Combined use of the ProSeal laryngeal mask airway and a bronchial blocker vs. a double-lumen endobronchial tube in thoracoscopic surgery: A randomized controlled trial

Lung isolation with a bronchial blocker placed in the lateral position for patients undergoing thoracic surgery: A multicenter, randomized clinical trial

Study objective Accurate bronchial blocker placement is essential for effective lung isolation during thoracic surgery. Approximately one-third of patients experience bronchial blocker malposition during the transition from the supine to lateral decubitus position. It has been unclear whether bronchial blocker placement directly in the lateral position can reduce the incidence of malposition. This study investigated the incidence of bronchial blocker malposition in the lateral versus supine position and evaluated the effectiveness of lateral placement.

PATIENTS

Adults aged ≥18 years scheduled for thoracic surgery were enrolled.

SETTING

Seven tertiary hospitals in China.

INTERVENTIONS

Bronchial blockers were placed either in the lateral or supine position.

MEASUREMENTS

The primary outcome was the incidence of bronchial blocker malposition. Secondary outcomes included the times of bronchial blocker reposition, perioperative complications, intubation duration, and satisfaction scores.

MAIN RESULTS

Among 324 patients who underwent randomization, 306 completed the study (152 in the lateral group and 154 in the supine group). The incidence of bronchial blocker malposition was significantly lower in the lateral group (1/152 (0.7 %)) than in the supine group 39/154 (25.3 %), P < 0.001). The times of bronchial blocker reposition was also lower in the lateral group (median [interquartile range]: 0 [0,0]) than in the supine group (1.0 [1.0, 2.0], P < 0.001). Lateral bronchial blocker placement was associated with lower incidences of postural injury (P < 0.001). The median intubation duration (single-lumen tube intubation plus bronchial blocker placement) was similar between the two groups (P = 0.089). Patients and surgeons reported higher satisfaction scores in the lateral group (P < 0.001).

CONCLUSIONS

Lateral bronchial blocker placement reduced the incidence of malposition in patients undergoing thoracic surgery; it was associated with fewer complications and higher satisfaction scores. These findings indicate that lateral placement is an effective approach with substantial advantages over conventional supine placement. Clinial trial registration:NCT05482230.

The effect of laryngeal mask combined with bronchial occluder in patients undergoing single lung ventilation in thoracic surgery: A retrospective study

This study evaluates the clinical efficacy of combining a laryngeal mask airway with a bronchial blocker (LMA-BB) in single-lung ventilation (OLV) during thoracic surgery compared to the traditional single-lumen tracheal tube with a bronchial blocker (single-lumen tracheal tube [SLT] + BB). A retrospective analysis was performed on 93 patients undergoing thoracic surgery with OLV from December 2021 to September 2023. After propensity score matching (1:1), 34 patients remained in each group (LMA-BB and SLT + BB). Key outcomes, including airway pressures, ventilation and oxygenation parameters, lung compliance, postoperative recovery, and complications, were compared between groups. After matching, the 2 groups had similar baseline characteristics. The LMA-BB group showed significant advantages in airway pressure management, with lower peak and plateau pressures (P < .05). Ventilation and oxygenation efficiency were superior in the LMA-BB group, including lower end-tidal carbon dioxide (37.8 ± 4.7 vs 39.2 ± 5.1 mm Hg, P = .04) and higher oxygenation index (255 ± 22 vs 245 ± 28, P = .04). Lung compliance was improved (P = .018), and more patients in the LMA-BB group achieved excellent lung collapse (76.5% vs 52.9%, P = .032). Additionally, postoperative recovery was faster, with shorter extubation times (12.4 ± 3.2 vs 14.8 ± 3.6 minutes, P = .003) and fewer complications, including hypoxemia (5.9% vs 23.5%, P = .027) and pulmonary issues (8.8% vs 20.6%, P = .046). The LMA-BB technique offers significant clinical benefits over the traditional SLT + BB method in thoracic OLV, including improved airway management, ventilation efficiency, lung compliance, and faster recovery. It also reduces postoperative complications, making it a promising alternative for thoracic surgery.

Nonintubated video-assisted thoracic surgery: myth or reality?

PURPOSE OF REVIEW

This review discusses nonintubated video-assisted thoracic surgery (NIVATS) by presenting its physiological, technical aspects and recent clinical data from the literature.

RECENT FINDINGS

In the last two decades, NIVATS has gained traction as an alternative to traditional intubated thoracic surgery, offering potential benefits in terms of reduced complications, faster recovery times, and improved patient satisfaction. Several approaches to this technique have been described in the literature, mainly divided into the awake patient technique (awake-NIVATS) and the asleep patient technique (asleep-NIVATS). The availability of various sedatives, numerous devices to ensure good oxygenation, and the countless loco-regional techniques available today for pain control in the thoracic region offer the possibility to develop many anesthesia protocols in this context. Numerous studies have already shown that NIVATS is feasible and safe with proper patient selection and adequate collaboration of the surgical team. Some studies have also shown that NIVATS may improve patient outcomes, but the evidence is still limited.

