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Purpose of Review: The present review summarizes the current knowledge and the barriers encountered when implementing tailoring lung-protective ventilation strategies to individual patients based on advanced monitoring systems., Recent Findings: Lung-protective ventilation has become a pivotal component of perioperative care, aiming to enhance patient outcomes and reduce the incidence of postoperative pulmonary complications (PPCs). High-quality research has established the benefits of strategies such as low tidal volume ventilation and low driving pressures. Debate is still ongoing on the most suitable levels of positive end-expiratory pressure (PEEP) and the role of recruitment maneuvers. Adapting PEEP according to patient-specific factors offers potential benefits in maintaining ventilation distribution uniformity, especially in challenging scenarios like pneumoperitoneum and steep Trendelenburg positions. Advanced monitoring systems, which continuously assess patient responses and enable the fine-tuning of ventilation parameters, offer real-time data analytics to predict and prevent impending lung complications. However, their impact on postoperative outcomes, particularly PPCs, is an ongoing area of research., Summary: Refining protective lung ventilation is crucial to provide patients with the best possible care during surgery, reduce the incidence of PPCs, and improve their overall surgical journey., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The effect of general anesthetics (propofol and volatile anesthetics) on pulmonary outcome after lung resection surgery with one-lung ventilation (OLV) is yet undetermined. We evaluated the effect of intravenous anesthesia (propofol) and volatile anesthesia (sevoflurane or desflurane) regimens on postoperative pulmonary complications (PPCs) in patients undergoing lung resection surgery., Methods: This prospective, randomized controlled trial enrolled 555 adult patients scheduled for lung resection surgery with OLV. Participants were randomized to 1 of 3 general anesthetic regimens (propofol, sevoflurane, or desflurane). Standard anesthesia and ventilation protocols were followed in all groups. The primary outcome was a composite of PPCs in the first 7 postoperative days. Secondary outcomes included the severity of PPCs and major postoperative complications classification. Intergroup difference in the primary outcome was assessed for significance using the Pearson χ2 test., Results: Of 837 patients who were assessed for eligibility, 555 were randomized and 545 were analyzed. One hundred and seventy-nine patients were assigned to the propofol group, 182 in the sevoflurane group, and 184 in the desflurane group. The incidence of PPCs did not differ between the combined volatile anesthetics (sevoflurane and desflurane) group and the propofol group (21.9% vs 24.0%; odds ratio, 0.89; 95% confidence interval, 0.58-1.35; P = .570). The PPCs grade and Clavien-Dindo scores did not differ significantly across groups., Conclusions: In patients undergoing lung resection surgery with OLV, general anesthesia with volatile anesthetics (sevoflurane or desflurane) did not reduce PPCs compared with propofol. No difference in secondary outcomes was observed., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use-associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Fast-track anesthesia in liver transplantation (LT) has been discussed over the past few decades; however, factors associated with immediate extubation after LT surgery are not well defined. This study aimed to identify predictive factors and examine impacts of immediate extubation on post-LT outcomes., Methods: A total of 279 LT patients between January 2014 and May 2017 were included. Primary outcome was immediate extubation after LT. Other postoperative outcomes included reintubation, intensive care unit stay and cost, pulmonary complications within 90 days, and 90-day graft survival. Logistic regression was performed to identify factors that were predictive for immediate extubation. A matched control was used to study immediate extubation effect on the other postoperative outcomes., Results: Of these 279 patients, 80 (28.7%) underwent immediate extubation. Patients with anhepatic time >75 minutes and with total intraoperative blood transfusion ≥12 units were less likely to be immediately extubated (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = 0.02; OR, 0.11; 95% CI, 0.05-0.21; P < 0.001). The multivariable analysis showed immediate extubation significantly decreased the risk of pulmonary complications (OR, 0.34; 95% CI, 0.15-0.77; P = 0.01). According to a matched case-control model (immediate group [n = 72], delayed group [n = 72]), the immediate group had a significantly lower rate of pulmonary complications (11.1% versus 27.8%; P = 0.012). Intensive care unit stay and cost were relatively lower in the immediate group (2 versus 3 d; P = 0.082; $5700 versus $7710; P = 0.11). Reintubation rates (2.8% versus 2.8%; P > 0.9) and 90-day graft survival rates (95.8% versus 98.6%; P = 0.31) were similar., Conclusions: Immediate extubation post-LT in appropriate patients is safe and may improve patient outcomes and resource allocation., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies., Methods: Over a 4-year period, data were obtained from 49,386 procedures and 109 attendings. Cases were restricted to patients aged 18 years or older requiring general anesthesia that lasted at least 60 minutes. We defined protective lung ventilation as a TV of 6-8 mL/kg ideal body weight and a PEEP of ≥4 cm H2O. There was a baseline period followed by 4 behavioral interventions: education, near real-time feedback, individualized post hoc feedback, and enhanced multidimensional decision support. Segmented logistic regression using generalized estimating equations was performed in order to assess temporal trends and effects of interventions on adherence to LPV strategies., Results: Consistent with improvement in adherence with LPV strategies during the baseline period, the predicted probability of adherence with LPV at the end of baseline was 0.452 (95% confidence interval [CI], 0.422-0.483). The improvements observed for each phase were relative to the preceding phase. Education alone was associated with an 8.7% improvement (P < .01) in adherence to lung-protective protocols and was associated with a 16% increase in odds of adherence (odds ratio [OR] = 1.16; 95% CI, 1.01-1.33; P = .04). Near real-time, on-screen feedback was associated with an estimated 15.5% improvement in adherence (P < .01) with a 69% increase in odds of adherence (OR = 1.69; 95% CI, 1.46-1.96; P < .01) over education alone. The addition of an individualized dashboard with personal adherence and peer comparison was associated with a significant improvement over near real-time feedback (P < .01). Near real-time feedback and dashboard feedback systems were enhanced based on feedback from the in-room attendings, and this combination was associated with an 18.1% (P < .01) increase in adherence with a 2-fold increase in the odds of adherence (OR = 2.23; 95% CI, 1.85-2.69; P < .0001) between the end of the previous on-screen feedback phase and the start of the individualized post hoc dashboard reporting phase. The adherence with lung-protective strategies using the multidimensional approach has been sustained for over 24 months. The difference between the end of the previous phase and the start of this last enhanced multidimensional decision support phase was not significant (OR = 1.08; 95% CI, 0.86-1.34; P = .48)., Conclusions: Consistent with the literature, near real-time and post hoc reporting are associated with positive and sustained behavioral changes aimed at adopting evidence-based clinical strategies. Many decision support systems have demonstrated impact to behavior, but the effect is often transient. The implementation of near real-time feedback and individualized post hoc decision support tools has resulted in clinically relevant improvements in adherence with LPV strategies that have been sustained for over 24 months, a common limitation of decision support solutions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Postoperative pulmonary complications (PPCs) are one of the most important cause of perioperative morbidity and mortality in patients undergoing noncardiothoracic surgery, leading to increased hospital length of stay and mortality rate. The principal purpose of this review is to provide an overview of the perioperative lung protection strategies in patients undergoing elective noncardiothoracic surgery, informing clinicians on evidence-based perioperative care pathways. We also conducted a systematic review and meta-analysis of randomized controlled trials in noncardiothoracic surgery focusing on the following aspects: preoperative physiotherapy, intraoperative protective mechanical ventilation, postoperative prophylactic continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC), and postoperative physiotherapy. Both preoperative physiotherapy (relative risk [RR], 0.49, 95% confidence interval [CI], 0.35-0.69, P < .01) and postoperative CPAP (RR, 0.53, 95% CI, 0.30-0.94, P = .029) reduced the incidence of PPCs. Intraoperative protective mechanical ventilation had unclear effects (RR, 0.90, 95% CI, 0.77-1.06, P = .22). No benefits were observed for HFNC (RR, 0.88, 95% CI, 0.70-1.11, P = .30) and physiotherapy regimens administered in the postoperative period only (RR, 0.89, 95% CI, 0.69-1.16, P = .40). Lung-protective strategies should be considered throughout the entire perioperative period. The prophylactic use of strategies initiated in the postoperative period only, such as physiotherapy, CPAP, or HFNC, offers limited benefits. Physiotherapy and patient training should be started early in the preoperative phase, and intraoperative protective mechanical ventilation should be titrated on an individual basis taking into account all the available evidence.

