Early nasal high-flow versus Venturi mask oxygen therapy after lung resection: a randomized trial.

BACKGROUND: Data on high-flow nasal oxygen after thoracic surgery are limited and confined to the comparison with low-flow oxygen. Different from low-flow oxygen, Venturi masks provide higher gas flow at a predetermined fraction of inspired oxygen (FiO2). We conducted a randomized trial to determine whether preemptive high-flow nasal oxygen reduces the incidence of postoperative hypoxemia after lung resection, as compared to Venturi mask oxygen therapy. METHODS: In this single-center, randomized trial conducted in a teaching hospital in Italy, consecutive adult patients undergoing thoracotomic lung resection, who were not on long-term oxygen therapy, were randomly assigned to receive high-flow nasal or Venturi mask oxygen after extubation continuously for two postoperative days. The primary outcome was the incidence of postoperative hypoxemia (i.e., ratio of the partial pressure of arterial oxygen to FiO2 (PaO2/FiO2) lower than 300 mmHg) within four postoperative days. RESULTS: Between September 2015 and April 2018, 96 patients were enrolled; 95 patients were analyzed (47 in high-flow group and 48 in Venturi mask group). In both groups, 38 patients (81% in the high-flow group and 79% in the Venturi mask group) developed postoperative hypoxemia, with an unadjusted odds ratio (OR) for the high-flow group of 1.11 [95% confidence interval (CI) 0.41-3] (p = 0.84). No inter-group differences were found in the degree of dyspnea nor in the proportion of patients needing oxygen therapy after treatment discontinuation (OR 1.34 [95% CI 0.60-3]), experiencing pulmonary complications (OR 1.29 [95% CI 0.51-3.25]) or requiring ventilatory support (OR 0.67 [95% CI 0.11-4.18]). Post hoc analyses revealed that PaO2/FiO2 during the study was not different between groups (p = 0.92), but patients receiving high-flow nasal oxygen had lower arterial pressure of carbon dioxide, with a mean inter-group difference of 2 mmHg [95% CI 0.5-3.4] (p = 0.009), and were burdened by a lower risk of postoperative hypercapnia (adjusted OR 0.18 [95% CI 0.06-0.54], p = 0.002). CONCLUSIONS: When compared to Venturi mask after thoracotomic lung resection, preemptive high-flow nasal oxygen did not reduce the incidence of postoperative hypoxemia nor improved other analyzed outcomes. Further adequately powered investigations in this setting are warranted to establish whether high-flow nasal oxygen may yield clinical benefit on carbon dioxide clearance. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02544477 . Registered 9 September 2015.

Learning curve of uniportal video-assisted lobectomy: analysis of 15-month experience in a single center.

BACKGROUND: Uniportal video-assisted thoracoscopic (U-VATS) lobectomy has been becoming the technique of choice in an increasing number of centers. The aim of our study was to review our experience, evaluating the learning curve of U-VATS for lung lobectomy and outcomes. METHODS: The prospectively collected clinical data of 43 consecutive patients, undergone U-VATS lobectomy from June 2016 to September 2017, were reviewed. The cumulative sum analysis was applied for defining the completion of learning curve (CLC), evaluating the relationship between operative time and the consecutive number of operations. RESULTS: The mean operative time of Uniportal VATS lobectomy was 179.93±43.41 min. According to the cumulative sum analysis, the CLC was reached after 25 patients. Using the cut-off of 25 patients, the whole populations was divided in group A (first 25 patients of the experience) and group B (the last 18 patients). The mean operative time in group B was significantly shorter than in group A (164.00±24.46 vs. 191.40±50.45 min, respectively, P=0.04). There were no differences in demographic characteristics, number of removed lymph nodes, chest tube duration, and hospital stay among the two groups. The number of conversions was higher in group A (4 vs. 0; P=0.07), as the number of major complications, like reoperations for bleeding (2 vs. 0; P=0.22). There was no postoperative 30-day-related death. CONCLUSIONS: U-VATS lobectomy seems to be a quite safe and feasible procedure, with a steep learning curve and low complication rate, if performed by experienced surgeons after proper training.

Unusual airways management during one-lung ventilation in thoracic surgery.

Airways management in thoracic surgery is usually more difficult than in other surgery. We reported a case of a patient who underwent surgery of evacuation of empyema where after a correct insertion of a left double-lumen tube 37 Fr (DLT), one-lung ventilation was not permitted by the high airways pressure. In fact, the hole of bronchial tip was just against the left bronchial wall retracted probably from inflammatory process. We introduced blindly an Arndt blocker 9 Fr inside the tracheal lumen of DLT until the orifice of the right upper lobe bronchus, the distance was checked before. After the positioning of the blocker, the DLT was pulled up to above the carina, and the single-lung ventilation was permitted. Sometimes, an unusual use of different devices permits to manage complications. In fact, in this case, the Arndt bronchial blocker helps us to solve an important ventilatory problem.

Dreams recall and auditory evoked potentials during propofol anaesthesia.

It is unclear whether shorter wave latencies of middle-latency-auditory-evoked-potentials may be associated to cognitive function other than nondeclarative memory. We investigated the presence of declarative, nondeclarative and dreaming memory in propofol-anaesthetized patients and any relationship to intraoperatively registered middle-latency-auditory-evoked-potentials. An audiotape containing one of two stories was presented to patients during anaesthesia. Patients were interviewed on dream recall immediately upon emergence from anaesthesia. Declarative and nondeclarative memories for intraoperative listening were assessed 24 h after awakening without pointing out positive findings. Six patients who reported dream recall showed an intraoperative Pa latency less than that of patients who were unable to remember any dreams (P<0.001). A high responsiveness degree of primary cortex was associated to dream recall formation during anaesthesia.

Preoperative anesthetic evaluation and preparation in patients requiring esophageal surgery for cancer.

Esophagectomy for carcinoma of the esophagus is associated with significant mortality and morbidity. Patients with esophageal cancer have frequently obstruction with dysphagia and they often develop malnutrition. In addition, patients can suffer from chronic aspiration leading to a poor preoperative respiratory status. Thorough preoperative evaluation is essential for assessing the operative risk in the individual patient. Respiratory and cardiac problems are the most common complications and assessment of surgical risk, preoperative performance status, particularly with regard to pulmonary and cardiac risk, is likely to be the most important factor. Clinical findings are more predictive of pulmonary complications than results of testing. Cardiac risk is evaluated according to the American College of Cardiology (ACC)/American Heart Association guidelines. With the identification of risk factors, patients undergoing esophageal surgery could be stratified. Appropriate preoperative risk-reduction strategies can be used to decrease morbidity and mortality rates associated with esophagectomy for cancer.