, Wilson risk sum score, history of previous difficult intubation, and diseases associated with difficult laryngoscopy or intubation. The Naguib model was significantly more sensitive (81.4%; P < 0.0001) than the Arné (54.6%) or Wilson (40.2%) models. Both the Naguib (76.8%) and Arné (74.7%) model classified more intubations correctly (P = 0.01) than the Wilson model (66.5%). The specificity of Arné, Wilson, and Naguib model was 94.9%, 92.8%, and 72.2%, respectively (P < 0.0001). The corresponding area under the receiver operating characteristic curve was 0.87, 0.79, and 0.82, respectively. Our new model for prediction of difficult intubation was developed using logistic regression and includes thyromental distance, Mallampati score, interincisor gap, and height. This model is 82.5% sensitive and 85.6% specific with an area under the receiver operating characteristic curve of 0.90.