Objectives: Bleomycin, etoposide, and cisplatin (BEP) is the most common and successful chemotherapy regimen for germ-cell tumor (GCT) patients, accompanied by a bleomycin-induced dose-dependent lung toxicity in certain patients. In an attempt to reduce bleomycin-toxicity, we developed a modified-BEP (mBEP) regimen., Materials and Methods: Between August 2008 and February 2018, 182 unselected mainly testicular GCT patients (39 with adjuvant purpose and 143 with curative purpose) received a tri-weekly 5-day hospitalization schedule with bleomycin 15 U intravenous (IV) push on day 1 and 10 U IV continuous infusion over 12 hours on days 1 to 3, cisplatin 20 mg/m IV, and etoposide 100 mg/m IV on days 1 to 5. Pulmonary toxicity was assessed through chest computed tomography scan and clinical monitoring., Results: Median number of mBEP cycles was 3 (range: 1 to 4). In the curative setting, according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic system, 112, 21, and 9 patients had good-risk, intermediate-risk, and poor-risk class, respectively; 66 (46%) patients had complete response (CR), 67 (47%) had partial response (52 of whom became CR afterwards), 6 (4%) had stable disease (that in 3 became CR afterwards), 3 (2%) progressed, and 1 (1%) died of brain stroke. At a median follow-up of 2.67 years (interquartile range: 1.23-5.00 y), 1 and 5-year overall survival and progression-free survival were 99% and 95%, and 90% and 88%, respectively. In the entire patient population, there was grade 3/4 neutropenia in 92 patients (51%), febrile neutropenia in 11 patients (6%), grade 1/2 nausea in 74 patients (41%), and no death due to pulmonary toxicity., Conclusion: In GCT patients, our mBEP-schedule would suggest an effective treatment modality without suffering meaningful pulmonary toxicity.

: Spirometry in the occupational health setting plays a critical role in the primary, secondary, and tertiary prevention of workplace-related lung disease. Recognizing the central role of spirometry in workplace respiratory programs, the American College of Occupational and Environmental Medicine (ACOEM) developed three spirometry position statements in the past two decades, which summarized advances of particular relevance to occupational health practice. However, since these statements were published, there have been important developments in federal regulations and in official American Thoracic Society recommendations which affect occupational spirometry testing. This 2020 ACOEM guidance statement incorporates these spirometry testing changes into its recommendations to provide current information for all users of spirometry test results, from those who perform or supervise testing to those who only interpret or review results.

Purpose of Review: Occupational exposures remain an underrecognized and preventable cause of lung disease in high-income countries. The present review highlights the emergence of cleaning-related respiratory disease and the re-emergence of silicosis as examples of trends in occupational lung diseases in the 21st century., Recent Findings: Employment trends, such as the shift from large-scale manufacturing to a service economy, the growth of the healthcare sector, and changing consumer products have changed the spectrum of work-related lung diseases. Following decades of progress in reducing traditional hazards such as silica in U.S. workplaces, cases of advanced silicosis have recently re-emerged with the production of engineered stone countertops. With growth in the healthcare and service sectors in the United States, cleaning products have become an important cause of work-related asthma and have recently been associated with an increased risk of chronic obstructive pulmonary disease (COPD) in women. However, these occupational lung diseases largely go unrecognized by practicing clinicians., Summary: The present article highlights how changes in the economy and work structure can lead to new patterns of inhalational workplace hazards and respiratory disease, including cleaning-related respiratory disease and silicosis. Pulmonary clinicians need to be able to recognize and diagnose these occupational lung diseases, which requires a high index of suspicion and a careful occupational history.

