Cardiorespiratory impact of intrathoracic pressure overshoot during artificial carbon dioxide pneumothorax: a randomized controlled study.

BACKGROUND: The aim of this study is to evaluate cardiovascular and respiratory effects of intrathoracic pressure overshoot (higher than insufflation pressure) in patients who underwent thoracoscopic esophagectomy procedures with carbon dioxide (CO2) pneumothorax. METHODS: This prospective research included 200 patients who were scheduled for esophagectomy from August 2016 to July 2020. The patients were randomly divided into the Stryker insufflator (STR) group and the Storz insufflator (STO) group. We recorded the changes of intrathoracic pressure, peak airway pressure, blood pressure, heart rate and central venous pressure (CVP) during artificial pneumothorax. The differences in blood gas analysis, the administration of vasopressors and the recovery time were compared between the two groups. RESULTS: We found that during the artificial pneumothorax, intrathoracic pressure overshoot occurred in both the STR group (8.9 mmHg, 38 times per hour) and the STO group (9.8 mmHg, 32 times per hour). The recorded maximum intrathoracic pressures were up to 58 mmHg in the STR group and 51 mmHg in the STO group. The average duration of intrathoracic pressure overshoot was significantly longer in the STR group (5.3 ± 0.86 s) vs. the STO group (1.2 ± 0.31 s, P < 0.01). During intrathoracic pressure overshoot, a greater reduction in systolic blood pressure (SBP) (5.6 mmHg vs. 1.1 mmHg, P < 0.01), a higher elevation in airway peak pressure (4.8 ± 1.17 cmH2O vs. 0.9 ± 0.41 cmH2O, P < 0.01), and a larger increase in CVP (8.2 ± 2.86 cmH2O vs. 4.9 ± 2.35 cmH2O, P < 0.01) were observed in the STR group than in the STO group. Vasopressors were also applied more frequently in the STR group than in the STO group (68% vs. 43%, P < 0.01). The reduction of SBP caused by thoracic pressure overshoot was significantly correlated with the duration of overshoot (R = 0.76). No obvious correlation was found between the SBP reduction and the maximum pressure overshoot. CONCLUSIONS: Intrathoracic pressure overshoot can occur during thoracoscopic surgery with artificial CO2 pneumothorax and may lead to cardiovascular adverse effects which highly depends on the duration of the pressure overshoot. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02330536 ; December 24, 2014).

Extraluminal Placement of a Bronchial Blocker Compared with Carbon Dioxide Artificial Pneumothorax in Infants Undergoing Video-Assisted Thoracoscopic Surgery.

OBJECTIVE: To investigate the safety and effectiveness of extraluminal placement of a bronchial blocker compared with carbon dioxide (CO2) artificial pneumothorax in infants undergoing video-assisted thoracoscopic surgery (VATS). METHODS: The study involved 33 infants (group A) who underwent one-lung ventilation (OLV) with extraluminal placement of a bronchial blocker and 35 other infants (group B) who underwent CO2 artificial pneumothorax. Clinical characteristics, the degree of lung collapse, and complications were compared. RESULTS: The degree of lung collapse in group A was significantly higher than that in group B at T2 and T3. The mean arterial pressure (MAP) of group B was significantly lower than that of group A at 10 min and 30 min after OLV. The partial pressure of carbon dioxide (PaCO2) of group B was significantly higher than that of group A at 30 min after OLV. The incidence of hypotension in group B was higher than that in group A. CONCLUSION: Compared with CO2 artificial pneumothorax, extraluminal placement of a bronchial blocker is associated with a better degree of lung collapse, fewer episodes of hypotension, and lower PaCO2 accumulation during OLV in infants undergoing VATS.

Application of Right Bronchial Occlusion under Artificial Pneumothorax in the Thoracic Phase of Minimally Invasive McKeown Esophagectomy.

