Heart rate to arterial pressure impulse response during one lung ventilation.

In this prospective, randomised study a double lumen tube (DLT) or an Arndt bronchial blocker (BB) was used for one lung ventilation (OLV). Intraoperative oxygenation, ventilation, haemodynamics, and ease of placement were compared. In 32 patients undergoing robotic harvesting of the left internal thoracic artery (ITA) a left-sided DLT or a BB controlled by bronchoscopy was used for OLV of the right lung. In 2 patients randomised for DLT, a single lumen tube and BB was used for difficult visualisation of the larynx. These 2 patients were excluded from the study. Correct placement of DLT (8.8 +/- 5.4 min, 87.5 % of the patients) as well as BB (6.5 +/- 4.0 min; n. s.; 100 % of the patients) was achieved rapidly. The Cormack-Lehane score for visualisation of the larynx was 2, 1 - 3 (median, range) in group DLT and 3, 1 - 4 (median, range) in group BB (p < 0.05). OLV lasted for 93 +/- 29 min in group DLT and 88 +/- 34 min in group BB (n. s.). Satisfactory conditions for harvesting ITA were achieved in all patients of both groups. There was no difference in any haemodynamic parameter at any time between the two groups. Mean pulmonary arterial pressure and pulmonary vascular resistance were increased without significant differences between the two groups during thoracoscopy for robotic preparation of left ITA. During OLV, index of paO (2)/FiO (2) was significantly (p < 0.05) lower in DLT patients compared to BB patients. Time to extubation did not differ between the two groups (DLT 14.3 +/- 4.6 h; BB 11.8 +/- 3.8 h). OLV in patients undergoing robotic cardiac surgery was safely achieved either by BB or by left-sided DLT. Positioning of the BB was easier than that of a DLT when intubation was difficult and tube exchange at the end of surgery is avoided. Therefore, we prefer a BB in patients undergoing robotic harvesting of left ITA.

Improvement of Arterial Oxygen Saturation with Selective Lobar Bronchial Block During Hemorrhage in a Patient with Previous Contralateral Lobectomy

The endothelial glycocalyx layer (EGL) coats the alveolar capillary endothelium and plays important roles in pulmonary vascular protection, modulation, and hemostasis. Ischemia-reperfusion, which occurs during lung resection surgery with one lung ventilation (OLV), can damage the EGL. Sevoflurane is known for its protective effect against ischemia-reperfusion injury. Therefore, we hypothesized that lung resection surgery produces EGL damage and sevoflurane protects the EGL better than the intravenous anesthetic propofol. Seventy-eight patients undergoing pulmonary resection were randomly allocated into the sevoflurane (n=38) and propofol (n=40) groups. All patients received OLV and protective ventilation under sevoflurane- or propofol-based anesthesia. The concentrations of EGL injury markers (heparan sulfate and human syndecan-1) and an inflammatory marker (vascular cell adhesion molecule-1) were measured from blood samples drawn at five time points (after induction, 60 min after OLV, 120 min after OLV, end of OLV, and end of surgery). OLV increased the concentrations of EGL injury markers; heparan sulfate concentrations increased from 120 minutes after OLV (120 minutes after OLV: sevoflurane, 13.3±6.8 ng/mL, P<0.05; propofol, 14.8±6.9 ng/mL, P<0.05). Human syndecan-1 concentrations also increased from 120 minutes after OLV (120 minutes after OLV: sevoflurane, 20.4±8.9 ng/mL, P<0.05; propofol, 20.5±11.8 ng/mL, P>0.05). However, no difference in EGL injury markers was observed between the sevoflurane and propofol groups at any time point. Vascular cell adhesion molecule-1 concentrations did not show any temporal changes in either group. Lung resection surgery with OLV produced EGL damage without any increase in inflammation. Although shedding of heparan sulfate induced by EGL injury during lung resection surgery with OLV, was less than propofol, it was not statistically significant.