Background: This study will evaluate the effects of nursing intervention (NIV) on lung infection prevention (LIP) in patients with tracheotomy., Methods: The electronic databases of MEDLINE, Cochrane Library, EMBASE, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be retrieved from inception to the June 1, 2019 for randomized controlled trials investigating the effects of NIV on LIP in patients with tracheotomy without any language limitations. In addition, we will also search grey literature to avoid missing any potential studies. Two independent authors will perform study selection, data extraction, and risk of bias evaluation., Results: This study will investigate the effects of NIV on LIP in patients with tracheotomy. The primary outcome is incidence of lung infection. The secondary outcomes include pulmonary function, quality of life, and complications post-surgery., Conclusion: The results of this study will summarize recent evidence for the effects of NIV on LIP in patients with tracheotomy.No ethic approval is needed in this study, because it will not need any individual data. The results of this study will be published at a peer-reviewed journal.

Purpose of Review: Occupational and environmental exposures to metals can result in multiple pulmonary conditions. This article will review recent epidemiologic and mechanistic studies that have enhanced our understanding of the association between particular lung diseases and exposure to specific metals., Recent Findings: Recent studies have broadened our understanding of the mechanisms of lung diseases such as CBD in established industries and drawn attention to conditions that may arise from exposure to metals such as indium in developing technologies. New diagnostic techniques such as elemental tissue analysis may help establish a diagnosis of metal-induced occupational lung disease. Electronic cigarette devices, environmental pollutants, and the growing use of nanoparticle-sized metals pose additional risks to workers and consumers., Summary: Recognizing the risks of pulmonary disease in workers exposed to metals and performing a thorough occupational history and diagnostic work-up in patients with unexplained respiratory findings is necessary to promote understanding and prevention of metal-induced lung disease.

Purpose of Review: Postoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common., Recent Findings: Results of recent quantitative effectiveness studies and clinical trials provide a framework that helps develop center-specific treatment guidelines, tailored to minimize the risk of PRCs. The implementation of those protocols should be guided by a local, respected, and visible facilitator who leads proper implementation while inviting center-specific input from surgeons, anesthesiologists, and other perioperative stakeholders., Summary: Preoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.

Background: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity., Objectives: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines., Methods: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review., Results: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews)., Conclusion: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation., (© 2017 by the American College of Cardiology Foundation and the American Heart Association, Inc.)

Protective ventilation is associated with a lower incidence of pulmonary complications. However, there are few published data on routine pulmonary management in adult cardiac surgery. The present study's primary objective was to survey pulmonary management in this high-risk population, as practiced by anesthesiologists in France. All 460 registered France-based cardiac anesthesiologists were invited (by e-mail) to participate in an online survey in January-February 2015. The survey's questionnaire was designed to assess current practice in pre-, per-, and postoperative pulmonary management. In all, 198 anesthesiologists (43% of those invited) participated in the survey. Other than during the cardiopulmonary bypass (CPB) per se, 179 anesthesiologists (91% of respondees) [95% confidence interval (CI): 87-95] used a low-tidal-volume approach (6-8 mL/kg), whereas techniques based on positive end-expiratory pressure and recruitment maneuvers vary greatly from 1 anesthesiologist to another. During CPB, 104 (53%) [95% CI: 46-60] anesthesiologists withdrew mechanical ventilation (with disconnection, in some cases) and 97 (49%) [95% CI: 42-56] did not prescribe positive end-expiratory pressure. One hundred sixty-five (83%) [95% CI: 78-88] anesthesiologists stated that a written protocol for peroperative pulmonary management was not available. Twenty (10%) [95% CI: 6-14] and 11 (5%) [95% CI: 2-8] anesthesiologists stated that they did use protocols for ventilator use and recruitment maneuvers, respectively. The preoperative period (pulmonary examinations and prescription of additional assessments) and the postoperative period (extubation, and noninvasive ventilation) periods vary greatly from 1 anesthesiologist to another. The great majority of French cardiac anesthesiologists use a low tidal volume during cardiac surgery (other than during CPB per se). However, pulmonary management procedures varied markedly from 1 anesthesiologist to another. There is a clear need for large clinical studies designed to identify best practice in pulmonary management.

