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Purpose: The aim of this study was to compare the effect of a pressure-controlled strategy allowing non-synchronised unassisted spontaneous ventilation (PC-SV) to a conventional volume assist-control strategy (ACV) on the outcome of patients with acute respiratory distress syndrome (ARDS). Methods: Open-label randomised clinical trial in 22 intensive care units (ICU) in France. Seven hundred adults with moderate or severe ARDS (PaO2/FiO2 < 200 mmHg) were enrolled from February 2013 to October 2018. Patients were randomly assigned to PC-SV (n = 348) or ACV (n = 352) with similar objectives of tidal volume (6 mL/kg predicted body weight) and positive end-expiratory pressure (PEEP). Paralysis was stopped after 24 h and sedation adapted to favour patients' spontaneous ventilation. The primary endpoint was in-hospital death from any cause at day 60. Results: Hospital mortality [34.6% vs 33.5%, p = 0.77, risk ratio (RR) = 1.03 (95% confidence interval [CI] 0.84–1.27)], 28-day mortality, as well as the number of ventilator-free days and organ failure-free days at day 28 did not differ between PC-SV and ACV groups. Patients in the PC-SV group received significantly less sedation and neuro-muscular blocking agents than in the ACV group. A lower proportion of patients required adjunctive therapy of hypoxemia (including prone positioning) in the PC-SV group than in the ACV group [33.1% vs 41.3%, p = 0.03, RR = 0.80 (95% CI 0.66–0.98)]. The incidences of pneumothorax and refractory hypoxemia did not differ between the groups. Conclusions: A strategy based on PC-SV mode that favours spontaneous ventilation reduced the need for sedation and adjunctive therapies of hypoxemia but did not significantly reduce mortality compared to ACV with similar tidal volume and PEEP levels. [ABSTRACT FROM AUTHOR]

Minimally invasive esophagectomy for cancer surgery remains associated with significant morbidity and surgical complications across the globe. Nonintubation video-assisted thoracic surgery (NIVATS) has been successfully employed in lung resection in recent years, but there are few reported cases with regard to the safety and feasibility of this approach in radical esophagectomy for patients with esophageal cancers. We present 4 consecutive cases with esophageal squamous cell carcinoma (ESCC) who received minimally invasive McKeown's esophagectomy under non-intubation general anesthesia from November 2022 to April 2023. All these patients were aged from 55 to 75 years old and were pathologically diagnosed with ESCC. All procedures of McKeown's esophagectomy in these patients were completed with non-invasive ventilation by laryngeal mask-assisted anesthesia. Operation duration ranged from 185 to 395 minutes and the estimated blood loss ranged from 25 to 60 ml in these 4 cases. No severe hypoxia was observed and transient hypercapnia was resolved intraoperatively. None of them was converted to endotracheal intubation with mechanical ventilation or to thoracotomy. The number of retrieved lymph nodes in mediastinum were 21-27 and all patients received R0 surgery with pathological stage as T1bN0M0 to T3N2M0. There was no serious complication (Clavien-Dindo grade III-IV) observed perioperatively and they were all discharged 11-14 days after the surgery with resumption of oral feeding. They are all alive without tumor recurrence at the date of data collection. The safety and efficacy of minimally invasive esophagectomy with non-invasive ventilation by laryngeal mask-assisted anesthesia for patients with ESCC are warranted for explored in a larger cohort study. [ABSTRACT FROM AUTHOR]

Abstract Background The use of nonintubated video-assisted thoracoscopic surgery (NI-VATS) has been increasingly reported to yield favourable outcomes. However, this technology has not been routinely used because its advantages and safety have not been fully confirmed. The aim of this study was to assess the safety and feasibility of nonintubated spontaneous ventilation (NI-SV) anesthesia compared to intubated mechanical ventilation (I-MV) anesthesia in VATS by evaluating of perioperative complications and practitioners’ workloads. Methods Patients who underwent uniportal VATS were randomly assigned at a 1:1 ratio to receive NI-SV or I-MV anesthesia. The primary outcome was the occurrence of intraoperative airway intervention events, including transient MV, conversion to intubation and repositioning of the double-lumen tube. The secondary outcomes included perioperative complications and modified National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores from anesthesiologists and surgeons. Results Thirty-five patients in each group were enrolled in the intention-to-treat analysis. The incidence of intraoperative airway intervention events was greater in the NI-SV group than in the I-MV group (12 [34.3%] vs. 3 [8.6%]; OR = 0.180; 95% CI = 0.045–0.710; p = 0.009). No significant difference was found in the postoperative pulmonary complications between the groups (p > 0.05). The median of the anesthesiologists’ overall NASA-TLX score was 37.5 (29–52) when administering the NI-SV, which was greater than the 25 (19-34.5) when the I-MV was administered (p

Background: The use of nonintubated video-assisted thoracoscopic surgery (NI-VATS) has been increasingly reported to yield favourable outcomes. However, this technology has not been routinely used because its advantages and safety have not been fully confirmed. The aim of this study was to assess the safety and feasibility of nonintubated spontaneous ventilation (NI-SV) anesthesia compared to intubated mechanical ventilation (I-MV) anesthesia in VATS by evaluating of perioperative complications and practitioners' workloads. Methods: Patients who underwent uniportal VATS were randomly assigned at a 1:1 ratio to receive NI-SV or I-MV anesthesia. The primary outcome was the occurrence of intraoperative airway intervention events, including transient MV, conversion to intubation and repositioning of the double-lumen tube. The secondary outcomes included perioperative complications and modified National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores from anesthesiologists and surgeons. Results: Thirty-five patients in each group were enrolled in the intention-to-treat analysis. The incidence of intraoperative airway intervention events was greater in the NI-SV group than in the I-MV group (12 [34.3%] vs. 3 [8.6%]; OR = 0.180; 95% CI = 0.045–0.710; p = 0.009). No significant difference was found in the postoperative pulmonary complications between the groups (p > 0.05). The median of the anesthesiologists' overall NASA-TLX score was 37.5 (29–52) when administering the NI-SV, which was greater than the 25 (19-34.5) when the I-MV was administered (p < 0.001). The surgeons' overall NASA-TLX score was comparable between the two ventilation strategies (28 [21-38.5] vs. 27 [20.5–38.5], p = 0.814). Conclusion: The NI-SV anesthesia was feasible for VATS in the selected patients, with a greater incidence of intraoperative airway intervention events than I-MV anesthesia, and with more surgical effort required by anesthesiologists. Trial registration: Chinese Clinical Trial Registry, ChiCTR2200055427. https://www.chictr.org.cn/showproj.html?proj=147872 was registered on January 09, 2022. [ABSTRACT FROM AUTHOR]

