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Perioperative Arrhythmias During Thoracic Surgery

Introduction Cardiac arrythmias are the most frequent postoperative complication affecting up to 20% of patients undergoing thoracic surgery. The most common arrhythmia is postoperative atrial fibrillation (POAF), which typically presents on postoperative day 1 to 5, peaks on postoperative day 2, and resolves within 4 to 6 weeks in more than 90% of patients. Despite its transient nature, POAF is associated with increased length of stay,…

Fluid Management During Lung Resection

Introduction Managing fluid administration during lung resection by the anesthesiologist is very similar to a tightrope walker trying to balance the risk of acute lung injury (ALI) and that of acute kidney injury (AKI); there is a narrow margin of safety between fluid overload and hypovolemia, two conditions that may impair lung and renal function, respectively. Maintaining fluid and electrolyte homeostasis represents a crucial challenge because…

Management of One-Lung Ventilation: Protective Lung Ventilation

Introduction One-lung ventilation (OLV) was first described in 1931, and the first pneumonectomy for cancer was performed in 1933. Although technology has evolved since then, OLV still poses a challenge for the anesthesiologist. For several decades, the impairment of gas exchange during OLV represented the focus of the attention. Accordingly, intraoperative mechanical ventilation settings were aimed at avoiding or reversing hypoxemia, as well as hypercapnia, without…

Intraoperative Lung Injury During One-Lung Ventilation: Causes and Prevention

Introduction The intraoperative period is critical for the patient undergoing thoracic surgery, frequently performed for resection of lung cancer. Both surgery and anesthesia are required to help the patient to overcome and survive a disease amenable to surgical treatment, however, both come at a cost to the patient. The cost of surgery is tissue destruction, bleeding, and ischemia-reperfusion injury which may lead to a varying degree…

Pathophysiology of Perioperative Lung Injury

Introduction Postoperative pulmonary complications remain a significant cause of morbidity and mortality after surgery. Approximately 230 million major surgical procedures are conducted annually worldwide. Perioperative pulmonary complications are common, occurring in up to 59% of patients. Approximately 2.7% of surgical patients will develop severe acute lung injury (ALI) causing postoperative respiratory failure. The risk is not uniform, and is significantly higher in surgery on the esophagus…

Lung Isolation in Patients With a Difficult Airway in Thoracic Anesthesia

Introduction One-lung ventilation (OLV) in the thoracic surgical patient who presents with a difficult airway can be achieved with the use of a single-lumen endotracheal tube with a bronchial blocker or with the use of a double-lumen endotracheal tube (DLT). It is estimated that between 5% and 8% of the patients who presented for thoracic surgery for primary lung carcinoma also have carcinoma of the pharynx,…

Separation of the Lung: Double-Lumen Endotracheal Tubes and Endobronchial Blockers

Introduction Lung separation techniques are designed to facilitate surgical exposure and provide one-lung ventilation (OLV) in patients undergoing thoracic, mediastinal, cardiac, vascular, esophageal, or selective spine surgery. Lung separation can be achieved with two different techniques. The first involves the double-lumen endotracheal tube (DLT) technique. This device is made of disposable polyvinyl, chloride material, or silicone material. , The DLT is a bifurcated tube with both…

Anesthesia, Mechanical Ventilation, and Hypoxic Pulmonary Vasoconstriction

Introduction One-lung ventilation (OLV) is a standard procedure required in thoracic surgery for cancer resection, treatment of bronchopulmonary fistula or bleeding, and lung transplantation, as well as for intrathoracic diagnostic investigations. Over the past 3 decades, the incidence of intraoperative hypoxemia has decreased and clinical outcome after thoracic surgery has largely been improved owing to the mastering of lung isolation techniques, better understanding of physiology related…

High-Frequency Ventilation: Applications in Thoracic Anesthesia

Introduction The term high-frequency ventilation (HFV) summarizes different techniques of ventilation with a ventilator frequency of more than 60 breaths per minute, tidal volumes (V T ) of equal or less than dead space, as well as lower peak airway pressure, lower transpulmonary pressure, and increased functional reserve capacity when compared with conventional mechanical ventilation. There are four types of HFV: high-frequency jet ventilation (HFJV), high-­frequency…

Flexible and Rigid Bronchoscopy in Thoracic Anesthesia

Introduction The complex cardiopulmonary interactions, combined with abnormal secretion and surgical impairment of lung-chest wall dynamics makes hypoxemia, hypo- and hypertension, dysrhythmia, hypercapnia, and acidosis common threats in the perioperative period. Bronchoscopy by definition is a procedure that allows for the visualization and examination of the tracheobronchial tree. This discipline has been one of the most significant advances in respiratory disease diagnosis and treatment, and is…

