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Background: It is uncertain whether protective ventilation reduces ventilation-induced pulmonary inflammation and injury during one-lung ventilation., Objective: To compare intra-operative protective ventilation with conventional during oesophagectomy with respect to pulmonary levels of biomarkers for inflammation and lung injury., Design: Randomised clinical trial., Setting: Tertiary centre for oesophageal diseases., Patients: Twenty-nine patients scheduled for one-lung ventilation during oesophagectomy., Interventions: Low tidal volume (VT) of 6 ml kg predicted body weight (pbw) during two-lung ventilation and 3 ml kgpbw during one-lung ventilation with 5 cmH2O positive end expired pressure versus intermediate VT of 10 ml kgpbw during two-lung ventilation and 5 ml kgpbw body weight during one-lung ventilation with no positive end-expiratory pressure., Outcome Measures: The primary outcome was the change in bronchoalveolar lavage (BAL) levels of preselected biomarkers for inflammation (TNF-α, IL-6 and IL-8) and lung injury (soluble Receptor for Advanced Glycation End-products, surfactant protein-D, Clara Cell protein 16 and Krebs von den Lungen 6), from start to end of ventilation., Results: Median [IQR] VT in the protective ventilation group (n = 13) was 6.0 [5.7 to 7.8] and 3.1 [3.0 to 3.6] ml kgpbw during two and one-lung ventilation; VT in the conventional ventilation group (n = 16) was 9.8 [7.0 to 10.1] and 5.2 [5.0 to 5.5] ml kgpbw during two and one-lung ventilation. BAL levels of biomarkers for inflammation increased from start to end of ventilation in both groups; levels of soluble Receptor for Advanced Glycation End-products, Clara Cell protein 16 and Krebs von den Lungen 6 did not change, while levels of surfactant protein-D decreased. Changes in BAL biomarkers levels were not significantly different between the two ventilation strategies., Conclusion: Intra-operative protective ventilation compared with conventional ventilation does not affect changes in pulmonary levels of biomarkers for inflammation and lung injury in patients undergoing one-lung ventilation for oesophagectomy., Trial Registration: The 'Low versus Conventional tidal volumes during one-lung ventilation for minimally invasive oesophagectomy trial' (LoCo) was registered at the Netherlands Trial Register (study identifier NTR 4391).

Background: Double-lumen tubes (DLT) and endobronchial blockers (EB) are used for one-lung ventilation in thoracic surgery. More complications are seen when using DLT when compared to EB, while major complications are rarely seen., Case: This case report describes a perforation of the right mainstem bronchus by an EZ-Blocker EB in a patient undergoing a minimally invasive esophagectomy after neoadjuvant chemoradiation., Conclusions: We advise to insert an EZ-BlockerTM EB with caution and only under direct bronchoscopic visualization, especially in previous irradiated patients.

Background: Pain is a common problem for critically ill patients treated in the intensive care unit (ICU) and can have serious consequences. For this reason, the appropriate recognition and treatment of pain is of extreme importance. However, pain assessment in critically ill patients can be challenging because these patients are often unable to self-report. To identify attitudes and practices regarding the assessment and management of pain in ICU patients unable to self-report, we surveyed all adult ICUs in the Netherlands., Methods: A multicenter, exploratory survey was sent by mail to all adult ICUs in the Netherlands., Results: Eighty-four of 107 ICUs returned the questionnaire for a response rate of 79%. In patients able to self-report, 94% (n = 79; 95% confidence interval [CI], 86.7%-98%) of the ICUs used a standardized pain score. Visual Analog Scale and Numerical Rating Scale were used in 57% (n = 48; 99.3% CI, 41%-72%) and 48% (n = 40; 99.3% CI, 33%-64%), respectively. Nonteaching hospitals used pain assessment tools more often than teaching hospitals (P = 0.012). In patients not able to self-report, pain assessment tools were used in 19% (n = 16) of the ICUs. In the ICUs that used behaviorally based scoring systems, the Critical Care Pain Observation Tool and Behavioral Pain Scale (BPS) were used in 6% (n = 5; 99.5% CI, 1.1%-17%) and 5% (n = 4; 99.5% CI, 0.1%-15%), respectively. Among Dutch nurses, nursing opinion was considered the gold standard assessment in 36% (n = 30; 98.8% CI, 23%-50%) of the respondents, even when a patient was able to self-report and pain scales were used. In patients unable to self-report, nurses judged themselves to be more accurate than a behavioral pain assessment tool in 98% (n = 82; 98.8% CI, 89.7%-99.9%) of the patients., Conclusions: In the Netherlands, most ICUs used a standardized pain score in patients able to self-report. Nonteaching hospitals used pain assessment tools more often than teaching hospitals. In patients unable to self-report, pain is not routinely measured with a validated behavioral pain assessment tool. Almost all nurses in our survey felt that their assessment of patient pain was more accurate than behavioral pain assessment tools in patients unable to self-report. More research is needed to identify factors preventing more widespread acceptance of validated behavioral pain scores in patients unable to self-report.