SUMMARY

Literature has demonstrated the feasibility of NIVATS and suggest that it can improve patient outcomes. High-quality international randomized multicenter studies comparing NIVATS and intubated video-assisted thoracic surgery are necessary for a strong comprehension to clarify whether it can be a technique that can guarantee safety and improve the perioperative course of patients.

Effects of Dexmedetomidine as an Adjuvant in Preoperative Ultrasound-Guided Internal Branch of Superior Laryngeal Nerve Block on Postoperative Sore Throat and Hemodynamics in Patients With Double-Lumen Endotracheal Intubation: A Randomized Controlled Trial

Background

Postoperative sore throat (POST) is a significant adverse effect after endotracheal intubation, especially with double-lumen endotracheal tubes (DLTs). Ultrasound-guided internal branch of the superior laryngeal nerve block (US-guided iSLNB) presents a potential intervention for POST. In this first randomized controlled trial to date, we aimed to investigate the effects of US-guided iSLNB, with or without perineural dexmedetomidine, on the incidence and severity of POST following DLTs.

Methods

A total of 159 patients were randomly assigned to three groups: control, bilateral US-guided iSLNB (2 mL 0.20% ropivacaine + 1 mL saline on each side), and bilateral US-guided iSLNB combined with perineural dexmedetomidine group (2 mL 0.20% ropivacaine + 1 mL 0.5 μg·kg-1 dexmedetomidine on each side). The incidence and severity of POST, hemodynamic fluctuations during intubation and extubation, the incidence and severity of cough and agitation during extubation, and perioperative complications were assessed. The primary outcome was the incidence of POST at 6 h after surgery.

Results

Compared with the control group, preoperative US-guided iSLNB significantly reduced the incidence and severity of POST at 1 and 6 h after surgery, mitigated the incidence and severity of cough during extubation, and attenuated hemodynamic responses, including heart rate, mean arterial pressure, and rate-pressure product during intubation, 1 min after intubation, and 1 min after extubation (all P < 0.01). Compared with US-guided iSLNB alone, the combination of US-guided iSLNB with perineural dexmedetomidine reduced the incidence and severity of POST at 1, 6, and 12 h, as well as coughing during extubation (all P < 0.01). However, it demonstrated little effect on hemodynamics (all P > 0.05). No significant perioperative complications were observed in the three groups (all P > 0.05).

Conclusion

Preoperative US-guided iSLNB combined with perineural dexmedetomidine effectively reduced the incidence, severity, and duration of POST and cough during extubation. No additional hemodynamic benefits were observed.

Clinical Trial Registration

Chinese Clinical Trial Registry (ChiCTR2200061001).

The feasibility and accuracy of the method for selecting the optimal size of double-lumen tube in thoracic surgery: a prospective, randomized controlled trial

Double-lumen tubes (DLTs) are commonly used for one-lung ventilation (OLV) in thoracic surgery and the selection of an optimal size of DLTs is still a humongous task. The purpose of this study was to assess the feasibility and accuracy of the method for selecting an optimal size of DLTs in thoracic surgery. Sixty adult patients requiring a left side double-lumen tube (LDLT) for elective thoracoscopic surgery were included in this study. All patients were randomly allocated to the following two groups: Cuffs Collapsed group (CC group, n = 30) and Cuffs Inflated group (CI group, n = 30). In the Cuffs Collapsed group, the outer diameter of LDLT (the outer diameter of the tracheal and bronchial cuffs when they were collapsed as the outer diameter of the LDLT) matched with the inner diameter of the trachea and bronchus measured by the anesthesiologist on the chest CT slice; In the Cuffs Inflated group, the outer diameter of LDLT (the outer diameter of the tracheal and bronchial cuffs when they were inflated as the outer diameter of the LDLT) matched with the inner diameter of the trachea and bronchus measured by the anesthesiologist on the chest CT slice. The primary outcomes were the incidences of airway complications postoperative such as hoarseness and sore throat. The time of intubation and alignment, the incidences of LDLT displacement and adjustment, the peak airway pressure, the plateau airway pressure and the end-tidal carbon dioxide were also recorded. The incidences of airway complications postoperative such as sore throat and hoarseness were lower in the CI group than the CC group (P < 0.05), the intubation times was shorter in the CI group than the CC group (P < 0.05), while the peak airway pressure, the plateau airway pressure and the end-tidal carbon dioxide during two-lung ventilation and one-lung ventilation were no significant difference between two groups (P > 0.05). The method which matched the inner diameter of the trachea and bronchus measured on chest CT slice with the outer diameter of the tracheal and bronchial cuffs when they were inflated to select an appropriate size of LDLT can reduce the incidence of airway complications.Trials registration: Clinical Trials: gov. no. NCT05739318. Registered at https://classic.clinicaltrials.gov 22/02/2023.