Hemodynamic Monitoring in Thoracic Surgical Patients

Introduction Thoracic surgery is a rapidly changing surgical subspecialty that presents the anesthesiology community with a myriad of challenges, one of which is hemodynamic monitoring. Thoracic surgical patients range from relatively healthy adults with refractory gastroesophageal reflux in need of a laparoscopic Nissen fundoplication, to patients with severe atherosclerosis and chronic obstructive pulmonary disease needing a pneumonectomy for cancer resection, to patients in need of lung…

Monitoring of Oxygenation and Ventilation

Introduction During anesthesia for a thoracic surgical procedure, many alterations in physiology occur, including changes in oxygenation and ventilation. Whether the patient is receiving monitored anesthesia care (MAC), regional anesthesia, or general anesthesia, it is essential that the anesthesiologist monitor each patient diligently to optimize management and avoid complications. (“Vigilance” is the motto of the American Society of Anesthesiologists [ASA]). Monitoring of oxygenation and ventilation are…

Positioning in Thoracic Surgery

Introduction Adequate patient position is essential to facilitate surgical exposure. This in turn has direct consequence on the anesthetic management. In addition to providing best access to the patient, optimal position should minimize any potential harm and injuries, especially when positional changes occur during general anesthesia, because of lack of patient feedback. The anesthesiologist has a key role during the perioperative period as the person in…

Prehabilitation for Thoracic Surgery

Introduction Lung cancer accounts for 30% of all cancer cases, with outcomes for patients improving at a modest pace. That said, 5-year survival for patients with stage IA to IIA cancer managed with a combination of chemotherapy and surgery exceeds 50%. Lung cancer screening programs are increasingly used to identify patients at a stage where lung resection is possible. Lung resection surgery is associated with a…

Preoperative Evaluation: Assessment of Preoperative Risk

Introduction The main purposes of a comprehensive preoperative evaluation before thoracic surgery are to assess the risk associated with anesthesia and surgery throughout the perioperative period; to identify, modify, and optimize the treatment of comorbidities that may affect perioperative outcome; and to provide the basis for the design of an appropriate, individually tailored, anesthetic plan. Additional advantages include patient education and consent, providing advanced knowledge to…

Modulating the Pulmonary Circulation: Nitric Oxide and Beyond

Introduction Thoracic surgery commonly requires the separation of the patient’s airway, followed by exclusion of one lung from ventilation (i.e., one-lung ventilation [OLV]) to facilitate surgical interventions. However, ventilation of one lung will result in an increased intrapulmonary shunt because of continuous perfusion in the nonventilated collapsed lung. In addition, insufficient oxygenation of pulmonary blood through the atelectatic regions of the ventilated lung will increase venous…

Physiology of the Lateral Position andOne-Lung Ventilation

Introduction Thoracic procedures are usually performed with the patient in the lateral decubitus position. To understand the distribution of ventilation and perfusion in the lateral decubitus position and the degree of venous admixture of shunt (Qs/Qt) is expressed as a percentage. Alveolar ventilation/perfusion ratio distributions are plots of the total amounts of ventilation and total amounts of perfusion that are supplying each collection of lung units…

Pulmonary Pathophysiology and Lung Mechanics in Anesthesiology

Introduction The practice of thoracic anesthesia, in addition to involving patients with impaired pulmonary function, also necessitates dynamic changes in ventilation that impact perfusion and ventilation/perfusion matching. Thus it is imperative that the thoracic anesthesiologist has a thorough understanding of normal pulmonary physiology, as well as states of pathophysiology. Further, the practitioner must have an intimate familiarity with the impact of mechanical ventilation on both normal…

Intrathoracic Tumors: Current Status and Classification

Introduction Thoracic oncology encompasses a large spectrum of diseases. Between the various anatomic spaces and the different organ systems, there are a large variety of benign and malignant tumors that can develop within the chest. This chapter will focus primarily on the surgical management of the most commonly encountered thoracic malignancies. General Diagnostic Principles Aside from a thorough history and examination, certain radiographic studies are essential…

Radiology of the Thorax

Introduction Radiologic images play an important role in the preoperative, intraoperative, and postoperative evaluation, and diagnosis of patients undergoing thoracic surgery. During the preoperative visit for evaluation of the thoracic surgical patient, the clinician must have an understanding of the disease and also become familiar with radiologic studies to be able to identify abnormal airway anatomy or compromises to the airway or to use caliper measurements…