End-tidal carbon dioxide tension (PETCO2) is widely used to estimate arterial carbon dioxide tension (PaCO2) under various clinical conditions. This study was conducted to determine if PETCO2 during one lung ventilation (OLV) is as useful as PETCO2 during two lung ventilation (TLV) for predicting PaCO2. Methods: Forty patients undergoing thoracic surgery were enrolled in this study. During OLV (n = 20) and TLV (n = 20), PaCO2 and PETCO2 were measured. The arterial-end tidal carbon dioxide difference (Pa-ETCO2) was then calculated and a correlation between PaCO2 and PETCO2 was evaluated during OLV and TLV. Results: Pa-ETCO2 was significantly higher during OLV (8.9 ± 5.1 mmHg) than during TLV (6.1 ± 3.9 mmHg). In addition, the correlation between PETCO2 and PaCO2 was less significant during OLV (R2 = 0.43) than during TLV (R2 = 0.59). Conclusions: PETCO2 during OLV was not as accurate as PETCO2 during TLV for predicting PaCO2, which indicates that greater attention should be given to the maintenance of normocarbia during OLV than during TLV.

Objective To investigate the incidence of with double-lumen endobronchial tube (DLT) in anesthesia induction, and discuss how to deal with with and strategy to achieve pulmonary isolation during surgery. Methods Medical records from patients scheduled for with in the Anesthesia Information Database of Shanghai Chest Hospital from May 2009 to May 2012 were retrospectively analyzed to search cases using the following three keywords: difficult intubation with DLT and one-lung ventilation (OLV). The primary outcome was the incidence of with DLT, while the secondary outcomes were airway evaluation in patients with before surgery, management strategy to solve intubation, the way to achieve perioperative lung collapse, and perioperative complications related to intubation. Results A total of 11 017 patients were included in the current study. Difficult happened in 112 patients (1.0%). Among the 112 patients, 22 patients (19.6%) had predictable or suspected airway, while the other 90 patients (80.4%) showed no obvious clinical signs of before induction. Furthermore, 90 patients (80.4%) adopted two or more types of devices. There were 22 patients who were intubated with single-lumen endotracheal tubes after induction, where 2 patients were successfully implanted with through the guidance of exchange catheters for pulmonary isolation, 13 patients were implanted with bronchial blockers under a fiberbronchoscope, and 7 patients received low tidal volume ventilation. There was no case of severe cardiovascular complications. Conclusions DLT has strict requirements for the conditions of glottic exposure, and airway assessment before anesthesia should be more cautious. The use of visual tools improves the safety and effectiveness of with DLT. Bronchial blockers provide more choices for with DLT. Key words: Double-lumen endobronchial tube; Difficult intubation; Difficult airway; Thoracic anesthesia; One lung ventilation

To describe a technique for blind thoracoscopic-assisted double-lumen endobronchial tube (DLT) placement for achieving one-lung ventilation (OLV) using 3 different DLT designs and to evaluate whether thoracic auscultation could reliably confirm OLV in dogs. Prospective randomized study. Mature female hound dogs (n = 6). Physical examination, baseline blood work and thoracic radiography confirmed the absence of preexisting disease in all dogs. Thoracoscopic observation was established through a subxiphoid portal and used for evaluation of differential lung lobe ventilation. Each dog was sequentially intubated using 1 of 3 DLT designs in random order; Robertshaw left-sided tube (RS-L), Carlens left-sided tube (C-L), Dr. White right-sided tube (DW-R). Incidence of initial and overall (after a maximum of 3 DLT manipulations) correct and complete OLV (CC-OLV) was recorded. After each blind thoracoscopic-assisted DLT placement, bronchoscopic evaluation was performed to document correct DLT position. Blind DLT placement achieved overall CC-OLV in all dogs using RS-L, 66% using C-L, and all using DW-R. Successful initial left-sided OLV (L-OLV) was statistically more likely when RS-L DLTs were used compared to C-L or DW-R. Of cases where overall CC-OLV was achieved, correct DLT position was present in only 44% of intubations. Blind DLT placement produced successful CC-OLV in all dogs using at least one DLT design evaluated. Use of thoracoscopic assistance may obviate the need for bronchoscopic observation during DLT placement in dogs. However, bronchoscopic observation may still refine DLT positioning in dogs after blind thoracoscopic-assisted DLT placement.

