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Tracheal Resection and Reconstruction

Introduction Anesthetic management of the patient who requires surgical resection of a portion of the large airways continues to challenge the skills of even the most experienced anesthesiologist. The large airways, including the trachea, carina, and major bronchi, can harbor myriad pathologic conditions that necessitate surgical resection and reconstruction. The patient presenting for airway surgery is often complex medically. Existing disease states frequently contribute to the…

Repair of Pectus Excavatum

Introduction Pectus excavatum (PE) is a congenital chest wall deformity characterized by a sternal depression, which typically begins at the manubrium and ends toward the xiphoid. Adjacent costal cartilages are displaced as well. The deformity can be symmetric or asymmetric. It is also called a funnel chest or trichterburst. PE has an incidence of 1 to 8 per 1000 and accounts for 88% of anterior chest…

Wedge Resection, Lobectomy, Pneumonectomy

Introduction The primary indications for resection of lung parenchyma include both malignant and benign conditions. Primary lung malignancy remains the leading cause of cancer-related deaths and lung resection surgery is the cornerstone of therapy for stage I and II (localized) primary lung nonsmall cell lung cancer malignancies, as well as for some patients presenting with stage III disease. The lung is the third most common location…

Thoracic Aortic Aneurysm Resection

Introduction Historical Notes on Thoracic Aortic Aneurysms The dilatation of arteries was first recognized as a disease of the cardiovascular system in Egypt in the 1550s bc , and the first to describe an abdominal aortic aneurysm was the Flemish physician Vesalius about three millennia later in 1555. Two centuries later, in 1785, the English surgeon John Hunter began to treat aneurysms of the peripheral vessels…

Thoracic Anesthesia for the Geriatric Patient

Introduction Among the geriatric population, there is great variability in physiologic condition from person to person. Because of this variability, the patient’s preoperative functional status, comorbidities, and tumor stage may influence surgical outcomes more than chronologic age alone. However, even an otherwise healthy older person will exhibit limited physiologic reserve because of the normal process of aging. Optimal management of these patients in the perioperative period…

Tubeless Thoracic Procedures

Tubeless thoracic procedures are performed without an endotracheal tube while the patient is spontaneously breathing. Initially it was defined as an “awake” thoracic procedure, but the term was updated to “tubeless” because these procedures are performed with sedation and/or regional block of variable extent while maintaining spontaneous ventilation. For decades, the use of a double-lumen tube (DLT) and the insertion of chest tube drainage were considered…

Lung Resection and Pulmonary Hypertension

Introduction Pulmonary hypertension (PH) has become an increasingly common diagnosis among patients presenting for surgery. With advances pertaining to the diagnosis and treatment of PH, these patients are now living longer with an improved quality of life. Although surgery still poses a significant risk, patients with PH can safely undergo noncardiac surgery. Patients with precapillary PH undergoing noncardiac surgery have a mortality rate ranging from 1%…

Mediastinoscopy

Introduction Cancer is the second leading cause of death in the United States; of these, lung cancer is the most common cause in both males and females. Although the lung cancer death rate has declined over the years primarily because of a reduction in smoking, the 5-year relative survival rate remains comparatively low at 19%. Early detection and treatment improves survival rates and can possibly offer…

Mediastinal Mass and Superior Vena Cava Syndrome

Introduction An anterior mediastinal mass is one of the most challenging pathologies an anesthesiologist may face during his or her career. To safely care for these patients, it is imperative to know the relevant anatomy of the mediastinum, understand how mediastinal pathology can compromise a patient’s respiratory and cardiovascular systems, and recognize how to prepare for and quickly intervene to treat these potentially life-threatening complications. In…

Thoracic Trauma

Introduction Thoracic trauma is the cause of 25% to 50% of all fatal injuries, making it the leading cause of death in the first 3 decades of life. , In addition, injuries to the thorax are accountable for more than 50% of deaths in children. Thoracic trauma is the third leading cause of death after neoplasms and atherosclerosis for all age groups. The mortality from thoracic…

