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A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

The EZ-Blocker (EZB) is a "Y-shaped," semirigid endobronchial blocker used for lung isolation and one-lung ventilation during thoracic surgery. Like many medical tools, initial efforts to use this endobronchial blocker may prove challenging for the uninitiated. However, some tips and tricks can be applied fairly rapidly to aid the clinician in properly placing the device, and, furthermore, may help the clinician get the most out of this innovative device. This article focuses on some of the technical aspects of its placement that the authors have developed over time. Additionally, other facets and potential pitfalls are discussed that relate to intraprocedural issues that may sometimes arise when using this device. The following aspects of the EZB as a lung-isolation device are discussed: standard positioning techniques, alternative positioning techniques, use in pediatric patients, approaches to achieving exceptional lung isolation, advanced uses, and limitations and potential issues. Although some information was taken from the authors' rather extensive experience with using this endobronchial blocker, some of the relevant literature are also reviewed, with the goal of being to improve the reader's knowledge of the device and improve the likelihood of its successful placement. The underlying design of the EZB remains unique among commercially available bronchial blockers in improving positional stability. The Y-shaped conformation, however, can lead to challenges when positioning the device in some patients. Therefore, some very practical tips and tricks are provided to assist the clinician in correctly positioning the device and other hints to improve the quality of lung isolation and surgical conditions., Competing Interests: Declaration of Competing Interest M. Rispoli and M.R. Piccioni received payment for lectures by Teleflex. G.L. Rosboch received lecture grants from Ambu Italia., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Compensatory hyperhidrosis is the leading cause of patients' dissatisfaction after thoracic sympathicotomy. The study aimed to reduce compensatory hyperhidrosis to increase patients' satisfaction. A prospective randomized study on palmar hyperhidrosis, May 2016-September 2019. Twenty-one patients T 3 -T 4 sympathicotomy and 21 T 3 -T 4 gray ramicotomy. Data prospectively collected. Analysis at study's end. Focus on the sweating, temperature, quality of life baseline and postoperatively, compensatory hyperhidrosis, hand dryness, patients' satisfaction, and if they would undergo the procedure again and recommend it. No baseline differences between groups. Hyperhidrosis was controlled postoperatively in all patients. No mortality, serious complications, or recurrences. Sympathicotomy worse postoperative quality of life (49.05 (SD: 15.66, IR: 35.50-63.00) versus ramicotomy 24.30 (SD: 6.02, IR: 19.75-27.25). After ramicotomy, some residual sweating on the face, hands, and axillae. Compensatory sweating worse with sympathicotomy. Satisfaction higher with ramicotomy. Better results with ramicotomy than sympathicotomy regarding hand dryness, how many times a day the patients had to shower or change clothes, intention to undergo the procedure again or recommend it to somebody else, and how bothersome compensatory hyperhidrosis was. T 3 -T 4 gray ramicotomy had better results than T 3 -T 4 sympathicotomy, with less compensatory sweating and higher patients' satisfaction., (© 2021. The Author(s).)

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Sympathectomy of the thoracic chain is an effective surgical procedure for treating axillary and palmar hyperhidrosis. The procedure has been performed with minimal invasion and good results in recent years through the use of videothoracoscopic surgery. This paper describes the technique and our experience with a series of 50 patients between 16 and 48 years old. The earliest approach was unilateral in successive operations. The procedure was later performed bilaterally, at first with the patients in sequential lateral decubitus positions and later in semi-seated position. Complications were 1 case of incomplete Claude-Bernard-Horner syndrome that resolved spontaneously two months after surgery; 1 failure when sympathectomy was performed without location of the chain, obliging rapid re-operation; laminar pneumothorax in 12% of the series; compensatory hyperhidrosis in 26%; 10% with chest pain due to intercostal involvement, resolving with time; and slight bleeding in 8%. Outcome was excellent, with complete disappearance of axillary and palmar perspiration. Patient satisfaction was 9.2/10 one year after surgery. Mean hospital stay was less than 36 h.

Objectives: The aim of this study was to evaluate the effects on pulmonary function and hemodynamics of three different types of analgesia after thoracotomy., Material and Methods: Forty-five ASA II-IV patients undergoing thoracotomy (for lobectomy or pneumonectomy) were randomized to three groups (n = 15 each) for double-blind study. After a test dose into the epidural space at T5-7 (groups T-A and T-AL) or L2-3 (group L-A) interspace, 10 micrograms/Kg of alfentanil was administered in all groups, followed by epidural infusion of 400 micrograms/h of alfentanil (group T-A and L-A) or 400 micrograms/h of alfentanil with 50 mg/h of lidocaine (group T-AL) during surgery and 24 hours postoperatively. The patients also used a patient-controlled analgesia device to administer intravenous morphine postoperatively. During the study period the following variables were recorded: hemodynamic parameters, lung function, quality of analgesia and respiratory complications. ANOVA was performed and Scheffé and Chi-square tests were applied with 0.05 as the level of statistical significance., Results: No differences were found between groups with respect to patient characteristics or type of surgery. Rescue analgesia requirements were higher in group L-A than in the other groups. PaO2 (6 and 18 hours) and spirometric parameters (12 and 18 hours) were significantly higher in group T-AL than in the other groups (p < or = 0.05). No other statistically significant differences were found., Conclusions: Respiratory parameters were better after thoracic epidural analgesia with alfentanil and lidocaine than after the other analgesic techniques studied. Group L-A patients had greater need for rescue analgesia than did patients in the other groups.