Clinical evaluation of laryngeal mask airways in video-assisted thoracic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Endotracheal intubation is often associated with postoperative complications such as sore throat discomfort and hoarseness, reducing patient satisfaction and prolonging hospital stays. Laryngeal mask airway (LMA) plays a critical role in reducing airway complications related to endotracheal intubation. This meta-analysis was performed to determine the efficacy and safety of LMA in video-assisted thoracic surgery (VATS).

METHODS

The PubMed, Embase, Cochrane Library, Medline and Web of Science databases were searched for eligible studies from inception until October 5, 2023. Cochrane's tool (RoB 2) was used to evaluate the possibility biases of RCTs. We performed sensitivity analysis and subgroup analysis to assess the robustness of the results.

RESULTS

Seven articles were included in this meta-analysis. Compared with endotracheal intubation, there was no significant difference in the postoperative hospital stay (SMD = -0.47, 95% CI = -0.98-0.03, P = 0.06), intraoperative minimum SpO2 (SMD = 0.00, 95% CI = -0.49-0.49, P = 1.00), hypoxemia (RR = 1.00, 95% CI = 0.26-3.89, P = 1.00), intraoperative highest PetCO2 (SMD = 0.51, 95% CI = -0.12-1.15, P = 0.11), surgical field satisfaction (RR = 1.01, 95% CI = 0.98-1.03, P = 0.61), anesthesia time (SMD = -0.10, 95% CI = -0.30-0.10, P = 0.31), operation time (SMD = 0.06, 95% CI = -0.13-0.24, P = 0.55) and blood loss (SMD =- 0.13, 95% CI = -0.33-0.07, P = 0.21) in LMA group. However, LMA was associated with a lower incidence of throat discomfort (RR = 0.28, 95% CI = 0.17-0.48, P < 0.00001) and postoperative hoarseness (RR = 0.36, 95% CI = 0.16-0.81, P = 0.01), endotracheal intubation was found in connection with a longer postoperative awake time (SMD = -2.19, 95% CI = -3.49 - -0.89, P = 0.001).

CONCLUSION

Compared with endotracheal intubation, LMA can effectively reduce the incidence of throat discomfort and hoarseness post-VATS, and can accelerate the recovery from anesthesia. LMA appears to be an alternative to endotracheal intubation for some specific thoracic surgical procedures, and the efficacy and safety of LMA in VATS need to be further explored in the future.

Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study

BACKGROUND

Postoperative pneumonia is one of the common complications after video-assisted thoracoscopic surgery. There is no related study on the effect of lung isolation with different airway devices on postoperative pneumonia. Therefore, in this study, the propensity score matching method was used to retrospectively explore the effects of different lung isolation methods on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery.

METHODS

This is A single-center, retrospective, propensity score-matched study. The information of patients who underwent VATS in Weifang People 's Hospital from January 2020 to January 2021 was retrospectively included. The patients were divided into three groups according to the airway device used in thoracoscopic surgery: laryngeal mask combined with bronchial blocker group (LM + BB group), tracheal tube combined with bronchial blocker group (TT + BB group) and double-lumen endobronchial tube group (DLT group). The main outcome was the incidence of pneumonia within 7 days after surgery; the secondary outcome were hospitalization time and hospitalization expenses. Patients in the three groups were matched using propensity score matching (PSM) analysis.

RESULTS

After propensity score matching analysis, there was no significant difference in the incidence of postoperative pneumonia and hospitalization time among the three groups (P > 0.05), but there was significant difference in hospitalization expenses among the three groups (P < 0.05).

CONCLUSIONS

There was no significant difference in the effect of different intubation lung isolation methods on postoperative pneumonia in patients undergoing thoracoscopic surgery.

Placement of bronchial occluder outside the tracheal tube in a patient combined with airway compression undergoing mediastinal tumors resection: a case report

BACKGROUND

Mediastinal tumors pose a challenging respiratory and circulatory management during anesthesia procedures, there is a risk of circulatory collapse or complete airway obstruction, which in severe cases can lead to cardiac arrest. We reported a case of anesthetic management using a bronchial blocker placed outside the tracheal tube. In this case report, the patient's trachea was so severely compressed that the airway was extremely narrow, only 4 mm at its narrowest point. By reporting the anesthetic management of this patient, we intend to provide an unusual approach for airway management.

CASE PRESENTATION

A 52-year-old male patient was admitted to the hospital due to cough and expectoration for one year. Additionally, the patient experienced chest tightness and asthma after physical activity. The enhanced computed tomography revealed there existed an irregular soft tissue mass in the right upper mediastinum, which significantly compressed the trachea and esophagus. The results of the mediastinal puncture pathology showed the presence of mesenchymal tumors. According to the results above, the patient was diagnosed with a mediastinal tumor and scheduled to undergo tumor resection under general anesthesia. We used a bronchial occluder outside the tracheal tube for general anesthesia. After surgery, the patient received thorough treatment and was subsequently discharged from the hospital.

CONCLUSION

In patients with severe airway compression from a mediastinal tumor airway compression, positioning a bronchial occluder externally to the tracheal tube is an effective method of airway management. However, we still need more clinical practice to help the process become more standardized.