Minimally invasive esophagectomy for cancer surgery remains associated with significant morbidity and surgical complications across the globe. Non-intubation video-assisted thoracic surgery (NIVATS) has been successfully employed in lung resection in recent years, but there are few reported cases with regard to the safety and feasibility of this approach in radical esophagectomy for patients with esophageal cancers. We present 4 consecutive cases with esophageal squamous cell carcinoma (ESCC) who received minimally invasive McKeown’s esophagectomy under non-intubation general anesthesia from November 2022 to April 2023. All these patients were aged from 55 to 75 years old and were pathologically diagnosed with ESCC. All procedures of McKeown’s esophagectomy in these patients were completed with non-invasive ventilation by laryngeal mask-assisted anesthesia. Operation duration ranged from 185 to 395 minutes and the estimated blood loss ranged from 25 to 60 ml in these 4 cases. No severe hypoxia was observed and transient hypercapnia was resolved intraoperatively. None of them was converted to endotracheal intubation with mechanical ventilation or to thoracotomy. The number of retrieved lymph nodes in mediastinum were 21-27 and all patients received R0 surgery with pathological stage as T1bN0M0 to T3N2M0. There was no serious complication (Clavien-Dindo grade III-IV) observed perioperatively and they were all discharged 11-14 days after the surgery with resumption of oral feeding. They are all alive without tumor recurrence at the date of data collection. The safety and efficacy of minimally invasive esophagectomy with non-invasive ventilation by laryngeal mask-assisted anesthesia for patients with ESCC are warranted for explored in a larger cohort study.

Thoracoscopic surgical biopsy has shown excellent histological characterization of undetermined interstitial lung diseases, although the morbidity rates reported are not negligible. In delicate patients, interstitial lung disease and restrictive ventilatory impairment morbidity are thought to be due at least in part to tracheal intubation with single-lung mechanical ventilation; therefore, spontaneous ventilation thoracoscopic lung biopsy (SVTLB) has been proposed as a potentially less invasive surgical option. This systematic review summarizes the results of SVTLB, focusing on diagnostic yield and operative morbidity. A systematic search for original studies regarding SVTLB published between 2010 to 2023 was performed. In addition, articles comparing SVTLB to mechanical ventilation thoracoscopic lung biopsy (MVTLB) were selected for a meta-analysis. Overall, 13 studies (two before 2017 and eleven between 2018 and 2023) entailing 675 patients were included. Diagnostic yield ranged from 84.6% to 100%. There were 64 (9.5%) complications, most of which were minor. There was no 30-day operative mortality. When comparing SVTLB to MVTLB, the former group showed a significantly lower risk of complications (p < 0.001), whereas no differences were found in diagnostic accuracy. The results of this review suggest that SVTLB is being increasingly adopted worldwide and has proven to be a safe procedure with excellent diagnostic accuracy. [ABSTRACT FROM AUTHOR]

The goal of the heart and lungs is to deliver oxygen at a tissue level, and this is determined by cardiac output (CO) and the oxygen content of arterial blood (CaO2), DO2 = CO × CaO2. ¹ The heart and lungs share the same intrathoracic space: mechanically this is akin to having a pump within a pump.2 Cardiopulmonary interactions refer to the relationship between airway pressures, lung volumes, and CO. ³ In health, the effect of cardiopulmonary interactions is minimal. It is important to look at each part of the heart separately as phasic changes in intrathoracic pressures (ITP) have differing effects. In a spontaneously breathing person, a negative ITP is transmitted to the right atrium. The flow of blood to the right atrium is governed by Ohm’s law, flow = ΔP/R, where ΔP is the driving pressure to the right atrium and R is the resistance of the capacitance vessels.4 With positive pressure ventilation (PPV) the increased ITP is transmitted to the right atrium, which results in a reduction of the driving pressure and ultimately the venous return (VR). The right ventricle afterload is the pressure that the heart must work against to eject blood during systole, and this is determined by the pulmonary vascular resistance (PVR). PVR is determined by the extra-alveolar vessels and the intra-alveolar vessels. The total PVR is the addition of the two and lowest at functional residual capacity.5 The left ventricle preload is essentially equal to the right ventricle output. There is a time lag as blood must traverse the pulmonary circulation. Left ventricle afterload can be expressed as left ventricular (LV) wall stress. Afterload increases as transmural pressure and vascular resistance increase. Positive pressure reduces the transmural pressure needed for the ejection of the stroke volume. With negative ITP there is a pressure pulling outwards as the ventricle attempts to eject its stroke volume, therefore higher transmural pressures are needed.4 Knowing how the heart and lungs work in the normal physiological state will help guide decision-making about heart-lung interactions in critically ill patients therefore mitigating any adverse consequences. [ABSTRACT FROM AUTHOR]

Background: When caring for mechanically ventilated adults with acute hypoxaemic respiratory failure (AHRF), clinicians are faced with an uncertain choice between ventilator modes allowing for spontaneous breaths or ventilation fully controlled by the ventilator. The preferences of clinicians managing such patients, and what motivates their choice of ventilator mode, are largely unknown. To better understand how clinicians' preferences may impact the choice of ventilatory support for patients with AHRF, we issued a survey to an international network of intensive care unit (ICU) researchers. Methods: We distributed an online survey with 32 broadly similar and interlinked questions on how clinicians prioritise spontaneous or controlled ventilation in invasively ventilated patients with AHRF of different severity, and which factors determine their choice. Results: The survey was distributed to 1337 recipients in 12 countries. Of these, 415 (31%) completed the survey either fully (52%) or partially (48%). Most respondents were identified as medical specialists (87%) or physicians in training (11%). Modes allowing for spontaneous ventilation were considered preferable in mild AHRF, with controlled ventilation considered as progressively more important in moderate and severe AHRF. Among respondents there was strong support (90%) for a randomised clinical trial comparing spontaneous with controlled ventilation in patients with moderate AHRF. Conclusions: The responses from this international survey suggest that there is clinical equipoise for the preferred ventilator mode in patients with AHRF of moderate severity. We found strong support for a randomised trial comparing modes of ventilation in patients with moderate AHRF. [ABSTRACT FROM AUTHOR]

