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This chapter provides an overview of the indications and techniques available for lung isolation in adult patients, using devices currently available in the UK. The double lumenendobronchial tube (DLT), bronchial blocker and an appropriately sized single lumen tracheal tube can all produce lung isolation, if placed in a main stem bronchus. There are two main configurations of bronchial blockers: the blocker is incorporated into a channel in the wall of a tracheal tube as in univent torque control blocker (TCB); and independent catheter as in Arndt Blocker. The independent bronchial blocker catheters can all be positioned coaxially down a standard tracheal tube under fiberoptic bronchoscope (FOB) guidance. Complications with the use of bronchial blockers include malposition and displacement resulting in life-threatening airway obstruction and hypoxia. Single lumen tracheal tubes, standard DLTs and bronchial blockers have all been used to provide lung isolation in patients with tracheostomy.
Rigid bronchoscopy (RB) was a necessary art of assessment of fitness for lung resection surgery and placing lung separator devices (LSD). For RB, general anesthesia is the norm. For short procedures a propofol and opioid supplemented induction is a usual regimen, followed by a short-acting non-depolarizing agent such as mivacurium. Manufacturers of positive pressure ventilation equipment pay little attention to the needs of patient ventilation during operation of their devices. Intrinsic and extrinsic lesions of the trachea can present as life-threatening emergencies. The erosion of a major vessel in the bronchial tree occasionally results in unstoppable hemoptysis. With much of the cardiac output coming up an RB, it is impossible to do anything to intervene. The advent of self-expanding devices has considerably eased the burden of sharing access to the airway with surgeons or physicians.
Esophagectomy is commonly performed for cancer of the esophagus and gastric cardia. The surgical approach to esophagectomy depends on several factors: anatomic location of tumor; preferred method of reconstruction: transposed stomach, interposed colon, pedicled jejunum; and location of the esophageal-enteric anastomosis. Conventional esophagectomy requires either a laparotomy with a trans-hiatal dissection or laparotomy combined with thoracotomy. A trans-hiatal approach is the most commonly performed operation for esophageal cancer resection. Evidence of chronic pulmonary disease, the ability to stand one-lung anesthesia and the likelihood of post-operative pulmonary complications may be predicted with the aid of the lung function test and cardiopulmonary exercise testing. The spectrum of gastro-esophageal reflux disease (GERD) involves the gastrointestinal and pulmonary organ systems. There is an association between GERD and end-stage lung disease, especially idiopathic pulmonary fibrosis (IPF). The presence of GERD may predispose to the development of bronchiolitis obliterans following lung transplantation.
Providing an easily readable source of information about the current spectrum of anesthesia and critical care management of patients undergoing thoracic surgery, this book forms part of the successful Core Topics brand. The book provides practical assistance to those commencing careers in thoracic anesthesia and will also to be a useful aide-memoire to those already working in the field. The comprehensive content includes discussion of some of the more contentious issues in the management of thoracic patients as well as giving a flavour of the rapid evolution of new techniques that are of increasing importance in the field, such as lung-assist devices, different modes of ventilation and VAT surgery. Both editors are practising cardiothoracic anesthetists/intensivists at an internationally recognized centre for thoracic surgery, particularly lung transplantation. The contributors are chosen for their clinical expertise and to give a spectrum of opinion across the range of thoracic anesthesia.
Thoracic surgery ranges from small low-risk procedures to major surgery, and for malignant and non-malignant disease. Assessment of the thoracic patient for surgery comprises two distinct areas. The first is the resectability of the lesion if malignant and the second is the fitness to withstand the morbidity it inevitably involves, referred to as operability by most surgeons. Lung function tests described in the chapter include spirometry, gas transfer capacity, functional tests, and arterial blood gas analysis. Sensitivity for detecting small lesions is reasonable but not as high as computerized tomography (CT) scans but the radiation exposure is very low and the investigation is widely available. In general, the resolution of the magnetic resonance imaging (MRI) scan is not superior to the CT scan and it is no better at confirming the presence or absence of invasion than CT scanning.
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