Objective: To compare both incidence and types of postoperative pulmonary complications (PPCs) between laparoscopic major hepatectomy (LMH) and open major hepatectomy (OMH)., Background: LMHs are increasingly performed. Yet, the benefits of laparoscopy over laparotomy regarding PPCs remain unknown., Methods: In this multi-institutional study, all patients undergoing OMH or LMH between 1998 and 2013 were retrospectively reviewed. Risk factors for PPCs were analyzed on multivariate analysis. Comparison of both overall rate and types of PPCs between OMH and LMH patients was performed after propensity score adjustment on factors influencing the choice of the approach., Results: LMH was performed in 226 (18.6%) of the 1214 included patients. PPCs occurred in 480 (39.5%) patients including symptomatic pleural effusion in 366 (30.1%) patients, respiratory insufficiency in 141 (11.6%), acute respiratory distress syndrome in 84 (6.9%), pulmonary infection in 80 (6.5%), and pulmonary embolism in 47 (3.8%) patients. On multivariate analysis, preoperative hypoprotidemia [hazard ratio (HR): 1.341, 95% confidence interval (CI): 1.001-1.795; P = 0.049], open approach (HR: 2.481, 95% CI: 1.141-6.024; P = 0.024), right-sided hepatectomy (HR: 2.143, 95% CI: 1.544-2.975; P < 0.001), concomitant extrahepatic procedures (HR: 1.742, 95% CI: 1.103-2.750; P = 0.017), transfusion (HR: 2.851, 95% CI: 2.067-3.935; P < 0.001), and operative time more than 6 hours (HR: 1.510, 95% CI: 1.127-2.022; P = 0.006) were independently associated with PPCs. After propensity score matching, the overall incidence of PPCs (13.2% vs 40.5%, P < 0.001), symptomatic pleural effusion (11.6% vs 26.4%, P = 0.003), pleural effusion requiring drainage (1.7% vs 9.9%, P = 0.006), and acute respiratory distress syndrome (1.7% vs 9.9%, P = 0.006) were significantly lower in the laparoscopy group than in the open group., Conclusions: Pure laparoscopy allows reducing PPCs in patients requiring major liver resection.

Effective analgesia in the early stages after any major traumatic event remains pivotal to optimal trauma management. For patients with significant thoracic injuries, this is paramount to ensure ongoing efficient respiratory function. The aim of this study was to investigate the use of analgesic modes in the management of patients with a primary thoracic injury and blunt mechanism of injury. By understanding variables that influence the use of varying analgesic modes and influence the development of pulmonary complications, there should be more uniform evidence-based prescription in the future.This retrospective study considered analgesic use in patients admitted after blunt thoracic injuries at one major trauma center over a 2-year period. Pulmonary complications measured included both infective and ventilator-associated failure. Univariate and multivariate analyses were used to identify patient and injury severity characteristics and their association with respiratory complications.A total of 401 cases were reviewed and analyzed: 159 received Patient Controlled Analgesia (PCA), 32 received PCA and epidural analgesia (EA), 6 received EA alone, and 204 received interval-administered analgesia. There were no significant differences in the rates of complication when compared between analgesic modes. Patients who developed pneumonia had significantly increased number of thoracic fractures and underlying organ injury (P < 0.05). Logistic regression analysis highlighted duration of intercostal drain insertion (OR 1.377, P = 0.001) and premorbid cardiac disease (OR 2.624, P = 0.042) and ICU length of stay (OR: 1.146, P < 0.001) as significant predictors of developing pneumonia in this patient group.Examining the different analgesic modes, this study failed to identify a particular analgesic mode that was more effective in preventing pulmonary complications in blunt thoracic injuries. However, variables that may influence usage of different analgesic modes and high-risk groups for the development of pneumonia were identified. Further work is warranted to consider the long-term benefits of analgesia in patients post-blunt thoracic injuries.

Purpose of Review: Modern food animal production is a major contributor to the global economy, owing to advanced intensive indoor production facilities aimed at increasing market readiness and profit. Consequences of these advances are accumulation of dusts, gases, and microbial products that diminish air quality within production facilities. Chronic inhalation exposure contributes to onset and exacerbation of respiratory symptoms and diseases in animals and workers. This article reviews literature regarding constituents of farm animal production facility dusts, animal responses to production building and organic dust exposure, and the effect of chronic inhalation exposure on pulmonary oxidative stress and inflammation., Recent Findings: Porcine models of production facility and organic dust exposures reveal striking similarities to observations of human cells, tissues, and clinical data. Oxidative stress plays a key role in mediating respiratory diseases in animals and humans, and enhancement of antioxidant levels through nutritional supplements can improve respiratory health., Summary: Pigs are well adapted to the exposures common to swine production buildings and thus serve as excellent models for facility workers. Insight for understanding mechanisms governing organic dust associated respiratory diseases may come from parallel comparisons between farmers and the animals they raise.

Objective: Lung diseases associated with military service are often a reflection of the conditions seen in the local civilian population, and with a few notable exceptions, are often related to unique environmental and occupational exposures., Methods: This article reviews important pulmonary diseases that have been associated with military service in the past 100 years in a question-and-answer format., Results: Traditionally, bacterial and viral pneumonias were the most common sources of military morbidity and mortality. With improved preventive medicine and antimicrobial therapy, other diseases related to battlefield injuries or inhalational exposures have assumed greater importance., Conclusions: The etiology of military morbidity and mortality has evolved over the past century. Many of the discoveries related to vaccine efficacy, trauma resuscitation, interstitial lung disease, and even carcinomas have a strong military association.

Background: We report a case of bilateral renal agenesis treated with serial amnioinfusion in which the newborn survived the newborn period and was able to undergo peritoneal dialysis as a bridge to planned renal transplantation., Case: A 34-year-old woman, gravida 1 para 0, presented at 23 1/7 weeks of gestation with a diagnosis of anhydramnios and bilateral renal agenesis. The patient underwent weekly serial amnioinfusion with the goal of improving fetal pulmonary development. At 28 weeks of gestation, the patient delivered a live newborn who required minimal respiratory support. The neonate is currently 9 months old and is undergoing daily peritoneal dialysis., Conclusion: Serial amnioinfusion appears to have mitigated the severe pulmonary compromise that has, in the past, led to the death of newborns with bilateral renal agenesis.

