Abstract
Objective: To evaluate the effect of 4 weeks of pulmonary rehabilitation (PR) versus chest physical therapy (CPT) on the preoperative functional
capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection.
Design: Randomized single-blinded study.
Setting: A teaching hospital.
Participants: Patients undergoing lung cancer resection (N=24).
Interventions: Patients were randomly assigned to receive PR (strength and endurance training) versus CPT (breathing exercises for lung
expansion). Both groups received educational classes.
Main Outcome Measures: Functional parameters assessed before and after 4 weeks of PR or CPT (phase 1), and pulmonary complications
assessed after lung cancer resection (phase 2).
Results: Twelve patients were randomly assigned to the PR arm and 12 to the CPT arm. Three patients in the CPT arm were not submitted to lung
resection because of inoperable cancer. During phase 1 evaluation, most functional parameters in the PR group improved from baseline to 1
month: forced vital capacity (FVC) (1.47L [1.27-2.33L] vs 1.71L [1.65-2.80L], respectively; P=.02); percentage of predicted FVC (FVC%;
62.5% [49%-71%] vs 76% [65%-79.7%], respectively; P<.05); 6-minute walk test (425.5
85.3m vs 475
86.5m, respectively; P<.05);
maximal inspiratory pressure (90
45.9cmH2O vs 117.5
36.5cmH2O, respectively; P<.05); and maximal expiratory pressure (79.7
17.1cmH2O
vs 92.9
21.4cmH2O, respectively; P<.05). During phase 2 evaluation, the PR group had a lower incidence of postoperative respiratory morbidity
(P=.01), a shorter length of postoperative stay (12.2
3.6d vs 7.8
4.8d, respectively; P=.04), and required a chest tube for fewer days (7.4
2.6d
vs 4.5
2.9d, respectively; P=.03) compared with the CPT arm.
Conclusions: These findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the
postoperative respiratory morbidity.
Archives of Physical Medicine and Rehabilitation 2013;94:53-8

Objectives
Patients requiring extracorporeal cardiorespiratory support during lung transplantation can be treated with conventional cardiopulmonary bypass (CPB) or venoarterial extracorporeal membrane oxygenation (ECMO). In a retrospective analysis, we compared the postoperative course and outcomes of patients treated using these approaches.
Methods
Between August 2008 and September 2011, 92 consecutive patients underwent lung transplantation with extracorporeal support (CPB group, n = 46; and, since February 2010, ECMO group, n = 46) at our institution. We evaluated survival, secondary organ failure, bleeding complications, and the need for blood and platelet transfusions in these 2 patient populations.
Results
Intraoperatively, the CPB group required more packed red blood cell transfusions (12 ± 11 vs 7 ± 9 U; P = .01) and platelet concentrates (2.5 ± 1.6 vs 1.5 ± 1 U; P < .01) than the ECMO group. In-hospital mortality (39% vs 13%; P = .004), the need for hemodialysis (48% vs 13%; P < .01), and new postoperative ECMO support (26% vs 4%; P < .01) were greater in the CPB group than in the ECMO group, respectively. After propensity score analysis, multivariate analysis identified retransplantation (odds ratio, 7; 95% confidence interval, 1-43; P = .034) and transplantation with CPB support (odds ratio, 4.9; 95% confidence interval, 1.2-20; P = .026) as independent risk factors for in-hospital mortality. The survival rate at 3, 9, and 12 months was 70%, 59%, and 56% in the CPB group and 87%, 81%, and 81% in the ECMO group (P = .004).
Conclusions
Intraoperative ECMO allows for better periprocedural management and reduced postoperative complications and confers a survival benefit compared with CPB, mainly because of lower in-hospital mortality. It is now the standard of care in our lung transplantation program.

