Current practice of thoracic anaesthesia in Europe – a survey by the European Society of Anaesthesiology Part I – airway management and regional anaesthesia techniques

Background The scientific working group for “Anaesthesia in thoracic surgery” of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) has performed an online survey to assess the current standards of care and structural properties of anaesthesia workstations in thoracic surgery. Methods All members of the European Society of Anaesthesiology (ESA) were invited to participate in the study. Results Thoracic anaesthesia was most commonly performed by specialists/board-certified anaesthetists and/or senior/attending physicians. Across Europe, the double lumen tube (DLT) was most commonly chosen as the primary device for lung separation (461/ 97.3%). Bronchial blockers were chosen less frequently (9/ 1.9%). Throughout Europe, bronchoscopy was not consistently used to confirm correct double lumen tube positioning. Respondents from Eastern Europe (32/ 57.1%) frequently stated that there were not enough bronchoscopes available for every intrathoracic operation. A specific algorithm for difficult airway management in thoracic anaesthesia was available to only 18.6% (n = 88) of the respondents. Thoracic epidural analgesia (TEA) is the most commonly used form of regional analgesia for thoracic surgery in Europe. Ultrasonography was widely available 93,8% (n = 412) throughout Europe and was predominantly used for central line placement and lung diagnostics. Conclusions While certain „gold standards “are widely met, there are also aspects of care requiring substantial improvement in thoracic anaesthesia throughout Europe. Our data suggest that algorithms and standard operating procedures for difficult airway management in thoracic anaesthesia need to be established. A European recommendation for the basic requirements of an anaesthesia workstation for thoracic anaesthesia is expedient and desirable, to improve structural quality and patient safety.

Analysis of modern anesthetic approaches in endoscopic phthisiosurgery

Objective — to analyze modern anesthetic approaches and their use in endoscopic phthisiosurgery. Materials and methods. During 2008—2021, we performed 133 VATS lung resections in patients with tuberculosis. The following VATS operations were performed: atypical segmentectomy — 29 (21.6 %), typical segmentectomy — 49 (36.9 %), lobectomy — 49 (36.9 %) cases, bilobectomy — 2 (1.5 %), pulmonectomy — 4 (3.1 %) observations.The number of patients diagnosed with newly diagnosed tuberculosis was 62 (46.3 %), with multidrug­resistant tuberculosis 45 (34.4 %) and extensively drug-resistant tuberculosis 26 (19 3 %). One-pulmonary ventilation, which was carried out by endobronchial intubation of the main bronchus of the contralateral lung using a double-lumen tube (DLT) in 115 (86.4 %) patients, in 15 (11.3 %) cases, endobronchial intubation was performed with a single-lumen tube (SLT) and in 3 (3.1 %) tracheal intubation. Results and discussion. The use of a DLT for intubation made it possible to reduce the duration of surgery by 20—25 % compared with the use of a SLT or tracheal intubation. When using a DLT, a more stable, faster and better collapse of the lungs was achieved, which in turn gave a decrease in trauma to its parenchyma due to the fact that additional instrumental actions were not required on the part of surgeons to achieve it.Intraoperative blood loss with DLT was (75.4 ± 38.7) and (112.6 ± 51.8) ml with SLT in experiments with intubation of the main bronchus of the contralateral lung and (184.3 ± 89.8) ml in tracheal intubation, largely due to visualization and comfort working conditions of the surgical team.In the recovery of costs, we adhere to restrictive infusion approaches, which allows avoiding overloading the pulmonary circulation, and therefore reducing the number of pulmonary complications. The qualitative composition of the intraoperative infusion program included crystalloid and colloidal solutions. The quantitative ratio during the intubation of DLT was 3 : 0.5, with SLT 3 : 1. The need for transfusion of blood components was only during tracheal intubation. Conclusions. The most important task of modern anesthesiology in endoscopic phthisiosurgery is to improve patient safety during surgery. The defining technologies of anesthetic protection in this case should be the following categories: means and methods of general anesthesia, methods of respiratory provision and technical means of their application; full intraoperative monitoring of vital functions.

Comparison of Double-Lumen Tube and EZ-Blocker for Lung Separation in Thoracic Surgery - A Randomised Controlled Clinical Trial

Background:Double lumen tube (DLT) intubation is the most commonly used technique for lung separation. Bronchial blockers (BB) are an alternative, especially for difficult airways. The EZ-bronchial blocker (EZB) is the newest device of the BB family. Methods:A randomised, controlled trial was conducted in 80 patients undergoing elective thoracic surgery using DLT or SLT plus EZB for lung separation (German Clinical Trial Register DRKS00014816). The objective of the study was to compare the clinical performance of EZB with DLT. Primary endpoint was total time to successful lung separation. Secondary endpoints were time subsections, quality of lung collapse, difficulty of intubation, any complications during the procedure, incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms.Results:74 patients were included, DLT group (n = 38), EZB group (n = 36). Median total time for lung separation [IQR] in DLT group was 234 seconds [207 to 294] versus 298 seconds [243 to 369] in EZB group (P=0.007). Quality of lung collapse was equal in both groups, DLT group 89.5% were excellent vs. 83.3 % in the EZB group (P=0.444). Inadequate lung collapse in five patients of the EZB group resulted in unsuccessful repositioning attempts and secondary DLT placement. Endoscopic examinations revealed significantly more carina trauma (P=0.047) and subglottic haemorrhage (P=0.047) in the DLT group. Additionally, postoperative subjective symptoms (sore throat, hoarseness) were more common in the DLT group, as were speech problems.Conclusions:Using the EZB results in prolonged lung separation compared to DLT, prima facie with equal quality of lung collapse for the thoracic surgeon. Five crossover cases demonstrated the superiority of the use of left-sided DLT especially in the indication for EZB for a right open thoracotomy or right video-assisted thoracoscopic surgery (VATS). Using the EZB showed only little evidence for reducing objective airway trauma e.g. less carina trauma as well as subjective complaints.Trial registration:German Clinical Trial Register DRKS00014816, prospectively registered on 07.06.2018https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014816