Purpose of Review: To provide the most recent and relevant clinical evidence regarding the use of prophylactic lung-protective mechanical ventilation in abdominal surgery., Recent Findings: Evidence is accumulating, suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary complications in patients undergoing abdominal surgery. Nonprotective ventilator settings, especially high tidal volume (>10-12 ml/kg), very low level of positive end-expiratory pressure (PEEP, <5 cm H2O), or no PEEP, may cause alveolar overdistension and repetitive tidal recruitment leading to ventilator-associated lung injury in patients with healthy lungs. Stimulated by the previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung-protective mechanical ventilation. Recent data provide compelling evidence that prophylactic lung-protective mechanical ventilation using lower tidal volume (6-8 ml/kg of predicted body weight), moderate PEEP (6-8 cm H2O), and recruitment maneuvers is associated with improved functional or physiological and clinical postoperative outcome in patients undergoing abdominal surgery., Summary: The use of prophylactic lung-protective ventilation can help in improving the postoperative outcome.

Background: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction., Methods: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups., Results: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation., Conclusions: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice., Clinical Question/level of Evidence: Therapeutic, III.

Objectives: The aim of this study was to evaluate in patients with cystic fibrosis (CF) the effect of Lactobacillus reuteri (LR) on the rate of respiratory exacerbations and of the infections of both upper respiratory and gastrointestinal tracts., Methods: Prospective randomized, double-blind, placebo-controlled study enrolling 61 patients with CF with mild-to-moderate lung disease at the Regional Center for CF of the Department of Pediatrics, University of Rome "La Sapienza." All of the patients were not hospital inpatients at the time of the enrollment. Inclusion criteria were forced expiratory volume in the first second (FEV1) >70% predicted; no inhaled or systemic steroids, no anti-inflammatory drugs, antileukotrienes, and mast cell membrane stabilizers; and no serious organ involvement. Exclusion criteria were a history of pulmonary exacerbation or upper respiratory infection in the previous 2 months; changes in medications in the last 2 months; a history of hemoptysis in the last 2 months; and colonization with Burkholderia cepacia or mycobacteria. Patients were randomly assigned to receive LR (30 patients) in 5 drops per day (10(10) colony-forming units) or placebo (31 patients) for 6 months. Main outcomes were number of episodes of pulmonary exacerbations and hospital admissions for pulmonary exacerbations, number of gastrointestinal and upper respiratory tract infections. FEV1, fecal calprotectin, and cytokine profile in induced sputum and plasma were assessed at baseline and at the end of the trial., Results: Pulmonary exacerbations were significantly reduced in the LR group compared with the placebo group (P<0.01; odds ratio 0.06 [95% confidence interval {CI} 0-0.40]; number needed to treat 3 [95% CI 2-7]). Similarly, the number of upper respiratory tract infections (in our series only otitis) was significantly reduced in the LR group compared with the placebo group (P<0.05; odds ratio 0.14 [95% CI 0-0.96]; number needed to treat 6 [95% CI 3-102]). The 2 groups did not differ statistically in the mean number and duration of hospitalizations for pulmonary exacerbations and gastrointestinal infections. There was no significant statistical difference in the mean delta value of FEV1, fecal calprotectin concentration, and tested cytokines (tumor necrosis factor-α and interleukin-8) between the 2 groups., Conclusions: LR reduces pulmonary exacerbations and upper respiratory tract infections in patients with CF with mild-to-moderate lung disease. LR administration may have a beneficial effect on the disease course of CF.

Background: The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function., Methods: Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery., Results: Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean ± SD): 77.1 ± 13.0 versus 64.9 ± 11.3 (P = 0.0006), 80.5 ± 10.1 versus 69.7 ± 9.3 (P = 0.0002), and 82.1 ± 10.7 versus 78.5 ± 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42)., Conclusion: A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay.

Purpose of Review: Postoperative pulmonary complications (PPCs) are common and lead to longer hospital stays and higher mortality. A wide range of patient, anaesthetic and surgical factors have been associated with risk for PPCs. This review discusses our present understanding of PPC risk factors that can be used to plan preoperative risk reduction strategies. The methodological and statistical basis for building risk scores is also described., Recent Findings: Studies in specific surgical populations or large patient samples have identified a range of predictors of PPC risk. Factors such as age, types of comorbidity and surgical characteristics have been found to be relevant in most of these studies. Recently, researchers have begun to develop risk scoring systems for a PPC composite outcome or for specific PPCs, especially pneumonia and respiratory failure. Preoperative arterial oxyhaemoglobin saturation is an objective measure that is easy to record and discriminates level of risk for impaired cardiorespiratory function. Preoperative anaemia and recent respiratory infection are factors that have lately been found to confer risk for PPCs., Summary: PPC risk prediction scales based on large population studies are being developed. New studies to confirm the validity of these scales in different geographic areas will be needed before we can be sure of their generalizability.

Purpose of Review: It is uncertain whether patients undergoing short-lasting mechanical ventilation for surgery benefit from lung-protective intraoperative ventilatory settings including the use of lower tidal volumes, higher levels of positive end-expiratory pressure (PEEP) and/or recruitment maneuvers. We meta-analyzed trials testing the effect of lung-protective intraoperative ventilatory settings on the incidence of postoperative pulmonary complications., Recent Findings: Eight articles (1669 patients) were included. Meta-analysis showed a decrease in lung injury development [risk ratio (RR) 0.40; 95% confidence interval (CI) 0.22-0.70; I 0%; number needed to treat (NNT) 37], pulmonary infection (RR 0.64; 95% CI 0.43-0.97; I 0%; NNT 27) and atelectasis (RR 0.67; 95% CI 0.47-0.96; I 48%; NNT 31) in patients receiving intraoperative mechanical ventilation with lower tidal volumes. Meta-analysis also showed a decrease in lung injury development (RR 0.29; 95% CI 0.14-0.60; I 0%; NNT 29), pulmonary infection (RR 0.62; 95% CI 0.40-0.96; I 15%; NNT 33) and atelectasis (RR 0.61; 95% CI 0.41-0.91; I 0%; NNT 29) in patients ventilated with higher levels of PEEP, with or without recruitment maneuvers., Summary: Lung-protective intraoperative ventilatory settings have the potential to protect against postoperative pulmonary complications.

