Congenital heart disease may require multiple cardiac surgeries during childhood. Subsequent non-cardiac surgeries increase the perioperative bleeding and hypoxia because of changes in circulation. An 18-year-old male patient with a history of multiple cardiac interventions, including Fontan surgery, underwent a thoracoscopic right lung suture and coverage for recurrent right spontaneous pneumothorax under general anesthesia with one lung ventilation (OLV). The superior dorsal and inferior lobes, which were inflatable before surgery, failed to expand during leakage testing. The trachea\'s condition was examined using a flexible bronchoscope, and no obstructions were found. A thoracic drainage catheter was inserted, and the lower lobe was dilated from outside the body using negative pressure control in a sealed environment. In the patient with previously treated Fontan circulation, both lungs were expanded by inserting a thoracic catheter during thoracoscopic right lung suture and maintaining negative external pressure.

BACKGROUND: For patients receiving one lung ventilation in thoracic surgery, numerous studies have proved the superiority of lung protective ventilation of low tidal volume combined with recruitment maneuvers (RM) and individualized PEEP. However, RM may lead to overinflation which aggravates lung injury and intrapulmonary shunt. According to CT results, atelectasis usually forms in gravity dependent lung regions, regardless of body position. So, during anesthesia induction in supine position, atelectasis usually forms in the dorsal parts of lungs, however, when patients are turned into lateral decubitus position, collapsed lung tissue in the dorsal parts would reexpand, while atelectasis would slowly reappear in the lower flank of the lung. We hypothesize that applying sufficient PEEP without RM before the formation of atelectasis in the lower flank of the lung may beas effective to prevent atelectasis and thus improve oxygenation as applying PEEP with RM.
METHODS: A total of 84 patients scheduled for elective pulmonary lobe resection necessitating one lung ventilation will be recruited and randomized totwo parallel groups. For all patients, one lung ventilation is initiated the right after patients are turned into lateral decubitus position. For patients in the study group, individualized PEEP titration is started the moment one lung ventilation is started, while patients in the control group will receive a recruitment maneuver followed by individualized PEEP titration after initiation of one lung ventilation. The primary endpoint will be oxygenation index measured at T4. Secondary endpoints will include intrapulmonary shunt, respiratory mechanics, PPCs, and hemodynamic indicators.
CONCLUSIONS: Numerous previous studies compared the effects of individualized PEEP applied alone with that applied in combination with RM on oxygenation index, PPCs, intrapulmonary shunt and respiratory mechanics after atelectasis was formed in patients receiving one lung ventilation during thoracoscopic surgery. In this study, we will apply individualized PEEP before the formation of atelectasis while not performing RM in patients allocated to the study group, and then we\'re going to observe its effects on the aspects mentioned above. The results of this trial will provide a ventilation strategy that may be conductive to improving intraoperative oxygenation and avoiding the detrimental effects of RM for patients receiving one lung ventilation.
BACKGROUND: www.Chictr.org.cn ChiCTR2400080682. Registered on February 5, 2024.

Bronchogenic cysts (BCs) are a congenital anomaly, forming fluid-filled sacs in the bronchial tree during fetal development, and are relatively rare in adults. Patients with large BCs in the mediastinum presenting with severe tracheal compression pose a significant challenge to anesthesiologists. The confined and narrow space of the mediastinum exacerbates the compression effect on surrounding structures, leading to potential respiratory or cardiovascular collapse during anesthesia and postoperatively. Herein, we report the stepwise anesthetic management of a patient with a BC in the paratracheal region of superior mediastinum, causing near-complete tracheal compression, scheduled for right posterolateral thoracotomy and tumor excision. The patient presented with dyspnea, chest pain, cough, and severe tracheal compression necessitating meticulous airway management. Utilizing awake fiberoptic intubation with a single-lumen endotracheal tube and one-lung ventilation facilitated by an EZ bronchial blocker, we successfully secured the airway, provided ideal surgical conditions through lung deflation, and ensured perioperative safety. This case underscores the crucial role of comprehending the underlying pathophysiology, anticipating complications, and meticulously planning, preparing, and executing strategies for airway management and perioperative care in patients with mediastinal masses leading to significant tracheal compression.