Asthma encompasses of respiratory symptoms that occur intermittently and with varying intensity accompanied by reversible expiratory airflow limitation. In acute exacerbations, it can be life-threatening due to its impact on ventilatory mechanics. Moreover, asthma has significant effects on the cardiovascular system, primarily through heart-lung interaction-based mechanisms. Dynamic hyperinflation and increased work of breathing caused by a sharp drop in pleural pressure, can affect cardiac function and cardiac output through different mechanisms. These mechanisms include an abrupt increase in venous return, elevated right ventricular afterload and interdependence between the left and right ventricle. Additionally, Pulsus paradoxus, which reflects the maximum consequences of this heart lung interaction when intrathoracic pressure swings are exaggerated, may serve as a convenient bedside tool to assess the severity of acute asthma acute exacerbation and its response to therapy. [ABSTRACT FROM AUTHOR]

Asthma encompasses of respiratory symptoms that occur intermittently and with varying intensity accompanied by reversible expiratory airflow limitation. In acute exacerbations, it can be life-threatening due to its impact on ventilatory mechanics. Moreover, asthma has significant effects on the cardiovascular system, primarily through heart-lung interaction-based mechanisms. Dynamic hyperinflation and increased work of breathing caused by a sharp drop in pleural pressure, can affect cardiac function and cardiac output through different mechanisms. These mechanisms include an abrupt increase in venous return, elevated right ventricular afterload and interdependence between the left and right ventricle. Additionally, Pulsus paradoxus, which reflects the maximum consequences of this heart lung interaction when intrathoracic pressure swings are exaggerated, may serve as a convenient bedside tool to assess the severity of acute asthma acute exacerbation and its response to therapy.

Background: To minimize the risks of barotrauma during nonintubated thoracoscopic-surgery under spontaneous ventilation, we investigated an adjuvant transthoracic negative-pressure ventilation (NPV) method in patients operated on due to severe emphysema or interstitial lung disease. Methods: In this retrospective study, NPV was employed for temporary low oxygen saturation and to achieve end-operative lung re-expansion during nonintubated lung volume reduction surgery (LVRS) for severe emphysema (30 patients, LVRS group) and in the nonintubated wedge resection of undetermined interstitial lung disease (30 patients, wedge-group). The results were compared following 1:1 propensity score matching with equivalent control groups undergoing the same procedures under spontaneous ventilation, with adjuvant positive-pressure ventilation (PPV) performed on-demand through the laryngeal mask. The primary outcomes were changes (preoperative–postoperative value) in the arterial oxygen tension/fraction of the inspired oxygen ratio (ΔPO2/FiO2;) and ΔPaCO2, and lung expansion completeness on a 24 h postoperative chest radiograph (CXR-score, 2: full or 1: incomplete). Results: Intergroup comparisons (NPV vs. PPV) showed no differences in demographic and pulmonary function. NPV could be accomplished in all instances with no conversion to general anesthesia with intubation. In the LVRS group, NPV improved ΔPO2/FiO2 (9.3 ± 16 vs. 25.3 ± 30.5, p = 0.027) and ΔPaCO2 (−2.2 ± 3.15 mmHg vs. 0.03 ± 0.18 mmHg, p = 0.008) with no difference in the CXR score, whereas in the wedge group, both ΔPO2/FiO2 (3.1 ± 8.2 vs. 9.9 ± 13.8, p = 0.035) and the CXR score (1.9 ± 0.3 vs. 1.6 ± 0.5, p = 0.04) were better in the NPV subgroup. There was no mortality and no intergroup difference in morbidity. Conclusions: In this retrospective study, NITS with adjuvant transthoracic NPV resulted in better 24 h oxygenation measures than PPV in both the LVRS and wedge groups, and in better lung expansion according to the CXR score in the wedge group. [ABSTRACT FROM AUTHOR]

With the growing adoption of Enhanced Recovery After Surgery protocols across all surgical groups, including thoracic surgery, coupled with improved video-assisted thoracoscopic surgery (VATS) equipment and techniques, nonintubated thoracoscopic surgery has gained significant popularity in recent years. Avoiding tracheal intubation with an endotracheal or double-lumen tube and general anesthesia may reduce or eliminate the risks associated with traditional mechanical ventilation, one-lung ventilation, and general anesthesia. Studies have shown a trend toward better preservation of postoperative respiratory function and improved postoperative lengths of hospital stay, morbidity, and mortality; however, these have not been conclusively proven. This review article discusses the advantages of nonintubated VATS, the types of thoracic surgery in which this technique has been described, patient selection, appropriate anesthetic techniques, surgical concerns, potential complications relevant to the anesthesiologist during the conduct of nonintubated VATS surgery, and suggested management of these complications. [ABSTRACT FROM AUTHOR]

Background: Opioid-free anesthesia (OFA) provides adequate analgesia and can reduce postoperative opioid consumption, but its efficacy in spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has not been demonstrated. We aimed to investigate the hypothesis that OFA could provide the same perioperative pain control as opioid anesthesia (OA), maintain safe and stable respiration and hemodynamics during surgery, and improve postoperative recovery. Methods: Sixty eligible patients (OFA group: n=30; OA group: n=30) treated between September 15, 2022, and December 15, 2022, at The First Hospital of Guangzhou Medical University were included. They were randomized to receive standard balanced OFA with esketamine or OA with remifentanil combined with sufentanil. The primary outcome was the pain numeric rating score (NRS) at postoperative 24 h, and the secondary outcomes were intraoperative respiratory and hemodynamic data, opioid consumption, vasoactive drug dosage, and recovery in the post-anesthesia care unit and ward. Results: There was no significant difference in the postoperative pain scores and recovery quality between the two groups. The OFA group had a significantly lower dose of phenylephrine (P=0.001) and a lower incidence of hypotension (P=0.004) during surgery. The OFA group resumed spontaneous respiration faster (P<0.001) and had a higher quality of lung collapse (P=0.02). However, the total doses of propofol and dexmetomidine were higher (P=0.03 and P=0.02), and the time to consciousness was longer (P=0.039) in the OFA group. Conclusions: OFA provides the same level of postoperative pain control as OA, but it is more advantageous in maintaining circulatory and respiratory stability and improving the quality of pulmonary collapse in SV-VATS. [ABSTRACT FROM AUTHOR]