Objective: To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy., Patients and Methods: Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment., Results: Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant., Conclusions: The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

A 46-year-old myasthenic man diagnosed two months earlier and experiencing nocturnal dyspnea was scheduled for transsternal thymectomy. The patient was premedicated with midazolam in the operating room. Anesthetic induction and maintenance were with inhaled sevoflurane and an intravenous infusion of remifentanil, with no need for neuromuscular relaxants. Airway management was achieved by inserting a Fastrach laryngeal mask (LM-Fastrach), through which an endotracheal tube could be inserted easily. The tube was withdrawn through the mask at the end of surgery and the mask was removed in the operating room 6 minutes later. Anesthesia in patients with myasthenia gravis is one of the greatest challenges in clinical anesthesiology. The interest of this case lies mainly in that the anesthetic technique chosen allows neuromuscular relaxants to be avoided. Moreover, airway access through the Fastrach laryngeal mask is highly useful for transsternal thymectomy of the patient with myasthenia gravis, providing immobility and adequate hemodynamic stability during sternotomy as well as facilitating safe and rapid postanesthetic recovery.

Objectives: To evaluate the effects on postoperative pulmonary function and quality of analgesia of two protocols for epidural infusion of alfentanil after lung resection., Patients and Methods: After informed consent, 30 ASA I-IV patients undergoing chest surgery (lobectomy or pneumonectomy) were randomly assigned to two groups of 15. A catheter was inserted into the epidural space at T5-7 (group T) or L2-3 (group L). After a test dose, an initial bolus of alfentanil (10 micrograms/kg) was administered. After anesthetic induction, epidural analgesia was performed with an infusion of 400 micrograms/h of alfentanil (group L) during and after surgery. Endovenous patent-controlled anesthesia (PCA) was provided with morphine. During the first 24 h after surgery, the following variables were recorded: arterial blood gas concentrations, spirometric parameters, pain on a visual analog scale (VAS) and side effects. ANOVA and Scheffé and chi-square tests were used to analyze the results (p < or = 0.05)., Results: In group T, PaO2 was significantly higher at 6 and 18 h (p < or = 0.05), while FEV1 and FVC were significantly higher at 12 and 18 h. Pain assessed by VAS and PCA need for morphine was significantly less in group T., Conclusions: Thoracic epidural analgesia with alfentanil and lidocaine improves postoperative lung function and reduces the need for top-up analgesia in comparison with lumbar epidural infusion of alfentanil.

Objectives: To evaluate the efficacy and incidence of side effects of two types of lumbar epidural analgesia with morphine, preemptive or postincisional, combined with total intravenous anesthesia in chest surgery., Patients and Methods: This double-blind prospective study enrolled 20 patients (ASA I-IV) undergoing lobectomy or pneumonectomy. Anesthetic induction and maintenance was provided with propofol, atracurium and alfentanil. Lumbar epidural analgesia (L2-L3) with morphine was provided for group A patients with 2 to 4 mg upon excision of tissue and for group B with 2 to 4 mg during anesthetic induction. The following variables were recorded: arterial blood gas concentrations, heart rate, SpO2, EtCO2, postanesthetic recovery, arterial gases, side effects and pain on a visual analogue scale. Top-up analgesia was provided by intravenous metamizole and/or epidural morphine. For statistical analysis we used ANOVA, chi-square tests and Student-Newman-Keuls tests., Results: The need for propofol and alfentanil during anesthesia, and for morphine and metamizole after surgery were statistically greater in group A. Pain 18 hours after surgery was also greater in group A. No significant differences between groups for other variables was observed., Conclusions: Preemptive analgesia with lumbar epidural morphine in addition to the general anesthesia described here seems to provide higher-quality analgesia with few side effects, reducing the need for propofol and alfentanil during surgery and for postoperative morphine and metamizole.

Twenty-four cases of bronchopleural fistula were found by fiberoptic bronchoscopy performed in 526 consecutive patients undergoing surgery for diagnosis or treatment of lung cancer between February 1990 and January 1997 in Hospital General Universitario in Valencia (Spain). In 327 of the patients lung resection was performed. Clinical symptoms included fever, purulent or bloodstained expectoration, chest pain, dyspnea and general unfitness, with 83.33% of the patients having pleural empyema. Treatment was based on pleural drainage and broad-spectrum antibiotic therapy, along with planning of the appropriate surgery technique to each patient. Surgery consisted in re-thoracotomy and bronchial closure in early detection cases without evidence of infection (< 48 h); thoracostomy (Clagett) and second stage myoplasty if confirmed pleural infection; thoracoplasty in cases of incomplete fistulas that were unresolved by pleural drainage. Biological glues were delivered by fiberoptic bronchoscope in one patient. The incidence of bronchopleural fistula was studied, as were associated factors and the results obtained by various surgical techniques.