PURPOSE: To evaluate the feasibility and safety of single-lumen endotracheal intubation combined with right bronchial occlusion (SLET) under artificial pneumothorax in minimally invasive McKeown esophagectomy. METHODS: A total of 165 patients who underwent minimally invasive McKeown esophagectomy at Peking Union Medical College Hospital were retrospectively analyzed. In all, 48 patients received double-lumen endotracheal intubation (DLET group), and 117 patients received SLET-B (SLET-B group). Clinical data, intraoperative hemodynamics, surgical variables, and postoperative complications were analyzed and compared. RESULTS: Compared with the DLET group, a shorter intubation time and lower tube dislocation rate were found in the SLET-B group. In the thoracic phase, with the application of artificial pneumothorax, patients in the SLET-B group had lower partial pressure of carbon dioxide (PaCO2) and end-tidal carbon dioxide pressure (PetCO2) values and higher pH than those in the DLET group. Patients in the SLET-B group had shorter thoracic phase times and hospital stays and less intraoperative hemorrhage than those in the DLET group. The numbers of thoracic and bilateral recurrent laryngeal lymph nodes harvested were significantly higher in the SLET-B group. CONCLUSION: SLET under artificial pneumothorax is feasible and safe in minimally invasive McKeown esophagectomy.

CO2 artificial pneumothorax on coagulation and fibrinolysis during thoracoscopic esophagectomy.

BACKGROUND: CO2 artificial pneumothorax creates a sufficient operative field for thoracoscopic esophagectomy. However, it has potential complications and continuous CO2 insufflation may impede coagulation and fibrinolysis. We sought to compare the effects of CO2 artificial pneumothorax on perioperative coagulation and fibrinolysis during thoracoscopic esophagectomy. METHODS: We investigated patients who underwent thoracoscopic esophagectomy with (group P, n = 24) or without CO2 artificial pneumothorax (group N, n = 24). The following parameters of coagulation-fibrinolysis function: intraoperative bleeding volume; serum levels of tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), thromboelastogram (TEG), D-Dimer; and arterial blood gas levels were compared with two groups. RESULTS: Group P showed higher levels of PaCO2, reaction time (R) value and kinetics (K) value, but significantly lower pH value, alpha (α) angle and Maximum Amplitude (MA) value at 60 minutes after the initiation of CO2 artificial pneumothorax than group N ((P < .05, all). The t-PA level after CO2 insufflation for 60 minutes was significantly higher in group P than in group N (P < .05), but preoperative levels were gradually restored on cessation of CO2 insufflation for 30 min (P > .05). There was no significant difference in D-dimer. CONCLUSION: CO2 artificial pneumothorax during thoracoscopic esophagectomy had a substantial impact on coagulation and fibrinolysis, inducing significant derangements in pH and PaCO2. TRIAL REGISTRATION: The study was registered at the Chinese clinical trial registry (ChiCTR1800019004).

[Robot-assisted Lobectomy under Port-only Mode with Artificial Pneumothorax].

BACKGROUND: Da Vinci robotic system is currently widely used in thoracic surgery. The ports employment and procedures vary in different medical center in China. Usually, a small incision was used for assistant. METHODS: Based on clinical practice, we summarized domestic and foreign experience, combined with the characteristics of the Chinese body anatomy, employ portal technique and artificial pneumothorax, summarized a set of simplified and easier surgical method. RESULTS: Port-only artificial pneumothorax robot-assisted lobectomy has further improvement in anatomical safety, hemostatic effect and aesthetic appearance of the wound. CONCLUSIONS: This study optimizes the procedure of port-only artificial pneumothorax robot-assisted lobectomy in order to serve lung cancer patients better.

Lung Cryobiopsy for the Diagnosis of Interstitial Lung Diseases: A Series Contribution to a Debated Procedure.

Introduction: Transbronchial cryobiopsy is an alternative to surgical biopsy for the diagnosis of fibrosing interstitial lung diseases, although the role of this relatively new method is rather controversial. Aim of this study is to evaluate the diagnostic performance and the safety of transbronchial cryobiopsy in patients with fibrosing interstitial lung disease. Materials and methods: The population in this study included patients with interstitial lung diseases who underwent cryobiopsy from May 2015 to May 2018 at the Division of Pneumology of San Giuseppe Hospital in Milan and who were retrospectively studied. All cryobiopsy procedures were performed under fluoroscopic guidance using a flexible video bronchoscope and an endobronchial blocking system in the operating room with patients under general anaesthesia. The diagnostic performance and safety of the procedure were assessed. The main complications evaluated were endobronchial bleeding and pneumothorax. All cases were studied with a multidisciplinary approach, before and after cryobiopsy. Results: Seventy-three patients were admitted to this study. A specific diagnosis was reached in 64 cases, with a diagnostic sensitivity of 88%; 5 cases (7%) were considered inadequate, 4 cases (5%) were found to be non-diagnostic. Only one major bleeding event occurred (1.4%), while 14 patients (19%) experienced mild/moderate bleeding events while undergoing bronchoscopy; 8 cases of pneumothorax (10.9%) were reported, of which 2 (2.7%) required surgical drainage. Conclusions: When performed under safe conditions and in an experienced center, cryobiopsy is a procedure with limited complications having a high diagnostic yield in fibrotic interstitial lung disease.