Background & Objective: Pressure support ventilation (PSV) is a target pressure mode that offers breath by breath mode of ventilation support, started by patients, and timed to respiratory effort. The fundamental idea behind PSV is to assist spontaneous breathing in response to the patient-initiated breaths. We evaluated the effects of PSV and spontaneous ventilation during awakening from anesthesia on lung atelectasis in the patients following laparoscopic gastric sleeve surgery. Methodology: Following clearance from the institutional ethical council, we enrolled 64 patients and divided them into two groups at random; pressure support group (Group PS) to receive PSV, and control group or spontaneous group (Group S) to continue with spontaneous ventilation mode during awakening from anesthesia in the patients following laparoscopic gastric sleeve surgery. Results: In the pressure support group, atelectasis was less common than in the control group at PACU (P = 0.042). Over the first 48 h following surgery, there were substantial differences between the groups in the level of oxygen saturation as determined by pulse oximetry ≤ 92%. The incidence of SpO2 ≤ 92% during 48 h postoperatively in the Group S and Group PS was 34% vs 12% respectively. No patient needed mechanical ventilatory support during the 48 h postoperatively. Conclusions: Pressure support ventilation during the recovery from general anesthesia to patients after laparoscopic gastric sleeve surgery resulted in reduced incidence of postoperative atelectasis than those who were allowed spontaneous ventilation with occasional manual support. Abbreviations: PACU: Post-Anesthesia Care Unit; PEEP: Positive End Expiratory Pressure; PSV: Pressure support ventilation; VT: Tidal Volume. [ABSTRACT FROM AUTHOR]

Abstract Objective Spontaneous ventilation under intravenous anesthesia allows the surgeon to work without interruption or obstruction of the operating field during suspension microlaryngoscopy (SML). High‐flow nasal oxygen therapy (HFNO) is increasingly used in anesthesia. We hypothesized that its use during SML would increase patient safety even in situations where the airway is compromised by tumor or stenosis. Study Design Retrospective observational study. Setting University Hospital of Lausanne, Switzerland. Methods Adults patients who were scheduled for elective microlaryngeal surgery and managed with HFNO in spontaneous ventilation under general anesthesia between October 2020 and December 2021. Results Twenty‐seven patients for a total of 32 surgical procedures were performed under HFNO with spontaneous ventilation. Seventy‐five percent of the patients had respiratory symptoms. Twelve patients (42.9%) were planned for the treatment of subglottic or tracheal stenosis and 5 patients were managed for vocal cord cancer (18.5%). Out of 32 surgeries, 4 cases of saturation

Objective: To evaluate the use of the caudal vena cava collapsibility index (CVCCI) and the inspiratory/minimum and expiratory/maximum diameters of the vena cava to predict fluid responsiveness in hospitalized, critically ill cats with hemodynamic and tissue perfusion abnormalities. Design: Diagnostic test study in a prospective cohort of hospitalized cats. Setting: Private practice referral hospital. Animals: Twenty‐four hospitalized cats with spontaneous breathing and compromised hemodynamics and tissue hypoperfusion. Interventions: Ultrasonographic examination before and after fluid expansion with 10 ml/kg of lactated Ringer's solution. Measurements and Main Results: Fluid responsiveness was evaluated using the velocity–time integral (VTI) of the subaortic blood flow, by measuring it before and after a fluid load of 10 ml/kg of lactated Ringer's solution. The CVCCI was calculated using the following formula: (maximum diameter – minimum diameter / maximum diameter) × 100. Ten cats were fluid responders (42 %) and 14 were nonresponders (58 %). The area under the receiver operating characteristic curve (AUROC) with their 95% confidence interval for the predictors and the best cutoff values were as follows: CVCCI, AUROC = 0.83 (0.66–1.00) and cutoff = 31%; inspiratory/minimum diameter, AUROC = 0.86 (0.70–1.00) and cutoff = 0.24 cm; expiratory/maximum diameter, AUROC = 0.88 (0.74–1.00) and cutoff = 0.22 cm. A significant lineal correlation was observed between the percentage of increase in VTI after expansion and CVCCI (rs = 0.68, P < 0.001), expiratory/maximum diameter (rs = –0.72, P < 0.001), and inspiratory/minimum diameter (rs = –0.71, P < 0.001). The intraobserver and interobserver variability was low for VTI, and the expiratory/maximum diameter and inspiratory/minimum diameter were high for CVCCI. Conclusions: Caudal vena cava measurements could be useful to predict the response to fluids in hospitalized cats with hemodynamic and tissue perfusion alterations. Additional studies are required to draw definitive conclusions about the role of these variables to guide fluid administration in cats. [ABSTRACT FROM AUTHOR]

Yolk sac tumor (YST), also known as endodermal sinus tumor, is a malignant germ cell tumor that usually affects children aged >3 years. It is commonly observed in the gonadal sites (testis or ovary) but is extremely rare in the mandibular regions. This study describes the anesthesia process for spontaneous ventilation bronchoscope intubation in the rare case of a 7‐year‐old child with extragonadal primary YST of the face, refractory to radiotherapy, and chemotherapy. [ABSTRACT FROM AUTHOR]

Background: We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP). Methods: Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates. Results: There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding. Conclusion: Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted. [ABSTRACT FROM AUTHOR]

Abstract Yolk sac tumor (YST), also known as endodermal sinus tumor, is a malignant germ cell tumor that usually affects children aged >3 years. It is commonly observed in the gonadal sites (testis or ovary) but is extremely rare in the mandibular regions. This study describes the anesthesia process for spontaneous ventilation bronchoscope intubation in the rare case of a 7‐year‐old child with extragonadal primary YST of the face, refractory to radiotherapy, and chemotherapy.

Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients' characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses. [ABSTRACT FROM AUTHOR]

Vertebral defects, anorectal anomalies, cardiac anomalies, tracheoesophageal fistula (TEF)/esophageal atresia, renal anomalies, and limb abnormalities (VACTERL) association is a rare congenital disorder presenting with a constellation of birth defects. The diagnosis is primarily clinical, and patients exhibit at least three of these anomalies. These patients' management involves a multidisciplinary approach tailored to the individual's condition. Anesthetic management is particularly challenging due to the diverse and complex anomalies. This article discusses the anesthetic management of a term newborn male (39 weeks, six days gestation, 3340 g) diagnosed with VACTERL association. The newborn was admitted to the neonatal intensive care unit (NICU) and scheduled for the surgical repair of TEF and derivative colostomy on the second day of life. To mitigate the risk of air leak and abdominal distension from positive pressure ventilation, a derivative colostomy was performed first under regional anesthesia preserving spontaneous ventilation. To achieve that, the patient was sedated with ketamine and dexmedetomidine, and an ultrasound-guided single-shot caudal block with ropivacaine was performed. Post-abdominal decompression, general anesthesia was induced, and intubation was managed via videolaryngoscopy. Thoracoscopic TEF repair required several pauses for ventilation and hemodynamic optimization. Dopamine was administered intraoperatively for blood pressure support. The newborn was extubated and started on enteral feeding by the seventh postoperative day, progressing well by the time of discharge. In this case, a derivative colostomy before TEF repair avoided positive pressure ventilation complications. Ultrasound-guided caudal block provided effective regional anesthesia with high success rates. Ketamine and dexmedetomidine offered balanced sedation with minimal respiratory compromise. Dopamine was used effectively to maintain adequate perfusion, monitored with invasive blood pressure and cerebral oximetry. Anesthetic management of newborns with VACTERL association undergoing simultaneous repair of TEF and anal atresia demands meticulous and tailored planning to address the specific needs and minimize associated risks. This case highlights the importance of comprehensive anesthetic management and its impact on the patient's outcome., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Costa et al.)