Purpose of Review: In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of nonventilatory strategies to prevent postoperative pulmonary complications (PPCs) after noncardiac surgery., Recent Findings: Although nonavoidable, most comorbidities can be modified in order to reduce the incidence of pulmonary events postoperatively. The physical status of patients suffering from chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, and congestive heart failure can be improved preoperatively, and a number of measures can be undertaken to prevent PPCs, including physiotherapy for pulmonary rehabilitation and drug therapies. Also, smokers may benefit from both short and long-term smoke cessation. Furthermore, the risk of PPCs may be reduced upon: choice of an adequate anesthesia strategy (e.g. regional vs. general); appropriate neuromuscular blockade and reversal; use of volatile instead of intravenous anesthetics in lung surgery; judicious intravascular volume expansion (restrictive vs. liberal strategy); regional instead of systemic analgesia after major surgery in high-risk patients; more strict indication for nasogastric decompression in order to avoid silent aspiration; and laparoscopic instead of open bariatric surgery., Summary: Nonventilatory strategies can play an important role in reducing PPCs and improving clinical outcome after noncardiac surgery, especially in high-risk patients.

Background: Remote ischemic preconditioning (RIPC) may confer the cytoprotection in critical organs. The authors hypothesized that limb RIPC would reduce intestinal and pulmonary injury in patients undergoing open infrarenal abdominal aortic aneurysm repair., Methods: In this single-center, prospective, double-blinded, randomized, parallel-controlled trial, 62 patients undergoing elective open infrarenal abdominal aortic aneurysm repair were randomly assigned in a 1:1 ratio by computerized block randomization to receive limb RIPC or conventional abdominal aortic aneurysm repair (control). Three cycles of 5-min ischemia/5-min reperfusion induced by a blood pressure cuff placed on the left upper arm served as RIPC stimulus. The primary endpoint was arterial-alveolar oxygen tension ratio. The secondary endpoints mainly included the intestinal injury markers (serum intestinal fatty acid-binding protein, endotoxin levels, and diamine oxidase activity), the markers of oxidative stress and systemic inflammatory response, and the scores of the severity of intestinal and pulmonary injury., Results: In limb RIPC group, a/A ratio was significantly higher than that in control group at 8, 12, and 24 h after cross-clamp release (66 ± 4 vs. 45 ± 4, P = 0.003; 60 ± 6 vs. 37 ± 4, P = 0.002; and 60 ± 5 vs. 47 ± 6, P = 0.039, respectively). All biomarkers reflecting intestinal injury increased over time, and there was significant differences between limb RIPC and control group (P < 0.001). The severity of intestinal and pulmonary injury was decreased by limb RIPC (P = 0.014 and P = 0.001, respectively)., Conclusions: Limb RIPC attenuates intestinal and pulmonary injury in patients undergoing elective open infrarenal abdominal aortic aneurysm repair without any potential risk.

Objective: The aim of this study was to ascertain whether an objective cough measure relates to the risk of pulmonary complications in dysphagic patients with persistent tracheobronchial aspiration., Design: This is a retrospective observational study involving 55 dysphagic patients who underwent a modified barium swallow study and pulmonary function tests including cough peak flow measurement. The results were compared between subjects with and without pulmonary complications because of aspiration., Results: The 18 patients (33%) with pulmonary complications had significantly lower mean cough peak flow values (202.2 ± 68.8 vs. 303.9 ± 80.7 liters/min; P < 0.001) than those without pulmonary complications. The finding of tracheobronchial coating in a modified barium swallow was not related to the occurrence of pulmonary morbidity. Receiver operating characteristic curve analysis showed that a CPF level lower than 242 liters/min predicted the development of pulmonary complications with a sensitivity of 77% and a specificity of 83%; the positive and negative predictive values were 65% and 90%, respectively., Conclusions: Our findings indicate that cough peak flow is a valuable predictor of respiratory prognosis in chronic aspiration. This finding suggests a new rehabilitation strategy aimed at improving cough flows for dysphagic patients.

Activation of the complement system has been associated with tissue injury after hemorrhage and resuscitation in animals. We investigated whether administration of recombinant human C1-esterase inhibitor (rhC1-INH), a regulator of complement and contact activation systems, reduces tissue damage and cytokine release and improves metabolic acidosis in a porcine model of hemorrhagic shock. Male Yorkshire swine were assigned to experimental groups and subjected to controlled, isobaric hemorrhage to a target mean arterial pressure of 35 mmHg. Hypotension was maintained for 20 min followed by a bolus intravenous injection of rhC1-INH or vehicle; animals were then observed for 3 h. Blood chemistry and physiologic parameters were recorded. Lung and small intestine tissue samples were subjected to histopathologic evaluation and immunohistochemistry to determine the extent of injury and deposition of complement proteins. Cytokine levels and quantitative assessment of renal and hepatic function were measured via enzyme-linked immunosorbent assay and chemistry analyzer, respectively. Pharmacokinetics of rhC1-INH revealed dose proportionality for maximum concentration, half-life, and the time span in which the functional C1-INH level was greater than 1 IU/mL. Recombinant human C1-INH significantly reduced renal, intestinal, and lung tissue damage in a dose-dependent manner (100 and 250 IU/kg). In addition, rhC1-INH (250 IU/kg) markedly improved hemorrhage-induced metabolic acidosis and circulating tumor necrosis factor α. The tissue-protective effects of rhC1-INH appear to be related to its ability to reduce tissue complement activation and deposition. Recombinant human C1-INH decreased tissue complement activation and deposition in hemorrhaged animals, improved metabolic acidosis, reduced circulating tumor necrosis factor α, and attenuated tissue damage in this model. The observed beneficial effects of rhC1-INH treatment on tissue injury 20 min into severe hypotension present an attractive model of low-volume resuscitation, particularly in situations with a restrictive medical logistical footprint.