One-lung ventilation is widely practiced in major thoracic and mediastinal surgery. In some circumstances, lung isolation is mandatory. We report the case of an incidentally found aberrant tracheal bronchus (right upper lobe bronchus originating in the trachea). This atypical origin of the right upper lobe bronchus complicated one-lung ventilation. In addition to a Univent tube, we used a Fogarty catheter to block the tracheal bronchus and successfully establish isolation of the right lung. Case Report A 47-yr-old man was scheduled for esophagectomy and reconstruction with gastric tube substitution because of esophageal cancer (T4N1M0). Six years ago, he suffered from right buccal cancer and received radical neck dissection, marginal mandibulectomy, and left forearm-free flap for inner and outer defects. Postoperative radiotherapy was completed. At this admission, preoperative laboratory workups, including biochemical tests, chest radiograph, and electrocardiogram, were unremarkable. Trismus was noted after the radiotherapy. The mouth opening was up to 2 cm. In the operating room, after routine monitors were placed, the patient received general anesthesia with IV atropine, fentanyl, thiopental, and vecuronium. A flexible fiberoptic bronchoscope was used as a guide to pass a Univent tube (inner diameter, 6.0 mm) through the right mouth angle into the trachea. The right mainstem bronchus was identified and blocked with a Univent bronchial blocker. A right thoracotomy was performed. Unfortunately, the right upper lobe was still inflated during mechanical ventilation, although the right middle and lower lobes were successfully collapsed. The position of the bronchial blocker was reconfirmed by bronchoscopy. Accidentally, we found an ectopic opening from the tracheal wall. Aberrant tracheal bronchus was suspected (Fig. 1). The surgeon requested complete lung collapse. We inserted a 6F Fogarty catheter through the left nostril to the opening of the tracheal bronchus, which had been tied together with the fiberoptic bronchoscope with a retractable knot. We successfully blocked the right upper lobe bronchus by inflation of the Fogarty catheter. The airway pressure under one-lung ventilation was up to 31 cm H2O, and no desaturation was noted through the procedure. The surgical procedure proceeded uneventfully with good visualization of the operative field.Figure 1: Fiberscopic view of the patient (left) and the relative position of the anatomical structures with the Univent tube blocker (Endo) and Fogarty tube (F), as illustrated (right). LMB, left main bronchus; RMB, right main bronchus; ATB, aberrant tracheal bronchus.Discussion Selective ventilation of one lung has been accomplished by several methods (1,2). The Univent tube might be advantageous for this purpose and easier to place, especially in patients with difficult airways (3). We described a patient with anticipated anatomical constraint of mouth opening, which disallowed the passage of the double-lumen tube. Using a flexible bronchoscope was a sure way to accomplish selective bronchial block by a Univent tube. The tracheal bronchus is an aberrant, accessory, or ectopic bronchial branch arising directly from the lateral wall of the trachea above the carina, with an incidence ranging from 0.1% to 2%(4). It occurs almost exclusively on the right side, involves the right upper lobe, and usually represents a displaced origin of the right main bronchus or apical segmental bronchus (5). Most cases of tracheal bronchus are asymptomatic, like our patient, but some patients may experience recurrent pneumonia, chronic bronchitis, or bronchiectasis (4). Although it is usually of little clinical significance, this atypical origin of the right upper lobe bronchus may complicate one-lung ventilation during thoracic surgery (6). The combination of a Fogarty catheter with a double-lumen endotracheal tube may be practically used to provide excellent lung separation and obviate the need to re-intubate the patient’s trachea (7). In this case, we used a Univent tube instead of a double-lumen endotracheal tube with a Fogarty catheter and provided excellent lung separation. Advantages of placing a Fogarty catheter within a Univent tube may include the ability to deflate/inflate a lung on the operative side, easier placement in patients with difficult airways, and avoiding the need for exchanging a double-lumen tube for a single-lumen tube when postoperative mechanical ventilation is planned. Although the combined use of a Fogarty catheter with a Univent tube is not a routine practice, it was useful in this patient who had an unanticipated tracheal anatomical anomaly. The case also illustrates the importance of a careful and thorough bronchoscopic examination to detect any tracheal bronchus anomaly before positioning for surgery.