Objectives: Non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy is a well-known procedure, but there are doubts regarding its safety. To solve this problem, we developed a safe procedure for spontaneous ventilation thoracic surgery (spontaneous ventilation with intubation). This study analyzed the intraoperative parameters and postoperative results of spontaneous ventilation with intubation. Methods: Between March 11, 2020 and March 26, 2021, 38 spontaneous ventilation with intubation video-assisted thoracic surgery lobectomies were performed. We chose the first 38 non-intubated spontaneous ventilation video-assisted thoracic surgery lobectomy cases with a laryngeal mask performed in 2017 for comparison. Results: There were no significant differences between the non-intubated spontaneous ventilation and spontaneous ventilation with intubation groups in postoperative surgical results (surgical time: 98,7 vs. 88,1 min (p = 0.067); drainage time: 3.5 vs. 2.7 days (p = 0.194); prolonged air leak 15.7% vs. 10.5% (p = 0.5); conversion rate to relaxation: 5.2% vs. 13.1% (p = 0.237); failure of the spontaneous ventilation rate: 10.5% vs. 13.1% (p = 0.724); and morbidity: 21% vs. 13.1% (p = 0.364)) and oncological outcomes. Significantly lower lowest systolic and diastolic blood pressure (systolic, 83.1 vs 132.3 mmHg, p = 0.001; diastolic 47.8 vs. 73.4 mmHg, p = 0.0001), lowest oxygen saturation (90.3% vs 94.9%, p = 0.026), and higher maximum pCO2 level (62.5 vs 54.8 kPa, p = 0.009) were found in the non-intubated spontaneous ventilation group than in the spontaneous ventilation with intubation group. Conclusions: Spontaneous ventilation with intubation is a more physiological procedure than non-intubated spontaneous ventilation in terms of intraoperative blood pressure stability and gas exchange. The surgical results were similar in the two groups. [ABSTRACT FROM AUTHOR]

Abstract Background Non-intubated video-assisted thoracic surgery (NiVATS) has been introduced to surgical medicine in order to reduce the invasiveness of anesthetic procedures and avoid adverse effects of intubation and one-lung ventilation (OLV). The aim of this study is to determine the time effectiveness of a NiVATS program compared to conventional OLV. Methods This retrospective analysis included all patients in Leipzig University Hospital that needed minor VATS surgery between November 2016 and October 2019 constituting a NiVATS (n = 67) and an OLV (n = 36) group. Perioperative data was matched via propensity score analysis, identifying two comparable groups with 23 patients. Matched pairs were compared via t-Test. Results Patients in NiVATS and OLV group show no significant differences other than the type of surgical procedure performed. Wedge resection was performed significantly more often under NiVATS conditions than with OLV (p = 0,043). Recovery time was significantly reduced by 7 min (p = 0,000) in the NiVATS group. There was no significant difference in the time for induction of anesthesia, duration of surgical procedure or overall procedural time. Conclusions Recovery time was significantly shorter in NiVATS, but this effect disappeared when extrapolated to total procedural time. Even during the implementation phase of NiVATS programs, no extension of procedural times occurs.

Background: Spontaneous breathing is desirable in most ventilated patients. We therefore studied the influence of isoflurane versus propofol sedation on early spontaneous breathing in ventilated surgical intensive care patients and evaluated potential mediation by opioids and arterial carbon dioxide during the first 20 h of study sedation. Methods: We included a single‐center subgroup of 66 patients, who participated in a large multi‐center trial assessing efficacy and safety of isoflurane sedation, with 33 patients each randomized to isoflurane or propofol sedation. Both sedatives were titrated to a sedation depth of −4 to −1 on the Richmond Agitation Sedation Scale. The primary outcome was the fraction of time during which patients breathed spontaneously. Results: Baseline characteristics of isoflurane and propofol‐sedated patients were well balanced. There were no substantive differences in management or treatment aside from sedation, and isoflurane and propofol provided nearly identical sedation depths. The mean fraction of time spent spontaneously breathing was 82% [95% CI: 69, 90] in patients sedated with isoflurane compared to 35% [95% CI: 22, 51] in those assigned to propofol: median difference: 61% [95% CI: 14, 89], p <.001. After adjustments for sufentanil dose and arterial carbon dioxide partial pressure, patients sedated with isoflurane were twice as likely to breathe spontaneously than those sedated with propofol: adjusted risk ratio: 2.2 [95%CI: 1.4, 3.3], p <.001. Conclusions: Isoflurane compared to propofol sedation promotes early spontaneous breathing in deeply sedated ventilated intensive care patients. The benefit appears to be a direct effect isoflurane rather than being mediated by opioids or arterial carbon dioxide. [ABSTRACT FROM AUTHOR]

Abstract Introduction: Currently, transesophageal echodopplercardiography is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient transesophageal echo exam, under sedation and using the oropharyngeal cannula. Method: 30 patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non-invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion and, comfort of examiner were analyzed. Results: The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and transesophageal echo probe handling was appropriate in 93.33% of exams performed. Conclusions: Transesophageal echo exams under sedation aided by the double-lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO2 during the exams.