Endoscopic Treatment of Chronic Obstructive Pulmonary Disease

One Way Valves in the Treatment of Emphysema and Persistent Air Leaks Emphysema Emphysema is one component of chronic obstructive pulmonary disease (COPD), the third leading cause of death in the United States. Emphysema has been defined as “a condition of the lung characterized by abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis.”…

Video-Assisted Thoracoscopy: Multiportal Uniportal

Introduction Video-assisted thoracoscopic surgery (VATS) is one of the major innovations in surgery. Within less than 30 years after its modern introduction, almost all of the operations, with only few exceptions, can be performed via VATS. It provides several benefits for the patients, as well as several challenges for the anesthetist. It is an “intentionally created” pneumothorax followed by the introduction of instruments into the cavity…

The Patient With Cardiovascular Disease for Lung Resection Surgery

Introduction The patient with cardiovascular disease (CVD) presenting for lung resection surgery has special concern. Identifying significant cardiac risk factors provides information to better quantify the risks of a possible cardiac event in the perioperative period. Cardiac complications in the perioperative period may prolong recovery in the immediate postoperative period and may also affect outcome following the surgery. Over the past decades, research initially focused on…

Lung Volume Reduction Surgery

Introduction Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. Emphysema is one component of COPD, and it is estimated that 3.1 million adults in the United States are currently diagnosed with emphysema. Emphysema is associated with permanent enlargement and destruction of the lung alveoli. The destruction of the alveolar walls of the distal terminal bronchioles results in loss…

Extracorporeal Ventilatory Therapies

Introduction Clinical use of extracorporeal ventilatory support technologies is increasing exponentially with an expanding range of indications for patients with cardiopulmonary disease. Rapid adoption is occurring despite limited basic and translational research on extracorporeal support and only a handful of large-scale multicenter trials to inform clinical practice. At present, clinicians must rely on pathophysiologic reasoning and understanding of device technology to guide the initiation, titration, and…

Postthoracotomy Complications

Introduction Thoracotomy is required to get surgical access to the thoracic cavity through the chest wall to the pleural space and the thoracic organs, such as heart, lung, thymus, and esophagus. The principles and techniques of thoracotomy are differentiated in the anterolateral (= muscle sparing) and posterolateral (= nonmuscle sparing) approach, which requires a lateral position of the patient. In addition, sternotomy, anterior or axillary thoracotomy,…

Postoperative Care of the Thoracic Patient

Introduction Anesthesiologists are responsible for the management of the surgical cases not only during the intraoperative stage, but rather through the entire perioperative period. In the multidisciplinary context of perioperative medicine, anesthesiology is an important component in addressing the challenges from all practical, financial, and scientific points of view. Providing anesthesia to thoracic procedures is probably the prime example within the field of anesthesiology to have…

Postthoracotomy Chronic Pain

Introduction According to the International Association for the Study of Pain, chronic postthoracotomy pain is defined as “pain that recurs or persists along a thoracotomy incision at least 2 months following the surgical procedure”. The condition may also be referred to as postthoracotomy pain syndrome (PTPS) or postthoracotomy neuralgia. The first cases were described in soldiers after World War II. Patients often describe pain along the…

Postoperative Management of Acute Pain

Introduction In 2021, noncardiac thoracic surgery can range from minimally invasive, robot-assisted procedures, such as lung biopsies or resections, to more invasive procedures requiring thoracotomy such as pneumonectomy, esophagectomy, tracheal resection, or lung transplantation. The noxious stimulus associated with thoracic surgery is among the most severe sources of postoperative pain and carries one of the highest incidences of persistent postsurgical pain (PPSP). , These procedures can…

Anesthesia for Pediatric Thoracic Surgery

Introduction Pediatric patients undergoing thoracic surgery can be particularly challenging because of the differences in anatomy, physiology, and behavior in comparison to adult patients. The anesthesiologists must be cognizant of these to successfully manage these patients. The availability of proper pediatric size equipment, such as bronchoscopes and bronchial blockers (BBs), allows the anesthesiologist to achieve optimal operating conditions particularly during minimally invasive procedures. However, oftentimes, because…