Cardiopulmonary transplantation

Paediatric lung isolation

In patients with a bronchocutaneous fistula, positive pressure ventilation leads to air leakage and potential hypoxemia. A male patient with a right upper bronchocutaneous fistula was scheduled for esophageal reconstruction. His preoperative chest computed tomography image revealed aeration in the right middle and lower lobe, a large bulla in the left upper lobe, and pleural effusion and pneumonia in the left lower lobe. Therefore, left one-lung ventilation was considered to result in hypoxemia. Before anesthesia induction, the bronchocutaneous fistula was covered with gauze and film to prevent air leakage. After anesthesia induction, mask ventilation was performed with a peak positive pressure of 10cmH2O. A left-sided double lumen endobronchial tube (DLT) was then inserted into the right main bronchus for occluding only the right superior bronchus, and two-lung ventilation was performed to minimize airway pressure and maintain oxygenation, which did not cause air leakage through the fistula. During anesthesia, no ventilation-related difficulty was faced. The method of inserting a left-sided DLT into the right main bronchus and occluding the right upper bronchus selectively by bronchial cuff is considered to be an option for mechanical ventilation in patients with a right upper bronchial fistula, as demonstrated in the present case.

The association between sarcoidosis and autonomic dysfunction is demonstrated but poorly known. Heart rate variability (HRV) studies can provide a simple, non-invasive analysis of sympathetic and vagal tone in sarcoidosis. To date, the burden of steroid treatment on HRV has not been investigated. We aim to compare the HRV in sarcoidosis with general population and to explorate the burden of steroid treatment in HRV. Prospective analysis of 30 patients enrolled in Sarcoidosis Clinic of Policlinico Gemelli Hospital compared to 72 healthy control subjects. Continuous EKG recording over 24 hours has been performed and HRV was assessed using time and frequency domain analysis. Results were evaluated using a propensity score matching 1:1. Patients affected by sarcoidosis presented a mean age of 59.7±10.1 y and female gender predominance (n=20, 71.4%) %) while the control group was 54.6±16.0 y. The HRV analysis outlined a remarkable difference when both time / frequency domain were compared to the general, healthy population (ΔSDNN: 89.4±6.7 p=0.0001; ΔrMSSD: 5.7±2.6 p=0.03; ΔLF: 497.0±142.3 p=0.0007; ΔHF: 325.0±159.5 p=0.0442) suggesting a significant impact of sarcoidosis in autonomic activation. Remarkably the lung function tests and scadding stage did not show any relationship with the HRV (p=NS). At the same time, steroid treatment of ≥10 mg/day of prednisone for the previous 3 months was associated with a significant reduction of HRV in time (SDNN: Δ17.2±6.9, p=0.020) and frequency domain (LF: Δ355.2±125.7, p=0.009 and HF: Δ116.2±65.2, p=0.087). Lastly, the propensity score matching did confirm the previous results regarding time/frequency domain analysis. HRV is an effective tool for the autonomic evaluation in patients affected by sarcoidosis. The time (r-MSSD, SDNN, pNN50%) and frequency domain (HF/LF mean) analysis in sarcoidosis suggested that autonomic dysfunction is not related to the lung function or scadding stage though steroid treatment may impact.