Contralateral tension pneumothorax is a rare but fatal complication of one-lung ventilation. The life-saving decompression of pleural space was frequently delayed by the difficult confirmation of diagnosis because of general anesthesia that masks specific clinical presentations when the patient is alert. We reported a case of tension pneumothorax in a patient who underwent thoracic spine instrumentation. There were no contralateral tension pneumothorax cases on file from the search of the Anesthesia Quality Institute Closed Claims Database from 2001 to 2017. We systematically searched PubMed, Ovid MEDLINE, Embase, and Google Scholar. Over the past 30 years, there were 21 single case reports and two case series were retrieved. It was a consensus that difficult confirmation of the diagnosis of contralateral tension pneumothorax is the culprit of delayed life-saving intervention. Difficulty of oxygenation with increasing inspiratory pressure was usually the first sign suggesting contralateral pneumothorax; however, earlier presentations of cardiovascular system failure than respiratory failure have significantly increased the incidence of cardiac arrest and death. It is paramount to maintain a high suspicion of tension pneumothorax. The application of esophageal stethoscope, lung ultrasound, and simulator training may improve the chance of early diagnosis and patient outcome.

BACKGROUND: Double-lumen tubes (DLTs) are the preferred device for lung isolation. Conventional DLTs (cDLT) need a bronchoscopic position control. Visualisation of correct DLT positioning could be facilitated by the use of a video double-lumen tube (vDLT). During the SARS-CoV-2-pandemic, avoiding aerosol-generation was suggesting using this device. In a large retrospective series, we report both general and pandemic related experiences with the device.
METHODS: All anesthesia records from patients aged 18 years or older undergoing surgery from April 1st, 2020 to December 31st, 2021 in the department of thoracic surgery requiring intraoperative lung isolation were analyzed retrospectively.
RESULTS: During the investigation period 343 left-sided vDLTs (77.4%) and 100 left-sided cDLTs (22.6%) were used for one lung ventilation. In the vDLT group bronchoscopy could be reduced by 85.4% related to the cDLT group. Additional bronchoscopy to reach or maintain correct position was needed in 11% of the cases. Other bronchoscopy indications occured in 3.6% of the cases. With cDLT, in 1% bronchoscopy for other indications than conforming position was observed.
CONCLUSIONS: The Ambu® VivaSight™ vDLT is an efficient, easy-to-use and safe airway device for the generation of one lung ventilation in patients undergoing thoracic surgery. The vDLT implementation was achieved easily with full interchangeability to the left-sided cDLT. Using the vDLT can reduce the need for aerosol-generating bronchoscopic interventions by 85.4%. Continuous video view to the carina enabling position monitoring of the DLT without need for bronchoscopy might be beneficial for both employee\'s and patient\'s safety.

BACKGROUND: The effect of two lung ventilation (TLV) with carbon dioxide artificial pneumothorax on cerebral desaturation and postoperative neurocognitive changes in elderly patients undergoing elective minimally invasive esophagectomy (MIE) is unclear.
OBJECTIVE: The first aim of this study was to compare the effect of TLV and one lung ventilation (OLV) on cerebral desaturation. The second aim was to assess changes in early postoperative cognitive outcomes of two ventilation methods.
METHODS: This prospective, randomized, controlled trial enrolled patients 65 and older scheduled for MIE. Patients were randomly assigned (1:1) to TLV group or OLV group. The primary outcome was the incidence of cerebral desaturation events (CDE). Secondary outcomes were the cumulative area under the curve of desaturation for decreases in regional cerebral oxygen saturation (rSO2) values below 20% relative to the baseline value (AUC.20) and the incidence of delayed neurocognitive recovery.
RESULTS: Fifty-six patients were recruited between November 2019 and August 2020. TLV group had a lower incidence of CDE than OLV group [3 (10.71%) vs. 13 (48.14%), P = 0.002]. TLV group had a lower AUC.20 [0 (0-35.86) % min vs. 0 (0-0) % min, P = 0.007], and the incidence of delayed neurocognitive recovery [2 (7.4%) vs. 11 (40.7%), P = 0.009] than OLV group. Predictors of delayed neurocognitive recovery on postoperative day 7 were age (OR 1.676, 95% CI 1.122 to 2.505, P = 0.006) and AUC.20 (OR 1.059, 95% CI 1.025 to 1.094, P < 0.001).
CONCLUSIONS: Compared to OLV, TLV had a lower incidence of CDE and delayed neurocognitive recovery in elderly patients undergoing MIE. The method of TLV combined with carbon dioxide artificial pneumothorax may be an option for these elderly patients. Chinese Clinical Trial Registry (identifier: ChiCTR1900027454).