Effects of Neonatal Thoracoscopic Surgery on Tissue Oxygenation: A Pilot Study on (Neuro-) Monitoring and Outcomes.

INTRODUCTION: Multiple reports have questioned the feasibility of neonatal thoracoscopic repair of congenital diaphragmatic hernia (CDH) and esophageal atresia (EA). The aim of this study is to examine the effects of CO2 pneumothorax on cerebral and renal rSO2 and to assess the potential predictive value of these data on neurodevelopmental outcome after neonatal thoracoscopic surgery for CDH or EA. MATERIALS AND METHODS: A prospective observational pilot study. Cerebral and renal regional tissue oxyhemoglobine saturation (rSO2) rSO2 were assessed using near-infrared spectroscopy (NIRS) during thoracoscopic surgery in neonates with CDH and with EA, in addition to routine anesthesia monitoring. Cerebral and renal rSO2, linked to repeated arterial blood gas analyses, heart rate, blood pressure, and to structured longitudinal neurodevelopmental follow-up. RESULTS: Baseline estimated marginal means of cerebral rSO2 values (CDH: 82%, EA: 91%) did not change significantly during pneumothorax (CDH: 81%, EA 79% [n.s. versus baseline]) despite severe acidosis (lowest pH, CDH: 6.99, EA: 7.1). Neurodevelopmental outcomes at 24 months were normal in all 7 patients who were available for evaluation. CONCLUSION: Neonatal thoracoscopic repair of CDH and EA using CO2-pneumothorax leads to severe acidosis. Cerebral rSO2 remained within clinical acceptable limits during intraoperative periods of acidosis. Neurodevelopmental outcome was favorable within the first 24 months. The potential of NIRS to further improve perioperative care and long-term outcome in this specific patient group deserves further investigation.

A Case of Massive Cerebral Arterial Air Embolism Induced by Artificial Pneumothorax and Its Analysis.

OBJECTIVE: This study aimed to investigate the characteristics of cerebral arterial air embolism. CLINICAL PRESENTATION AND INTERVENTION: The clinical data of a patient with cerebral arterial air embolism induced during artificial pneumothorax were retrospectively analyzed. The patient needed the induction of artificial pneumothorax for medical thoracoscopy but developed hemiplegia and disturbance of consciousness during the induction. Cerebral arterial air embolism was detected by head computed tomography. CONCLUSION: Artificial pneumothorax may induce cerebral arterial air embolism.

Inflammatory response and long-term behavioral assessment after neonatal CO2-pneumothorax: study in a rodent model.

BACKGROUND: Carbon-dioxide (CO2)-pneumothorax during minimally invasive surgery induces well-known metabolic changes. However, little is known about its impact on the central nervous system. The aim of this work is to evaluate the acute impact of CO2-pneumothorax over central cytokine response and its long-term effect on animal behavior. METHODS: This is an experimental study where neonatal Sprague-Dawley rats are submitted to CO2-pneumothorax. Peripheral and central cytokine response was evaluated 24h after insufflation, and peripheral immune cell phenotyping was evaluated 24h and 4weeks post-insufflation. Progenitor cell survival was evaluated in the hippocampal dentate gyrus, and the behavioral analysis was performed in adulthood to test cognition, anxious-like, and depressive-like behavior. RESULTS: Significantly increased IL-10 levels were observed in the cerebrospinal-fluid (CSF) of animals submitted to CO2-pneumothorax, while no differences were found in serum. Regarding pro-inflammatory cytokines, no differences were observed in the periphery or centrally. CO2-pneumothorax event did not alter the survival of newborn cells in the hippocampal dentate gyrus, and no impact on long-term behavior was observed. CONCLUSIONS: Neonatal animals submitted to CO2-pneumothorax present acutely increased CSF IL-10 levels. The CO2-pneumothorax seems to result in no significant outcome over neurodevelopment as no functional behavioral alterations were observed in adulthood.