Purpose of Review: To review the impact of comorbidity in heart failure patients who are approaching the end of life and consider current treatment options in alleviating symptom burden., Recent Findings: Renal failure, respiratory disease, anaemia, cognitive impairment, falls and urinary incontinence are common comorbidities in heart failure patients approaching the end of life. This review describes the impact of these comorbidities and gives practical advice to aid clinicians in their management., Summary: Limited evidence exists for how best to manage the majority of comorbidities in heart failure patients at the end of life. As a result a comprehensive assessment and a patient-centred approach should be sought. Prevention of many complications such as falls or delirium is likely to be possible with this approach and hence reduce the burden of these problems at the end of life.

Objective: Postoperative pulmonary complications are a major contributor to the overall risk of surgery. We convened a patient safety summit to discuss ways to enhance physician awareness of postoperative pulmonary complications, advance postoperative pulmonary complications as a substantive public health concern demanding national attention, recommend strategies to reduce the deleterious impact of postoperative pulmonary complications on clinical outcomes and healthcare costs, and establish an algorithm that will help identify patients who are at increased risk for postoperative pulmonary complications., Data Sources: We conducted PubMed searches for relevant literature on postoperative pulmonary complications in addition to using the summit participants' experience in the management of patients with postoperative pulmonary complications., Data Synthesis: Postoperative pulmonary complications are common, are associated with increased morbidity and mortality, and adversely affect financial outcomes in health care. A multifaceted approach is necessary to reduce the incidence of postoperative pulmonary complications. Identifying a measurable marker of risk will facilitate the targeted implementation of risk-reduction strategies., Conclusions: The most practicable marker that identifies patients at highest risk for postoperative pulmonary complications is the need for postoperative mechanical ventilation of a cumulative duration >48 hrs.

Purpose: The review deals with the clinical and functional assessment that is requested before surgical operations and with the pulmonary effects of surgery. Moreover, an evidence-based approach to prevent postoperative pulmonary complications is provided., Recent Findings: Spirometry is recommended for patients with a history of tobacco use or dyspnoea who are considered for cardiac or upper abdominal surgery and for all patients who are candidates for lung resection. For patients undergoing lung resection, low complication rates have been associated with a preoperative forced expiratory volume at first second value of at least 2 litres or 80% of the predicted value and at least 1.5 litres or 60% of the predicted value in the case of pneumonectomy or lobectomy, respectively. At-risk patients are recommended to undergo split lung function studies to estimate the residual parenchyma function after surgery. In patients with borderline estimated values, a cardiopulmonary exercise test is recommended to stratify further risk. Preventive interventions of postoperative pulmonary complications, including pain control, respiratory chest physiotherapy and continuous positive airway pressure may effectively reduce the occurrence of pulmonary complications., Summary: Pulmonary functional assessment is relevant in patients candidates for surgery. The prevention of the postoperative pulmonary complications is one of the most important goals of the treatment of patients undergoing surgery.

Background: Pharmacological blockade of the renin-angiotensin system is thought to maintain gut perfusion during circulatory stress and thereby avoid later failure of distant organs. In this controlled experimental study, we investigated the effects of carperitide, a synthetic atrial natriuretic peptide that inhibits the renin-angiotensin system, on the systemic and splanchnic circulation during fluid-resuscitated endotoxemia in pigs., Methods: Sixteen domestic pigs of both sexes were randomly divided into 2 groups. The pigs were anesthetized and their lungs ventilated before receiving either saline (Group A: n = 8) or carperitide (Group B: n = 8). After a baseline measurement was taken, the pigs from both groups received a continuous infusion (1.7 microg x kg(-1) x h(-1)) of endotoxin for 240 min. Group B received a continuous infusion of carperitide (0.05 microg x kg(-1) x min(-1)) starting 30 min before the endotoxin infusion and lasting until the end of the study, whereas Group A received the same volume of saline. Fluid resuscitation was titrated to maintain pulmonary artery wedge pressure between 10 and 12 mm Hg. Systemic and regional hemodynamics, oxygenation variables, and the arterial-to-intestinal PCO(2) gap were measured at baseline and after endotoxin infusion for 240 min. The primary end points were cardiac index, superior mesenteric artery flow index, and PCO(2) gap at the end of this study (T240)., Results: Cardiac index and superior mesenteric artery flow index in Group B were significantly higher than those in Group A at T240 (83 +/- 15 vs 135 +/- 23 mL x kg(-1) x min(-1), P < 0.001; 2.6 +/- 1.4 vs 7.9 +/- 4.8, P = 0.01), respectively. Carperitide administration resulted in a significantly better maintenance of intestinal mucosal perfusion assessed by the PCO(2) gap at T240 (33.0 +/- 14.5 vs 11.6 +/- 10.0 mm Hg, P = 0.004). The PaO(2)/FIO(2) ratio in Group B was significantly greater than that in Group A from T60 to T240., Conclusions: In this porcine fluid-resuscitated endotoxemia model, a low dose of carperitide administered before endotoxemia maintained systemic and splanchnic circulation, and prevented the deterioration of oxygenation. Atrial natriuretic peptide infusion is a potentially beneficial therapy with respect to systemic and splanchnic circulation as well as the respiratory system during sepsis.