Tracheal bronchi (TB) is a rare anomaly and is usually asymptomatic. Although it is generally not a problem when a single lumen tube is used, it may cause ventilation difficulties in the intraoperative period in procedures requiring one lung ventilation, such as minimally invasive cardiac surgery. Therefore, these difficulties may cause intraoperative and postoperative complications. While a double-lumen tube is recommended as the primary choice for one-lung ventilation in patients with TB, bronchial blockers can be used to avoid the need for tube exchange in patients who will remain intubated in the postoperative period.

Maintaining oxygenation during neonatal open repair of esophageal atresia/tracheoesophageal fistula is difficult. Inverse ratio ventilation can be used during one lung ventilation to improve the oxygenation and lung mechanics.
The aim of this study was to describe the impact of two different ventilatory strategies (inverse ratio ventilation vs. conventional ratio ventilation) during one lung ventilation in neonatal open repair of esophageal atresia/tracheoesophageal fistula on the incidence of oxygen desaturation episodes.
We enrolled 40 term neonates undergoing open right thoracotomy for esophageal atresia/tracheoesophageal fistula repair and randomly assigned into two groups based on inspiratory to expiratory ratio of mechanical ventilation parameters (2:1 in inverse ratio ventilation \"IRV\" and 1:2 in conventional ratio ventilation \"CRV\"). The incidence of desaturation episodes that required stopping the procedure and reinflation of the lung were recorded as the primary outcome while hemodynamic parameters, incidence of complications, and length of surgical procedure were recorded as the secondary outcomes.
There was a trend toward a reduction in the incidence of severe desaturations (requiring stopping of surgery) with the use of inverse ratio ventilation (15% in IRV vs. 35% in CRV, RR [95% CI] 0.429 [0.129-1.426]). Incidence of all desaturations (including those requiring only an increase in ventilatory support or inspired oxygen saturation) was also reduced (40% in IRV vs. 75% in CRV, RR [95% CI] 0.533 [0.295-0.965]). This in turn affected the length of surgical procedure being significantly shorter in inverse ratio ventilation group (mean difference -16.3, 95% CI -31.64 to -0.958). The intraoperative fraction of inspired oxygen required to maintain adequate oxygen saturation was significantly lower in the inverse ratio ventilation group than in the conventional ratio ventilation group (mean difference -0.22, 95% CI -0.33 to -0.098), with no significant difference in hemodynamic stability or complications apart from higher blood loss in inverse ratio group.
There may be a role for inverse ratio ventilation with appropriate positive end-expiratory pressure to reduce the incidence of hypoxemia during open repair of esophageal atresia/tracheoesophageal fistula in neonates, further studies are required to establish the safety and efficacy of this technique.

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. This report presents a rare case of a pediatric patient who developed a TEF due to battery ingestion, which was diagnosed during intubation and resulted in cardiac arrest. A 4-year-old child with a two-year history of battery ingestion presented with severe dehydration, weight loss, and recurrent respiratory tract infections. Chest X-ray revealed a radiopaque foreign body in the esophagus. During general anesthesia for central venous line insertion and after endotracheal intubation, some difficulties in ventilation occurred, characterized by the inability to reach tidal volume, absence of capnography, and stomach distention which led to hypoxia and ultimately to cardiac arrest. Prompt resuscitation (CPR) was initiated, and selective right bronchial intubation during CPR improved the patient\'s condition. Subsequent bronchofibroscopy performed in the ICU confirmed the TEF, which was surgically corrected during the hospital stay. TEF poses challenges in anesthesia and airway management, particularly when positive pressure ventilation is used. In this case, the TEF was diagnosed during intubation, highlighting the critical role of clinical expertise and prompt intervention in managing this unexpected pediatric critical event.

Louis-Bar Syndrome is a synonym for a very rare complex neurodegenerative disorder ataxia-telangiectasia (A-T). This is an autosomal recessive inherited disease that encompasses abnormalities in the cerebellum, multisystem degeneration, immunodeficiency, increased risk for malignancy and consecutive respiratory insufficiency. Most of the patients are radiosensitive and any exposing to ionization may lead to progression of the disease. Potential risks from anesthesia, mechanical ventilation, and postoperative complications in these patients have been insufficiently discussed in the literature. We present a successful anesthetic and respiratory management with one-lung ventilation in a patient with Louis-Bar Syndrome who underwent video assisted thoracoscopy (VATS) for recurrent pleural effusion.