I.V. fluid therapy does not result in the extracellular volume distribution expected from Starling’s original model of semi-permeable capillaries subject to hydrostatic and oncotic pressure gradients within the extracellular fluid. Fluid therapy to support the circulation relies on applying a physiological paradigm that better explains clinical and research observations. The revised Starling equation based on recent research considers the contributions of the endothelial glycocalyx layer (EGL), the endothelial basement membrane, and the extracellular matrix. The characteristics of capillaries in various tissues are reviewed and some clinical corollaries considered. The oncotic pressure difference across the EGL opposes, but does not reverse, the filtration rate (the ‘no absorption’ rule) and is an important feature of the revised paradigm and highlights the limitations of attempting to prevent or treat oedema by transfusing colloids. Filtered fluid returns to the circulation as lymph. The EGL excludes larger molecules and occupies a substantial volume of the intravascular space and therefore requires a new interpretation of dilution studies of blood volume and the speculation that protection or restoration of the EGL might be an important therapeutic goal. An explanation for the phenomenon of context sensitivity of fluid volume kinetics is offered, and the proposal that crystalloid resuscitation from low capillary pressures is rational. Any potential advantage of plasma or plasma substitutes over crystalloids for volume expansion only manifests itself at higher capillary pressures.

Abstract
BACKGROUND: Postoperative acute kidney injury (AKI) is associated with increased perioperative morbidity and mortality in a variety of surgical settings, but has not been well studied after lung resection surgery. In the present study, we defined the incidence of postoperative AKI, identified risk factors, and clarified the relationship between postoperative AKI and outcome in patients undergoing lung resection surgery.

METHODS: A retrospective, observational study of patients who underwent lung resection surgery between January 2006 and March 2010 in a tertiary care academic center was conducted. Postoperative AKI was diagnosed within 72 hours after surgery based on the Acute Kidney Injury Network creatinine criteria. Logistic regression was used to model the association between perioperative factors and the risk of AKI within 72 hours after surgery. The relationship between postoperative AKI and patient outcome including mortality, days in hospital, and the requirement of reintubation was investigated.

RESULTS: A total of 1129 patients (pneumonectomy n = 71, bilobectomy n = 30, lobectomy n = 580, segmentectomy n = 35, wedge resection/bullectomy n = 413) were included in the final analysis. Patients were an average of 61 years (SD 15) and 50% were female. AKI was diagnosed in 67 patients (5.9%) based on Acute Kidney Injury Network criteria (stage 1, n = 59; stage 2, n = 8; and stage 3, n = 0) within 72 hours after surgery, and only 1 patient required renal replacement therapy. Multivariate analysis demonstrated an independent association between postoperative AKI and hypertension (adjusted odds ratio [OR] 2.0, 95% confidence interval [CI]: 1.1-3.8), peripheral vascular disease (OR 4.4, 95% CI: 1.8-10), estimated glomerular filtration rate (OR 0.8, 95% CI: 0.69-0.93), preoperative use of angiotensin II receptor blockers (OR 2.2, 95% CI: 1.1-4.4), intraoperative hydroxyethyl starch administration (OR 1.5, 95% CI: 1.1-2.1), and thoracoscopic (versus open) procedures (OR 0.37, 95% CI: 0.15-0.90). Development of AKI was associated with increased rates of tracheal reintubation (12% vs 2%, P < 0.001), postoperative mechanical ventilation (15% vs 3%, P < 0.001), and prolonged hospital length of stay (10 vs 8 days, P < 0.001). There was no difference in mortality between the 2 groups (3% vs 1%, P = 0.12).

CONCLUSIONS: Preoperative risk factors for AKI after lung resection surgery overlap with those established for other surgical procedures. Perioperative management seems to influence the risk of AKI after lung resection; in particular, the use of synthetic colloids may increase the risk, whereas thoracoscopic procedures may decrease the risk of AKI. Early postoperative AKI is associated with respiratory complications and prolonged hospitalization.

Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical
significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway
obstruction is an extremely rare event found almost exclusively in the intensive care unit. We
describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an
emergent return to CPB during valve replacement surgery. We used a rigid bronchoscope,
without an endotracheal tube, to facilitate airway patency in a patient with diffuse airway
bleeding after bronchial disimpaction to separate from CPB.