Background: Acute lung injury is a common complication in critically ill patients. Several studies suggest that volatile anesthetics have immunomodulating effects. The aim of the current study was to assess possible postconditioning with sevoflurane in an in vivo model of endotoxin-induced lung injury., Methods: Rats were anesthetized, tracheotomized, and mechanically ventilated. Lipopolysaccharide (saline as control) was administered intratracheally. Upon injury after 2 h of propofol anesthesia, general anesthesia was continued with either sevoflurane or propofol for 4 h. Arterial blood gases were measured every 2 h. After 6 h of injury, bronchoalveolar lavage was performed and lungs were collected. Total cell count, albumin content, concentrations of the cytokines cytokine-induced neutrophil chemoattractant-1 and monocyte chemoattractant protein-1, and phospholipids were analyzed in bronchoalveolar lavage fluid. Expression of messenger RNA for the two cytokines and for surfactant protein B was determined in lung tissue. Histopathologic examination of the lung was performed., Results: Significant improvement of the ratio of oxygen tension to inspired oxygen fraction was shown with sevoflurane (mean + or - SD: 243 + or - 94 mmHg [32.4 kPa]) compared with propofol (88 + or - 19 mmHg [11.7 kPa]). Total cell count representing effector cell recruitment as well as albumin content as a measure of lung permeability were significantly decreased in the sevoflurane-lipopolysaccharide group compared with the propofol-lipopolysaccharide group in bronchoalveolar lavage fluid. Expression of the cytokines protein in bronchoalveolar lavage fluid as well as messenger RNA in lung tissue was significantly lower in the sevoflurane-lipopolysaccharide group compared with the propofol-lipopolysaccharide group., Conclusions: Postconditioning with sevoflurane attenuates lung damage and preserves lung function in an in vivo model of acute lung injury.

Background: Tidal hyperinflation may occur in patients with acute respiratory distress syndrome who are ventilated with a tidal volume (VT) of 6 ml/kg of predicted body weight develop a plateau pressure (PPLAT) of 28 < or = PPLAT < or = 30 cm H2O. The authors verified whether VT lower than 6 ml/kg may enhance lung protection and that consequent respiratory acidosis may be managed by extracorporeal carbon dioxide removal., Methods: PPLAT, lung morphology computed tomography, and pulmonary inflammatory cytokines (bronchoalveolar lavage) were assessed in 32 patients ventilated with a VT of 6 ml/kg. Data are provided as mean +/- SD or median and interquartile (25th and 75th percentile) range. In patients with 28 < or = PPLAT < or = 30 cm H2O (n = 10), VT was reduced from 6.3 +/- 0.2 to 4.2 +/- 0.3 ml/kg, and PPLAT decreased from 29.1 +/- 1.2 to 25.0 +/- 1.2 cm H2O (P < 0.001); consequent respiratory acidosis (Paco2 from 48.4 +/- 8.7 to 73.6 +/- 11.1 mmHg and pH from 7.36 +/- 0.03 to 7.20 +/- 0.02; P < 0.001) was managed by extracorporeal carbon dioxide removal. Lung function, morphology, and pulmonary inflammatory cytokines were also assessed after 72 h., Results: Extracorporeal assist normalized Paco2 (50.4 +/- 8.2 mmHg) and pH (7.32 +/- 0.03) and allowed use of VT lower than 6 ml/kg for 144 (84-168) h. The improvement of morphological markers of lung protection and the reduction of pulmonary cytokines concentration (P < 0.01) were observed after 72 h of ventilation with VT lower than 6 ml/kg. No patient-related complications were observed., Conclusions: VT lower than 6 ml/Kg enhanced lung protection. Respiratory acidosis consequent to low VT ventilation was safely and efficiently managed by extracorporeal carbon dioxide removal.

Obstructive sleep apnea and obstructive lung disease may increase a patient's risk of perioperative pulmonary complications. This practice advisory provides an overview of the preoperative steps that should be performed to ensure appropriate patient selection and the safety of patients with these conditions. Also discussed are recommendations for perioperative management and strategies for minimizing complications.

Purpose of Review: To review the rational for use of the many regional anesthetic/analgesic techniques and acute pain management modalities in the elderly and cognitively impaired high-risk patients, as increasing numbers of older adults are presenting for surgery., Recent Findings: There are numerous studies examining short and long-term consequences of regional anesthesia/analgesia along with identification of the many potential advantages, but those studying the influence and potential benefits in elderly and cognitively impaired patients are only beginning to be developed as issues related to cognitive dysfunction associated with surgery/anesthesia are beginning to be observed., Summary: Pain management therapy, including regional anesthesia, along with multimodal analgesia may help reduce the risk of negative influences in the elderly patient along with reducing postoperative delirium and cognitive dysfunction. Improvements in analgesic efficacy with regional anesthesia may attenuate pathophysiological surgical responses, reduce the length of hospitalization, and accelerate patient rehabilitation and recovery. Analgesic techniques that provide optimal pain control and low side effect profiles with minimal opioid exposure should always be considered for elderly high-risk and cognitively impaired patients.

Purpose of Review: Despite some controversy regarding the strength of the available data, the use of regional anesthesia and analgesia does provide improvement in patient outcomes. Although the majority of available data have examined the effect of epidural anesthesia and analgesia on patient outcomes, an increasing number of studies recently have investigated the effect of peripheral regional techniques on patient outcomes., Recent Findings: Data generally indicate that the perioperative use of regional anesthesia and analgesia may be associated with improvement in both major (e.g. mortality, major morbidity) outcomes and rehabilitation. The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications and there is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery. Overall, regional analgesic techniques provide statistically superior analgesia compared with systemic opioids., Summary: Perioperative use of regional analgesic techniques may provide improvement in conventional outcomes, although the benefit appears to be limited to high-risk patients and those undergoing high-risk procedures. The benefits conferred by perioperative regional anesthetic techniques need to be weighed against any potential risks and this should be assessed on an individual basis.