Thoracic anesthesia, ventilation, and oxygen delivery: ‘A review of the recent advancements’

In conjunction with thoracic surgery, the field of thoracic anesthesia has witnessed the development of several innovative techniques. To ensure optimal patient care and outcome, these innovations require a collaborative approach between anesthesiologists and surgeons.

Preoperatively, the primary objective is risk assessment, which should drive modifications and enhancements to the patient’s functional status and overall quality of life. Timing is crucial for any prehabilitation program, encompassing both physical and mental aspects.

Thoracic surgery includes a wide range of soperations, addressing pathologies of the lower airway, lung, esophagus, and/or mediastinum. Challenges and considerations for thoracic surgeries include the need for one lung ventilation and the selection of the best suited lung isolation device for each patient [ , ]. Every thoracic anesthesiologist should therefore be familiar with evaluating the normal and abnormal airway anatomy, employing various lung isolation techniques, and assuring optimal individualized single lung ventilation strategies. Furthermore, the ability to manage ventilatory complications during surgery is of great importance.

Ultrasound-based imaging has evolved into an indispensable tool in perioperative medicine, and more recently in thoracic anesthesia. It facilitates placement of various peripheral and central nerve blocks which were previously performed “blind” using external landmarks. It also provides a unique approach to perioperative monitoring of lung and heart function [ , ]. While basic echocardiography and lung ultrasound in thoracic surgery offer specific advantages over other monitoring tools, there is considerable variation in practice among anesthesiologists.

In recent years, the COVID-19 pandemic has emerged as the most important challenge confronting the human race. Healthcare personnel will most likely continue to deal with various patients with active COVID-19 infections undergoing different surgeries. Due to the complexity of airway management in thoracic anesthesia, intraoperative precautions to prevent infection spread should be applied to all patients, including the noninfected population. Specific recommendations for healthcare providers are essential to mitigate the risk of hospital-acquired infections in the operating room setting [ , ].

Efficient diagnostic strategies with high accuracy and low complication rates are required for prompt diagnosis and treatment of early-stage lung cancer. Robotic assisted bronchoscopy is becoming the procedure of choice for staging peripheral lung pathology, especially when combined with endobronchial ultrasound-guided biopsy [ ].

The expanding role of extracorporeal membrane oxygenation (ECMO) as an intraoperative supportive tool has opened new frontiers in several areas of thoracic surgery. It has enabled procedures that were previously considered unimaginable due to their inherent risks and challenges [ , ]. The role of ECMO in the field of lung transplantation has recently been established, and its applications are continuing to expand [ , ]. Anesthesiologists should be well-versed in the initiation and management of ECMO, as it significantly enhances patient safety in the operating room and serves as a critical lifeline in complex thoracic surgical procedures. This will ultimately elevate the standard of care and expand the capabilities of anesthesiologists in the modern healthcare landscape.

Significant strides have been made in the field of postoperative pain control. The multimodal approach, combining opioid and non-opioid analgesia with regional anesthesia techniques, offers improved pain control and reduces postoperative complications compared to relying solely on opioid-based analgesia [ ]. Moreover, some recent data suggest that opioids could impact the overall oncologic outcome [ ]. Based on the current literature, perioperative administration of acetaminophen and non-steroidal anti-inflammatory drugs as well as intraoperative dexmedetomidine infusion are useful analgesic adjuncts in patients undergoing thoracic surgery [ ]. Regional analgesia is instrumental for the success of multimodal analgesia, and it is strongly advocated by enhanced recovery after surgery (ERAS) pathways. Ultrasound-guided serratus plane block, erector spinae block, or paravertebral block are relatively easy and safe techniques that provide adequate postoperative pain control.

Postoperative management requires taking patients from their nadir at the end of thoracic surgical procedures to a level of functional independence in just a few days. ERAS protocols integrate multiple evidence-based interventions aimed at mitigating the effects of the surgical stress response, with the explicit goal of expediting a return to normal function. Early mobilization, a proactive chest tube strategy, and opioid-sparing analgesia are the most important postoperative goals of the thoracic ERAS protocol. While implementing these protocols may present challenges, the “aggregation of marginal gains” and the “key care elements” approaches result in improved outcomes with fewer postoperative complications, a shorter hospital stay, and a better overall recovery [ ].

In summary, thoracic anesthesia is a rapidly evolving field, and parallels developments seen in thoracic surgery. The purpose of publishing the reviews in this issue is to guide anesthesiologists in delivering optimal perioperative care during thoracic surgery in an aging and sicker patient population requiring complex surgical procedures. It is the hope of the editors that providing educational support in the areas of growth in thoracic anesthesia, will lead to improved patient outcomes, and in particular improving quality of life after thoracic surgery.

We sincerely thank all the authors for their significant contributions to this topic.

Funding

This work did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Stefaan Bouchez: Writing – review & editing. Jan F.A. Hendrickx: Writing – review & editing. Wanda M. Popescu: Writing – review & editing.