Double-lumen endotracheal tubes (DL-ETT) and bronchial blockers (BB) are frequently used to allow one-lung ventilation (OLV) during video-assisted thoracic surgery (VATS). Recently, faster lung collapse has been documented with a BB than with a DL-ETT. The physiologic mechanisms behind this faster collapse remained unknown. We aimed to measure ambient air absorption (Vresorb) and intra-bronchial pressure (Pairway) into the non-ventilated lung during OLV using DL-ETT and BB. Patients undergoing VATS and OLV for lung resection were randomly assigned to have measurements made of Vresorb or Pairway within the non-ventilated lung using either a DL-ETT or BB. Thirty-nine patients were included in the analyses. The mean (standard error of the mean [SEM]) Vresorb was similar in the DL-ETT and BB groups [504 (85) vs 630 (86) mL, respectively; mean difference, 126; 95% confidence interval [CI], -128 to 380; P = 0.31]. The mean (SEM) Pairway became progressively negative in the non-ventilated lung in both the DL-ETT and the BB groups reaching [-20 (5) and -31 (10) cmH2O, respectively; mean difference, -11; 95% CI, -34 to 12; P = 0.44]at the time of the pleural opening. During OLV before pleural opening, entrainment of ambient air into the non-ventilated lung occurs when the lumen of the lung isolation device is kept open. This phenomenon is prevented by occluding the lumen of the isolation device before pleural opening, resulting in a progressive build-up of negative pressure in the non-ventilated lung. Future clinical studies are needed to confirm these physiologic results and their impact on lung collapse and operative outcomes. www.clinicaltrials.gov (NCT02919267); registered 28 September 2016.

To test the hypothesis that protective ventilation strategy (PVS) as defined by the use of low stretch ventilation (tidal volume of 5 ml x kg(-1) and employing 5 cm of positive end expiratory pressure (PEEP) during one lung ventilation (OLV) in piglets would result in reduced injury compared to a control group of piglets who received the conventional ventilation (tidal volume of 10 ml x kg(-1) and no PEEP). PVS has been found to be beneficial in adults to minimize injury from OLV. We designed the current study to test the beneficial effects of PVS in a piglet model of OLV. Ten piglets each were assigned to either 'Control' group (tidal volume of 10 ml x kg(-1) and no PEEP) or 'PVS' group (tidal volume of 5 ml x kg(-1) during the OLV phase and PEEP of 5 cm of H2O throughout the study). Experiment consisted of 30 min of baseline ventilation, 3 h of OLV, and again 30 min of bilateral ventilation. Respiratory parameters and proinflammatory markers were measured as outcome. There was no difference in PaO2 between groups. PaCO2 (P < 0.01) and ventilatory rate (P < 0.01) were higher at 1.5 h OLV and at the end point in the PVS group. Peak inflating pressure (PIP) and pulmonary resistance were higher (P < 0.05) in the control group at 1.5 h OLV. tumor necrosis factor-alpha (P < 0.04) and IL-8 were less (P < 0.001) in the plasma from the PVS group, while IL-6 and IL-8 were less (P < 0.04) in the lung tissue from ventilated lungs in the PVS group. Based on this model, PVS decreases inflammatory injury both systemically and in the lung tissue with no adverse effect on oxygenation, ventilation, or lung function.

One-lung ventilation in a patient with tracheobronchomegaly: a case report and literature review

The advantages of video assisted thoracoscopic surgery (VATS) in children have led to its increased usage over the years. VATS, however, requires an efficient technique for one lung ventilation. Today, there is an increasing interest in developing the technique for lung isolation to meet the anatomic and physiologic variations in infants and children. This article aims to provide an updated and comprehensive review on one-lung ventilation strategies for infants and children undergoing VATS. Search of terms such as ‘One lung ventilation for infants and children’, ‘Video assisted thoracoscopic surgery for infants and children’, and ‘Physiologic changes during one lung ventilation for infants and children’ were used. The search mechanics and engines for this review included the following: Kandang Kerbau Hospital (KKH) eLibrary, PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. During the search the author focused on significant current and pilot randomized control trials, case reports, review articles, and editorials. Critical decision making on what device to use based on the age, weight, and pathology of the patient; and how to use it for lung isolation are discussed in this article. Furthermore, additional information regarding the advantages, limitations, techniques of insertion and maintenance of each device for one lung ventilation in infants and children were the highlights in this article.