Abstract Background Mechanical ventilation (MV), compared to spontaneous breathing (SB), has been found to increase abdominal edema and inflammation in experimental sepsis. Our hypothesis was that in primary acute respiratory distress syndrome (ARDS) MV would enhance inflammation and edema in the abdomen. Methods Thirteen piglets were randomized into two groups (SB and MV) after the induction of ARDS by lung lavage and 1 h of injurious ventilation. 1. SB: continuous positive airway pressure 15 cmH2O, fraction of inspired oxygen (FIO2) 0.5 and respiratory rate (RR) maintained at about 40 cycles min− 1 by titrating remifentanil infusion. 2. MV: volume control, tidal volume 6 ml kg− 1, positive end-expiratory pressure 15 cmH2O, RR 40 cycles min− 1, FIO2 0.5. Main outcomes: abdominal edema, assessed by tissues histopathology and wet-dry weight; abdominal inflammation, assessed by cytokine concentration in tissues, blood and ascites, and tissue histopathology. Results The groups did not show significant differences in hemodynamic or respiratory parameters. Moreover, edema and inflammation in the abdominal organs were similar. However, blood IL6 increased in the MV group in all vascular beds (p

Background: Anesthesia remains challenging for bronchoscopic tracheobronchial surgeries (BTS) involving surgical manipulations for central airway obstruction within shared airways. To provide complete airway use through intervention with spontaneous breathing without endotracheal tubes, monitored non-intubated anesthesia has been successfully applied with electroencephalogram-derived monitored total intravenous anesthesia. This study evaluated the feasibility and the outcomes of BTS with monitored non-intubated anesthesia. The factors associated with desaturation and complications were also analyzed., Methods: Data from patients receiving non-intubated BTS performed between October 2019 and August 2022 were retrospectively collected. Intraoperative results and postoperative outcomes were analyzed., Results: Data of 92 patients were collected. Supraglottic airways devices and high-flow nasal oxygen were used in 68 and 24 patients respectively. Surgery was successfully completed in 87 patients (94.6%), whereas three patients required conversion to intubation because of substantial bleeding. In total, 11% of patients experienced desaturation [oxygen saturation (SpO 2 ) <90%] for an average of 9 minutes. Unexpected admission to the intensive care unit (ICU) occurred in 12.2% (5/41) of patients from outpatient department and 7.8% (4/51) of hospitalization settings because of high-grade surgical bleeding. With comparable desaturation incidence, tracheal surgery had significantly longer desaturation times (14.5±6.9 min) than bronchial surgeries (5.8±2.6 min) did., Conclusions: Monitored non-intubated anesthesia with spontaneous breathing is feasible for BTS, with high success rate, few complications, and rapid recovery. High-grade bleeding remains the most unpredictable risk for intraoperative desaturation and postoperative ICU admission, especially in tracheal obstruction cases., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1935/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Our goal was to assess the results and the costs of the quasilobar minimalist (QLM) thoracoscopic lung volume reduction (LVR) surgical method developed to minimize the trauma from the operation and the anaesthesia and to maximize the effect of the lobar volume reduction. METHODS Forty patients with severe emphysema underwent QLM-LVR that entailed adoption of sole intercostal block analgesia and lobar plication through a single thoracoscopic incision. Results were compared after propensity matching with 2 control groups undergoing non-awake resectional LVR with double-lumen tracheal intubation or awake non-resectional LVR by plication with thoracic epidural anaesthesia. As a result, we had 3 matched groups of 30 patients each. RESULTS Baseline forced expiratory volume in 1 s, residual volume, the 6-min walking test and the modified Medical Research Council dyspnoea index were 0.77 ± 0.18, 4.97 ± 0.6, 328 ± 65 and 3.3 ± 0.7, respectively, with no intergroup difference after propensity score matching. The visual pain score was better (P  < 0.007), the hospital stay was shorter (P  < 0.04) and overall costs were lower (P  < 0.04) in the QLM-LVR group than in the control groups. The morbidity rate was lower with QLM-LVR than with non-awake resectional-LVR (P  = 0.006). Significant improvements (P  < 0.001) occurred in all study groups during the follow-up period. At 24 months, improvements in residual volume and dyspnoea index were significantly better with QLM-LVR (P  < 0.04). CONCLUSIONS QLM-LVR proved safe and showed better perioperative outcomes and lower procedure-related costs than the control groups. Similar clinical benefit occurred at 12 months, but absolute improvements in residual volume and dyspnoea index were better in the QLM-LVR group at 24 months. [ABSTRACT FROM AUTHOR]

Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients’ characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses.

Vocal cord papillomas are rare growths of viral etiology caused by human papillomavirus (HPV). Large polyps are known to obstruct glottic opening and can cause acute airway obstruction. We report a case of 4-year-old male child with progressive hoarseness of voice and stridor posted for excision of vocal cord papillomas. Paediatric age of the patient and the position of the growth obstructing the glottic opening at vocal cords provided an extremely challenging environment for induction of anaesthesia. [ABSTRACT FROM AUTHOR]

Objective: We present the combination of spontaneous ventilation and double-lumen tube intubation in thoracic surgery. Methods: At the beginning of the procedures, the patients with a body mass index of ≤ 30 were relaxed for a short time, and a double-lumen tube was inserted. After the utility incision or thoracotomy, the vagus nerve was blocked (in right side in the upper mediastinum; in left side in the aorto-pulmonary window) with 3–5 ml of 0.5% bupivacaine. The patients had a bispectral index of 40–60. After the short relaxation period, the patients were ventilating spontaneously without any cough during the manipulation. Results: Between March 10 and September 18. 2020, 26 spontaneous ventilation combined with intubation surgeries were performed: 19 uniportal video-assisted thoracic surgery (15 lobectomies, 1 segmentectomy, and 3 wedge resections) and 7 open (5 lobectomies and 1 sleeve segmentectomy, 1 wedge resection). The mean mechanical and spontaneous one-lung ventilation time was 25.5 (15–115) and 73.3 (45–100) minutes, respectively. In 2 cases conversion to relaxation were necessary (2/26; 7.7%). The mean maximal carbon dioxide pressure was 52.3 (38–66) Hgmm and the mean lowest oxygen saturation was 93.8 (86–99) %. Breathing frequency ranged between 10–25/minute. The mean surgical times was 83.3 (55–130) minutes. Conclusions: Spontaneous ventilation combined with intubation in video-assisted thoracic surgery or open resections is a safe method in selected patients. It can reduce the mechanical one-lung ventilation period with 76.6% and give safe airway for spontaneous ventilation thoracic procedures. [ABSTRACT FROM AUTHOR]

Anaesthetic management of tracheal resection and reconstruction in patients with difficult tracheal pathologies, poses unique challenges—such as pre-operative assessment and preparation, the induction of general anaesthesia, airway sharing with surgeons during the intra-operative period while performing resection and reconstruction, emergence from general anaesthesia, and post-operative care. While there are no guidelines on choosing the ideal airway technique for the intra-operative period, we describe a simple-yet-effective airway modality, viz. spontaneous ventilation, as a key airway technique during the crucial open airway phase during tracheal reconstruction.