Artificial pneumothorax: a safe and simple method to relieve pain during microwave ablation of subpleural lung malignancy.

BACKGROUND: Microwave ablation has been extensively used for eliminating pulmonary tumors; however, it is usually associated with severe pain under local anesthesia. Decreasing the power and shortening the ablation time can help to relieve the pain; however, this leads to incomplete ablation and an increasing recurrence rate. This research aims to employ an artificial pneumothorax to increase both the curative effect and pain relief during the ablation procedure. MATERIAL AND METHODS: From July 2013 to January 2015, nine patients presenting with 10 subpleural lung tumors (age: 44-78 years) with a high possibility of severe pain underwent the artificial pneumothorax during microwave ablation. The pain assessment scores and complications induced by the artificial pneumothorax were recorded and analyzed by a CT scan follow-up. RESULTS: The tumors of the nine patients were eliminated successfully using microwave ablation with artificial pneumothorax under local anesthesia. The pain caused by the ablation was relieved to a great extent with an average rate of 94.66% (range: 63.3%-100%) and all tumors were ablated completely. No severe complications occurred after the operation. CONCLUSIONS: The artificial pneumothorax is a reliable therapy to improve the curative effect of microwave ablation under local anesthesia by relieving the pain of the patients.

Impact of artificial capnothorax on coagulation in patients during video-assisted thoracoscopic esophagectomy for squamous cell carcinoma.

BACKGROUND: Compared with the lung isolation using double-lumen endobronchial tube intubation, the artificial capnothorax using single-lumen endotracheal tube intubation has shown to be a safe, more convenient, and cost-effective procedure for thoracoscopic esophagectomy. However, the impact of capnothorax on coagulation is not well defined. Herein, we evaluate the impact of a capnothorax on coagulation and fibrinolysis in patients who undergoing thoracoscopic esophagectomy. METHODS: Between March 2014 and August 2014, 24 patients underwent thoracoscopic esophagectomies for esophageal cancer with the procedure of artificial capnothorax (group P); we also performed 24 thoracoscopic esophagectomy cases without using capnothorax (group N). The demographics and arterial blood gas, as well as the parameters of coagulation and fibrinolysis, of the two groups were analyzed. RESULTS: The pH value of group P after CO2 insufflation was significantly lower than in group N (P < 0.05), and the partial pressure of carbon dioxide (PaCO2) was significantly increased compared with group N (P < 0.05). The R and K values after CO2 insufflation were significantly longer than before anesthesia (P < 0.05), and both α angle and MA value after CO2 insufflation were significantly lower than those before anesthesia (P < 0.05). No significant differences in R value, K value, α angle, or MA value were observed between pre-anesthesia and termination of capnothorax. No significant difference in LY30 data was found between different groups (P > 0.05). CONCLUSION: Artificial capnothorax in patients receiving endoscopic resection of esophageal carcinoma had a significant impact on coagulation. These patients showed significant impairments in coagulation not observed in patients without artificial capnothorax.

Bolshevik disease and Stalinist terror: on the historical casuistry of artificial pneumothorax.

From its initial development by Carlo Forlanini at the end of the nineteenth century until the advent of antibiotics in the 1940s, artificial pneumothorax was one of the most widely used treatments for pulmonary tuberculosis. However, there were strongly held reservations about this therapy because of its risks and side effects. In the Soviet Union under Stalin, such uncertainties became instruments of political denunciation. The leading Soviet pulmonary physician Volf S. Kholtsman (1886-1941) was alleged to have used the so-called 'aristocratic therapy' of artificial pneumothorax to kill prominent Bolsheviks. Drawing on documents from Stalin's personal Secretariat, this historical study of the pneumothorax scandal contributes to the cultural history of tuberculosis, showing how it was instrumentalised for political purposes.

Purposeful creation of a pneumothorax and chest tube placement to facilitate CT-guided coil localization of lung nodules before video-assisted thoracoscopic surgical wedge resection.

