Remote Ischemic Preconditioning Decreases Oxidative Lung Damage After Pulmonary Lobectomy: A Single-Center Randomized, Double-Blind, Controlled Trial.

BACKGROUND: During lobectomy in patients with lung cancer, the operated lung is often collapsed and hypoperfused. Ischemia/reperfusion injury may then occur when the lung is re-expanded. We hypothesized that remote ischemic preconditioning (RIPC) would decrease oxidative lung damage and improve gas exchange in the postoperative period. METHODS: We conducted a single-center, randomized, double-blind trial in patients with nonsmall cell lung cancer undergoing elective lung lobectomy. Fifty-three patients were randomized to receive limb RIPC immediately after anesthesia induction (3 cycles: 5 minutes ischemia/5 minutes reperfusion induced by an ischemia cuff applied on the thigh) and/or control therapy without RIPC. Oxidative stress markers were measured in exhaled breath condensate (EBC) and arterial blood immediately after anesthesia induction and before RIPC and surgery (T0, baseline); during operated lung collapse, immediately before resuming two-lung ventilation (TLV) (T1); immediately after resuming TLV (T2); and 120 minutes after resuming TLV (T3). The primary outcome was 8-isoprostane levels in EBC at T1, T2, and T3. Secondary outcomes included the following: NO2+NO3, H2O2 levels, and pH in EBC and in blood (8-isoprostane, NO2+NO3) and pulmonary gas exchange variables (PaO2/FiO2, A-aDO2, a/A ratio, and respiratory index). RESULTS: Patients subjected to RIPC had lower EBC 8-isoprostane levels when compared with controls at T1, T2, and T3 (differences between means and 95% confidence intervals): -15.3 (5.8-24.8), P = .002; -20.0 (5.5-34.5), P = .008; and -10.4 (2.5-18.3), P = .011, respectively. In the RIPC group, EBC NO2+NO3 and H2O2 levels were also lower than in controls at T2 and T1-T3, respectively (all P < .05). Blood levels of 8-isoprostane and NO2+NO3 were lower in the RIPC group at T2 (P < .05). The RIPC group had better PaO2/FiO2 compared with controls at 2 hours, 8 hours, and 24 hours after lobectomy in 95% confidence intervals for differences between means: 78 (10-146), 66 (14-118), and 58 (12-104), respectively. CONCLUSIONS: Limb RIPC decreased EBC 8-isoprostane levels and other oxidative lung injury markers during lung lobectomy. RIPC also improved postoperative gas exchange as measured by PaO2/FiO2 ratio.

Oxidative lung injury correlates with one-lung ventilation time during pulmonary lobectomy: a study of exhaled breath condensate and blood.

OBJECTIVES: During lung lobectomy, the operated lung is collapsed and hypoperfused; oxygen deprivation is accompanied by reactive hypoxic pulmonary vasoconstriction. After lung lobectomy, ischaemia present in the collapsed state is followed by expansion-reperfusion and lung injury attributed to the production of reactive oxygen species. The primary objective of this study was to investigate the time course of several markers of oxidative stress simultaneously in exhaled breath condensate and blood and to determine the relationship between oxidative stress and one-lung ventilation time in patients undergoing lung lobectomy. METHODS: This single-centre, observational, prospective study included 28 patients with non-small-cell lung cancer who underwent lung lobectomy. We measured the levels of hydrogen peroxide, 8-iso-PGF2α, nitrites plus nitrates and pH in exhaled breath condensate (n = 25). The levels of 8-iso-PGF2α and nitrites plus nitrates were also measured in blood (n = 28). Blood samples and exhaled breath condensate samples were collected from all patients at five time points: preoperatively; during one-lung ventilation, immediately before resuming two-lung ventilation; immediately after resuming two-lung ventilation; 60 min after resuming two-lung ventilation and 180 min after resuming two-lung ventilation. RESULTS: Both exhaled breath condensate and blood exhibited significant and simultaneous increases in oxidative-stress markers immediately before two-lung ventilation was resumed. However, all these values underwent larger increases immediately after resuming two-lung ventilation. In both exhaled breath condensate and blood, marker levels significantly and directly correlated with the duration of one-lung ventilation immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation. Although pH significantly decreased in exhaled breath condensate immediately after resuming two-lung ventilation, these pH values were inversely correlated with the duration of one-lung ventilation. CONCLUSIONS: During lung lobectomy, the operated lung is collapsed and oxidative injury occurs, with the levels of markers of oxidative stress increasing simultaneously in exhaled breath condensate and blood during one-lung ventilation. These increases were larger after resuming two-lung ventilation. Increases immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation were directly correlated with the duration of one-lung ventilation.

Single-staged laryngotracheal reconstruction for idiopathic tracheal stenosis.

BACKGROUND: This study retrospectively evaluated the results of surgically treated idiopathic tracheal stenosis. METHODS: Of the 220 patients surgically treated for idiopathic subglottic and tracheal stenosis in the participating hospitals, we reviewed the surgical records of all patients with idiopathic tracheal stenosis. This subgroup required resection of all of the involved mucosa but frequently had undergone more conservative treatments that damaged the tracheal mucosa and cartilage and complicated the definitive surgical treatment. RESULTS: During the study period, 60 women (93.8%) and 4 men (6.2%), who were a mean age of 50 years (range, 19 to 77 years), were surgically treated for idiopathic tracheal stenosis, with no operative deaths. Of these 64 patients, 38 (59.3%) had undergone previous treatments in other centers: dilation, 26 (40.6%); laser only, 19 (31%); laser plus tracheal prosthesis, 5 (7.8%); tracheostomy, 7 (11.6%); T tube, 2 (3%); and laryngotracheal operations, 5 (7.8%). All patients were treated with a single-staged tracheal or laryngotracheal operation, of which 59 (98%) successful. Four of the most complex stenoses, with vocal cords and cricoid plate involvement, underwent reoperation for restenosis or larynx inconsistency. One patient was considered biologically unfit for reoperation and required a permanent T tube for restenosis. Half of the operations were temporary tracheostomies with T tube for larynx modelling. The most frequent postoperative complications were dysphonic voice in 10 patients (although in 7 instances this began months or years before the operation), granulation tissue in 10, aspiration in 3, and wound infections in 2. CONCLUSIONS: Idiopathic stenosis occurred predominantly (90% of cases) in women. Single-staged laryngotracheal correction was successful in 97%. Technique selection, with or without temporary laryngeal stenting, must be individualized with respect to the vocal cords' mobility, function, and distance from the stenosis.

Surgical management of benign tracheal stenosis.

This chapter provides a step-by-step explanation of the indications, basic technique and pitfalls of tracheal surgery for cases of benign tracheal stenosis. Approach, trachea dissection and end-to-end anastomosis in tracheal surgery is described in detail. An algorithm for laryngotracheal technique selection according to different criteria (stenosis location, vocal cords status and tracheal mucosa and/or cartilaginous larynx involvement) is also depicted. Finally, a review of the most important reported series in tracheal surgery is presented.

Infección tórpida sobre pulmón poliquístico / Torpid infection on a polycystic lung

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