Thoracic surgery clinics
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The progress in lung separation technology has allowed anesthesiologists to become skillful in fiberoptic bronchoscopy techniques and to provide excellent lung exposure in thoracic surgery patients. Given the availability of two technologies--DLTs (right-sided and left-sided) and bronchial blocker technology (TCBU, Arndt, and Cohen--every case that requires lung collapse and OLV should receive the benefit of these devices. ⋯ For a patient who requires lung separation and presents with the dilemma of a difficult or abnormal airway, bronchial blockers offer more advantages. Regardless of the device used, the optimal position of these devices (DLTs and bronchial blockers) is achieved best with the use of fiberoptic bronchoscopy techniques first in supine and then in lateral decubitus position or whenever repositioning of the device is needed.
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The ability to manage OLV effectively in patients with significant pulmonary disease is increasing. Knowledge of pulmonary ventilation and perfusion physiology, improvements in the ability to prevent and treat hypoxia, and a thorough grasp of traditional and novel ventilatory techniques may promote improved perioperative outcomes.
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Advances in anesthesia involve refinements in understanding, technique, and technology. These refinements have led to better control of the anesthetic state, effective anesthesia for a wider variety of situations, and the ability to bring sicker patients to the operating room. Although the molecular mechanisms underlying the general anesthetic state are unknown, evidence suggests a specific, receptor-based effect. ⋯ New anesthesia ventilators have better monitoring and better flow delivery at high airway pressures. These improvements significantly narrow the performance gap between anesthesia and ICU ventilators. In patients with COPD, pulmonary hypertension, or severe hypoxemia, heliox may improve gas flow, and NO may reduce pulmonary vascular resistance and improve oxygenation.
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The specialty of thoracic surgery has evolved along with the modem practice of anesthesia. This close relationship began in the 1930s and continues today. Thoracic surgery has grown from a field limited almost exclusively to simple chest wall procedures to the present situation in which complex procedures, such as lung volume reduction or lung transplantation, now can be performed on the most severely compromised patient. ⋯ Exchange of information, status and plans are mandatory". This team approach between the thoracic surgeon and the anesthesiologist reflects the history of the two specialties. With new advances in technology, such as continuous blood gas monitoring and the pharmacologic management of pulmonary circulation to maximize oxygenation during one-lung ventilation, in the future even more complex procedures may be able to be performed safely on even higher risk patients.
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Thoracic surgery clinics · Nov 2004
ReviewPreoperative assessment and therapeutic options for patients with malignant pleural mesothelioma.
Prompt medical evaluation and aggressive treatment can lead to prolonged survival or successful palliation of symptoms for patients with malignant pleural mesothelioma, but the window for implementing treatment is short. Clinical recognition of the cancer is confounded by numerous factors, including long latency between exposure to asbestos and expression of the disease, nonspecific nature of the presenting symptoms, rarity of the disease, a lack of experience in clinical diagnosis, and rapidly deteriorating clinical course after diagnosis. Heightened clinical suspicion and proper patient selection through accurate staging and pathologic identification are paramount to defining and delivering therapy for this rare, lethal cancer.