PURPOSE: To evaluate the feasibility and efficacy of pneumothorax creation and chest tube insertion before computed tomography (CT)-guided coil localization of small peripheral lung nodules for video-assisted thoracoscopic surgical (VATS) wedge resection. MATERIALS AND METHODS: From May 2011 to October 2013, 21 consecutive patients (seven men; mean age, 62 y; range, 42-76 y) scheduled for VATS wedge resection required CT-guided coil localization for small, likely nonpalpable peripheral lung lesions at a single institution. Outcomes were evaluated retrospectively for technical success and complications. RESULTS: There were 12 nodules and nine ground-glass opacities. Mean lesion distance from the pleural surface was 15 mm (range, 5-35 mm), and average size was 13 mm (range, 7-30 mm). A pneumothorax was successfully created in all patients with a Veress needle, and a chest tube was inserted. All target lesions were marked successfully, leaving one end of the coil within/beyond the lesion and the other end of the coil in the pleural space. The inserted chest tube was used to insufflate air to widen the pleural space during coil positioning and to aspirate any residual air before transfer of the patient to the operating room holding area. Intraparenchymal hemorrhages smaller than 7 cm in diameter developed in two patients during coil placement. All lesions were successfully resected with VATS. Histologic examinaiton revealed 13 primary adenocarcinomas, four metastases, and four benign lesions. CONCLUSIONS: Pneumothorax creation and chest tube placement before CT-guided coil localization of peripheral lung nodules for VATS wedge resection facilitates the deployment of the peripheral end of the coil in the pleural space and provides effective management of procedure-related pneumothorax until surgery.

The application of single-lumen endotracheal tube anaesthesia with artificial pneumothorax in thoracolaparoscopic oesophagectomy.

Double-lumen endotracheal tube (DLET) anaesthesia is the commonly used method in minimally invasive oesophagectomy (MIE). However, DLET intubation does have its disadvantages. Firstly, the placement of the DLET needs a skilled anaesthetist with familiarity of the technique and subsequent ability to perform a fibre-optic bronchoscopy for confirmation. Secondly, DLET intubation and one-lung ventilation are associated with numerous complications, including hoarseness, tracheobronchial injury and vocal injury. In this report, a retrospective analysis was performed on 42 consecutive patients who underwent MIE using single-lumen endotracheal tube (SLET) anaesthesia with CO2 artificial pneumothorax compared with 81 patients who underwent the same procedure with DLET intubation. Our findings showed that SLET intubation with artificial pneumothorax by CO2 insufflation is a feasible and safe method for MIE procedures.

Pyothorax-associated lymphoma: complete remission achieved by chemotherapy alone.

We present the case of a patient with malignant lymphoma resulting from chronic pyothorax after artificial pneumothorax for pulmonary tuberculosis. The 81-year-old female patient had a medical history of artificial pneumothorax from left pulmonary tuberculosis when she was 23 years old and subsequent chronic pyothorax. She had become aware of pain in the left back from October 2008. Chest computed tomography revealed a tumor measuring 61 mm × 27 mm behind the left sixth and seventh ribs. After biopsy revealed pyothorax-associated lymphoma, 4 courses of R-CHOP therapy were administered, leading to complete remission. No recurrences were noted during follow-up over a 4-year period after the initiation of therapy.

Does thoracoscopic congenital diaphragmatic hernia repair cause a significant intraoperative acidosis when compared to an open abdominal approach?

PURPOSE: Thoracoscopic congenital diaphragmatic hernia (CDH) repair is increasingly reported. A significant intraoperative acidosis secondary to the pneumocarbia, as well as an increased recurrence rate, are possible concerns. Our aim was to review our early experience of the technique. METHODS: A prospective and retrospective data collection was carried out on all patients undergoing either an open or thoracoscopic CDH repair for a 4-year period. Preoperative blood gas values were identified at various stages of the operative procedure. A pH of 7.2 was considered to be a significant acidosis. The duration of surgery, complications, and recurrence rates were also recorded. Data were analyzed using the Mann-Whitney U test, and a P value of .05 or less was considered significant. RESULTS: Twenty-two patients were included. One death occurred before surgery. Twelve patients underwent thoracoscopic repair (8 neonatal), and 9 underwent open repair (8 neonatal). There were 9 left-sided defects in the thoracoscopic group and 9 in the open group. Operative time was longer in the thoracoscopic group compared to the open group (median, 135 vs 93.5 minutes; P = .02). Neonates undergoing thoracoscopic repair were heavier compared to the open group (median, 3.9 vs 2.9 kg; P = .05), and their preoperative requirements for ventilation and inotropes were comparable. However, the association between those patients who required preoperative inotropes and those who required a patch repair was statistically significant P = .03. Two patients in each group developed an intraoperative acidosis. A further patient in the thoracoscopic group had a severe acidosis present at the beginning of surgery. There was no statistical difference in pH values or recurrence rate between the 2 groups. All recurrences were in patients requiring patch repairs. No postoperative mortality occurred. CONCLUSIONS: We present our early experience of thoracoscopic CDH repair. Our results from thoracoscopic repair appear similar to the open procedure performed over the same period. No clear difference in intraoperative pH or recurrence rate has been demonstrated in our series. There is a need for a multicenter prospective study to establish the longer term outcome of this technique.