Background: Non-intubated video-assisted thoracic surgery (NiVATS) has been introduced to surgical medicine in order to reduce the invasiveness of anesthetic procedures and avoid adverse effects of intubation and one-lung ventilation (OLV). The aim of this study is to determine the time effectiveness of a NiVATS program compared to conventional OLV. Methods: This retrospective analysis included all patients in Leipzig University Hospital that needed minor VATS surgery between November 2016 and October 2019 constituting a NiVATS (n = 67) and an OLV (n = 36) group. Perioperative data was matched via propensity score analysis, identifying two comparable groups with 23 patients. Matched pairs were compared via t-Test. Results: Patients in NiVATS and OLV group show no significant differences other than the type of surgical procedure performed. Wedge resection was performed significantly more often under NiVATS conditions than with OLV (p = 0,043). Recovery time was significantly reduced by 7 min (p = 0,000) in the NiVATS group. There was no significant difference in the time for induction of anesthesia, duration of surgical procedure or overall procedural time. Conclusions: Recovery time was significantly shorter in NiVATS, but this effect disappeared when extrapolated to total procedural time. Even during the implementation phase of NiVATS programs, no extension of procedural times occurs. [ABSTRACT FROM AUTHOR]

Pneumopericardium is a rare complication of a blunt thoracic trauma. It is defined as the presence of air in the pericardial sac. There are just a few cases described in the literature.This article brings pneumopericardium to light, reinforcing the importance of considering it within the blunt chest trauma and remarking its management with a careful monitoring for the patients whose stable or even asymptomatic with spontaneous ventilation because of the risk of tension pneumopericardium and cardiac arrest.Diagnosis is often difficult, and it can be life-threatening by the occurrence of gas tamponade.We report the case of a 48 years old patient victim of a severe traumatism with pneumothorax and pneumopericardium; he was stable with spontaneous ventilation.

While spontaneous ventilation (SV) anesthesia is in use for clinical patients, there is still little systematic experimental research into its basic aspects. The rabbit SV model that we established previously has some limitations including the model being too small, differences in anesthetic drugs and anesthesia procedures, so we set out to establish an SV anesthesia model for beagle dogs.•Single lumen tracheal intubation was performed on beagles connecting a ventilator, and the anesthetic dosage was adjusted for spontaneous ventilation before surgery.•5 mL of 1 % lidocaine was applied as a local infiltration anesthesia at the surgical incision.•After thoracotomy, 5 mL of 1% lidocaine was sprayed onto the surface of the lungs and a T3-T7 intercostal nerve block (1:1 2 % lidocaine:0.75 % ropivacaine) was performed., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier B.V.)

Background and Aims: The Supreme laryngeal mask airway (SLMA) and the laryngeal tube suction-disposable (LTS-D), both second-generation supraglottic airway devices, have a record of efficiency when used for airway management in mechanically ventilated patients, during general anesthesia. There is no published data comparing these two devices in patients breathing spontaneously during general anesthesia. Material and Methods: Eighty patients with normal airways undergoing elective general anesthesia with spontaneous ventilation were randomized to airway management with a SLMA or LTS-D. Efficacy and adequacy of oxygenation and ventilation were compared. Results: No cases of desaturation of oxygen saturation (SpO2) values of less than 95% occurred with either device. The mean difference for SpO2between the two devices (0.7%) has no clinical significance. Slight hypercapnia was noted with both devices to acceptable values during spontaneous ventilation. Conclusions: Both SLMA and LTS-D are suitable and effective for airway management in patients breathing spontaneously during general anesthesia for minor surgery of short duration.

Mediastinal masses have been associated with fatal airway obstruction and cardiovascular collapse during the induction of anesthesia. Since the 1970s, the knowledge base and management techniques have improved, however, perioperative complications are estimated to occur during 9% to 20% of anesthetic procedures in patients with mediastinal masses. 1 This article describes a case in which a patient with an anterior mediastinal mass required anesthesia for a thoracic magnetic resonance imaging (MRI). In addition, the scientific evidence is examined to identify the best anesthetic techniques in order to provide the safest care to this patient population. [ABSTRACT FROM AUTHOR]

The objective for the present study was to compare the collapsibility (IcIVC) and distensibility (IdIVC) indices of the inferior vena cava with pulse pressure variation (PPV) and determine the accuracy and cutoff points of IcIVC and IdIVC that best predict response to intravenous fluid therapy in surgical patients. Observational, prospective, nonblinded, single center. Hospital do Servidor Público Estadual de São Paulo, in São Paulo, Brazil. Volunteer surgical patients. This prospective study evaluated adult surgical patients before and after they underwent mechanical ventilation. IcIVC and IdIVC measurements were obtained with echocardiography and PPV through arterial catheterization. Twenty-two patients with a mean age of 55.7 ± 10.9 years were included; 31.8% of the study participants had PPV values >13% and were shown to be responsive to fluid. A good correlation was detected between PPV and icIVC (R2 = 0.71; p < 0.001) and between PPV and idIVC (R2 = 0.79; p < 0.001). The area under the receiver operating characteristic curve was 0.98 for icIVC (95% confidence interval 0.81-0.99; p < 0.001) and 0.88 for idIVC (95% confidence interval 0.67-0.98; p < 0.001). PPV was found to have good correlation with the inferior vena cava diameter variation using echocardiography in surgical patients undergoing spontaneous and artificial ventilation. The cutoff values that best predicted PPV >13% were >40% for icIVC and >17.6% for idIVC. [ABSTRACT FROM AUTHOR]

Introduction: Children with an anterior mediastinal mass (AMM) need general anaesthesia (GA) or deep sedation for diagnostic procedures more often than adult patients. Anaesthetic management to prevent such complications includes maintenance of spontaneous ventilation (SV) and prebiopsy corticosteroids/radiotherapy.Methods: We reviewed the medical records of children with AMM who were brought to the operating theatre for diagnostic procedures (prior to chemotherapy) between 2001 and 2013. Our aim was to describe the clinical features, radiological findings and anaesthetic management, as well as determine any association with complications.Results: 25 patients (age range 10 months-14 years) were identified during the study period. Corticosteroid therapy was started before the biopsy for one patient. All 25 patients had GA/sedation. A senior paediatric anaesthesiologist was involved in all procedures. Among 13 high-risk patients, SV was maintained in 11 (84.6%) patients, ketamine was used as the main anaesthetic in 8 (61.5%) patients, 6 (46.2%) patients were in a sitting position and no airway adjunct was used for 7 (53.8%) patients. There were 3 (12.0%) minor complications.Conclusion: Based on our results, we propose a simplified workflow, wherein airway compression of any degree is considered high risk. For patients with high-risk features, multidisciplinary input should be sought to decide whether the child would be fit for a procedure under GA/sedation or considered unfit for any procedure. Recommendations include the use of less invasive methods, involving experienced anaesthesiologists to plan the anaesthetic technique and maintaining SV. [ABSTRACT FROM AUTHOR]