Pyothorax-associated lymphoma: imaging findings.

OBJECTIVE: The purpose of this study was to evaluate the radiologic features of pyothorax-associated lymphoma on CT scans and chest radiographs. MATERIALS AND METHODS: Radiographs and CT scans of 21 patients with biopsy-proven pyothorax-associated lymphoma (17 men, four women; median age, 71 years; range 52-77 years) were retrospectively identified. Two readers in consensus analyzed the morphologic imaging features of pyothorax-associated lymphoma and determined their relation to the preexisting chronic empyema cavity. In 13 cases, gallium scans were available and were reviewed. RESULTS: Sixteen patients had a history of artificial pneumothorax therapy for tuberculosis. Pyothorax-associated lymphoma was visualized mainly (71.4% of cases) as extrapulmonary pleural masses on chest radiographs. The CT features included a lenticular (60%) or crescentic (20%) soft-tissue mass located eccentrically at the margin of a coexistent empyema cavity, which was present in all cases. Masses of pyothorax-associated lymphoma were commonly located in the lateral costal pleura (50%) or at the costophrenic angle (30%). The tumor matrix often appeared heterogeneous and contained areas of necrosis (60%). Direct invasion of the chest wall, ribs, lung parenchyma, and abdomen was found in 75%, 50%, 25%, and 25% of patients. Gallium scans, when available, showed marked uptake in 10 of 13 patients (76.9%). CONCLUSION: In patients who have undergone artificial pneumothorax therapy for tuberculosis more than 20 years in the past, a pleural soft-tissue mass adjacent to the margin of a coexistent empyema cavity suggests the presence of pyothorax-associated lymphoma. Knowledge of the typical radiologic findings and locations of pyothorax-associated lymphoma help in the diagnosis of this rare pathologic entity.

[A case of pyothorax-associated lymphoma treated by operation following radiation therapy].

A 70-year-old man was admitted to our hospital with complaints of right back to anterior chest pain and fever. He had a history of artificial pneumothorax for tuberculosis when he was 21 years old. The chest CT showed a partial thickness of right pleural cavity. The decortication and fenestration were performed for pyothorax, and a diagnosis of pyothorax-associated lymphoma (PAL) was obtained by pathological examination. After the surgery, chest CT revealed a rapid tumor growth in three months and suspicion of invasion to the ribs. After radiation therapy with a total dose of 40 Gy was performed, right pleuropneumonectomy was carried out. The tumor was not remained in the specimen. Postoperative chemotherapy was not performed. He lived for 5 years after the operation without recurrence. It is important to control local recurrence for PAL with the combined therapy of operation, chemotherapy and radiotherapy.

Managing pulmonary artery catheter-induced pulmonary hemorrhage by bronchial occlusion.

A 76-year-old woman underwent mitral valve repair and coronary artery bypass grafting. Intrabronchial bleeding occurred after inflation of the balloon tip of the pulmonary artery catheter in the wedge position. A Forgaty catheter was introduced into the trachea parallel to the endotracheal tube and advanced under bronchoscopic vision into the intermediate bronchus. Tamponade of the bleeding was achieved by by filling the Forgaty balloon tip with saline. Weaning from extracorporeal circulation was uneventful. On the first postoperative day, the Forgaty catheter was removed and bronchial lavage of the middle and lower lobe was performed without any additional bleeding complication.