Background: Mechanical ventilation (MV), compared to spontaneous breathing (SB), has been found to increase abdominal edema and inflammation in experimental sepsis. Our hypothesis was that in primary acute respiratory distress syndrome (ARDS) MV would enhance inflammation and edema in the abdomen.Methods: Thirteen piglets were randomized into two groups (SB and MV) after the induction of ARDS by lung lavage and 1 h of injurious ventilation. 1. SB: continuous positive airway pressure 15 cmH2O, fraction of inspired oxygen (FIO2) 0.5 and respiratory rate (RR) maintained at about 40 cycles min- 1 by titrating remifentanil infusion. 2. MV: volume control, tidal volume 6 ml kg- 1, positive end-expiratory pressure 15 cmH2O, RR 40 cycles min- 1, FIO2 0.5.Main Outcomes: abdominal edema, assessed by tissues histopathology and wet-dry weight; abdominal inflammation, assessed by cytokine concentration in tissues, blood and ascites, and tissue histopathology.Results: The groups did not show significant differences in hemodynamic or respiratory parameters. Moreover, edema and inflammation in the abdominal organs were similar. However, blood IL6 increased in the MV group in all vascular beds (p < 0.001). In addition, TNFα ratio in blood increased through the lungs in MV group (+ 26% ± 3) but decreased in the SB group (- 17% ± 3).Conclusions: There were no differences between the MV and SB group for abdominal edema or inflammation. However, the systemic increase in IL6 and the TNFα increase through the lungs suggest that MV, in this model, was harmful to the lungs. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide It remains unclear whether non-intubated video-assisted thoracoscopic surgery (VATS) is comparable or advantageous compared with conventional intubated VATS. Thus, we systematically assessed the feasibility and safety of non-intubated VATS compared with intubated VATS perioperatively for the treatment of different thoracic diseases. An extensive search of literature databases was conducted. Perioperative outcomes were compared between 2 types of operations. The time trend of the overall results was evaluated through a cumulative meta-analysis. Subgroup analyses of different thoracic diseases and study types were examined. Twenty-seven studies including 2537 patients were included in the analysis. A total of 1283 patients underwent non-intubated VATS; intubated VATS was performed on the other 1254 patients. Overall, the non-intubated VATS group had fewer postoperative overall complications [odds ratios (OR) 0.505; P  < 0.001]; shorter postoperative fasting times [standardized mean difference (SMD) −2.653; P  < 0.001]; shorter hospital stays (SMD −0.581; P  < 0.001); shorter operative times (SMD −0.174; P  = 0.041); shorter anaesthesia times (SMD −0.710; P  < 0.001) and a lower mortality rate (OR 0.123; P  = 0.020). Non-intubated VATS may be a safe and feasible alternative to intubated VATS and provide a more rapid postoperative rehabilitation time than conventional intubated VATS. [ABSTRACT FROM AUTHOR]

Nos dias atuais, exames de ecocardiografia transesofágica (ETE) são realizados de forma frequente sob sedação em regime ambulatorial. A sedação está relacionada com aumento de intercorrências nas vias aéreas. Dentro desse contexto, desenvolvemos uma cânula orofaríngea de duplo‐lúmen com finalidade de manutenção da via aérea pérvia, reduzindo riscos aos pacientes durante procedimentos endoscópicos sob sedação. O principal objetivo do nosso estudo foi avaliar a incidência de dessaturação em uma série de casos de pacientes adultos submetidos a ETE ambulatorial sob sedação com o uso da cânula orofaríngea. Foram avaliados 30 pacientes sedados com midazolam e propofol intravenoso. A cânula foi inserida após perda da consciência e os pacientes foram mantidos com ventilação espontânea. Analisados saturação de oxigênio, capnometria, frequência cardíaca e pressão arterial não invasiva, além de dados subjetivos: patência das vias aéreas, manuseio e inserção da cânula e conforto ao examinador. A incidência de dessaturação leve foi de 23.3% e não houve dessaturação grave em nenhum caso. A inserção da cânula orotraqueal foi considerada fácil em 29 pacientes (96,6%) e o manuseio da sonda de ETE foi adequada em 93,33% dos exames realizados. A realização dos exames de ETE sob sedação com auxílio da cânula orofaríngea de duplo lúmen apresentou baixa incidência de dessaturação nos pacientes avaliados, além de permitir análise do CO 2 expirado durante a realização dos exames. Currently, transesophageal echodopplercardiography (TEE) is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient TEE exam, under sedation and using the oropharyngeal cannula. Thirty patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non‐invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion, and comfort of examiner were analyzed. The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and TEE probe handling was appropriate in 93.33% of exams performed. TEE exams under sedation aided by the double‐lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO 2 during the exams. [ABSTRACT FROM AUTHOR]

Introduction Tracheobronchial foreign body aspiration is a common life-threatening condition in children. There are controversies in the management of this condition, including the type of ventilation during bronchoscopy. This study aims to compare anesthesia with controlled ventilation versus spontaneous ventilation in rigid bronchoscopy in children with foreign body aspiration. Materials and Methods: Patients who were candidates for rigid bronchoscopy due to foreign body aspiration were randomly assigned to either anesthesia with spontaneous ventilation or controlled ventilation. End tidal CO2 (ETCO2), electrocardiogram (ECG), heart rate (HR), oxygen saturation (SpO2), non-invasive blood pressure (NIBP) and complications and accidents during the surgery and recovery were recorded for each patient. Surgeon comfort during the procedure was also evaluated for each patient. A 20% change in HR or NIBP was considered significant. SpO2 values under 90% are considered desaturation. Results: Fifty-one patients (31 male and 20 female) entered the study. The mean age was 26.76 months, ranging from 6 to 100 months. Choking and cough were present in 94% and 96.1% of the patients, respectively. Nuts were the most common foreign body (76.9%). The controlled ventilation group had significantly fewer complications, and surgeon comfort was significantly higher in this group. Oxygen desaturation was significantly more prevalent in the spontaneous ventilation group during laryngoscopy and bronchoscopy (P