Background. This study was conducted to determine whether an alveolar recruitment
strategy (ARS) applied during two-lung ventilation (TLV) just before starting one-lung
ventilation (OLV) improves ventilatory efficiency.
Methods. Subjects were randomly allocated to two groups: (i) control group: ventilation with
tidal volume (VT) of 8 or 6 ml kg21 for TLV and OLV, respectively, and (ii) ARS group: same
ventilatory pattern with ARS consisting of 10 consecutive breaths at a plateau pressure of
40 and 20 cm H2O PEEP applied immediately before and after OLV. Volumetric capnography
and arterial blood samples were recorded 5 min (baseline) and 20 min into TLV, at 20 and
40 min during OLV, and finally 10 min after re-establishing TLV.
Results. Twenty subjects were included in each group. In all subjects, the airway
component of dead space remained constant during the study. Compared with baseline,
the alveolar dead space ratio (VDalv/VTalv) increased throughout the protocol in the
control but decreased in the ARS group. Differences in VDalv/VTalv between groups were
significant (P,0.001). Except for baseline, all PaO2 values in kPa (SD) were higher in the
ARS than in the control group (P,0.001), respectively [70 (7) and 55 (9); 33 (9) and 24
(10); 33 (8) and 22 (10); 70 (7) and 55 (10)].
Conclusions. Recruitment of both lungs before instituting OLV not only decreased alveolar
dead space but also improved arterial oxygenation and the efficiency of ventilation.
Keywords: lung, atelectasis; lung, gas exchange; surgery, thoracic; ventilation, dead space;
ventilation, one-lung ventilation

Objective. The authors sought to provide a snapshot of contemporary thoracic anesthetic practice in the United Kingdom and Ireland.
Design. An online survey.
Setting. United Kingdom.
Participants. An invitation to participate was e-mailed to all members of the Association of Cardiothoracic Anaesthetists.
Measurements and Main Results
A total of 132 responses were received; 2 were excluded because they did not originate from the United Kingdom. Values are number (percent).
Anesthetic Technique. The majority of respondents (109, 85%) maintain anesthesia with a volatile anesthetic agent, with a lesser proportion (20, 15%) reporting use of a total intravenous anesthetic technique. The majority of respondents (78, 61%) favor pressure control ventilation over volume control (50, 39%); just under half (57, 45%) report the routine use of positive end-expiratory pressure (median = 5 cmH2O [interquartile range (IQR), 4-5]). Fifty-two (40%) respondents report ventilating to a target tidal volume (median = 6 mL/kg [IQR, 5-7]). Most (114, 89%) respondents routinely ventilate with an FIO2 less than 1.0. Thoracic epidural blockade (TEB) is favored by nearly two thirds of respondents (80, 62%) compared with paravertebral block (39, 30%) and other analgesic techniques (10, 8%). Anesthesiologists favoring TEB are significantly less likely to prescribe systemic opioids (17, 21% v 39, 100% [p < 0.001]). Proponents of TEB are significantly more likely to “routinely” use vasopressor infusions both intra- and postoperatively (16, 20% v 0, 0% [p = 0.003] and 28, 35% v 4, 11% [p =0.013], respectively). Most respondents (127, 98%) report a double-lumen tube as their first choice. Many (82, 64%) report “rarely” using bronchial blockers.
Conclusions.
The authors hope this survey both provides interest and serves as a useful resource reflecting the current practice of thoracic anesthesia.

ABSTRACT
A joint initiative by the British Thoracic Society and the
Society for Cardiothoracic Surgery in Great Britain and
Ireland was undertaken to update the 2001 guidelines for
the selection and assessment of patients with lung cancer
who can potentially be managed by radical treatment.

SYNOPSIS OF RECOMMENDATIONS

SECTION 1: SELECTION OF PATIENTS FOR
RADICAL TREATMENT
1.1 Diagnosis and staging
1.1.1 Imaging
1. View all available historical images at the onset
of the diagnostic pathway and review them prior to
treatment. [C]
2. Ensure contemporaneous imaging is available at
the time of radical treatment. [C]
3. Ensure a CTscan that is <4 weeks old is available
at the time of radical treatment of borderline
lesions. [D]
4. Arrange a CT scan of the chest, lower neck and
upper abdomen with intravenous contrast medium
administration early in the diagnostic pathway for
all patients with suspected lung cancer potentially
suitable for radical treatment. [C]
5. Avoid relying on a CT scan of the chest as the
sole investigation to stage the mediastinal lymph
nodes. [B]
6. Ensure positron emission tomography (PET)-CT
scanning is available for all patients being considered
for radical treatment. [B]
7. Offer radical treatment without further mediastinal
lymph node sampling if there is no significant
uptake in normal sized mediastinal lymph nodes on
PET-CT scanning. [C]
8. Evaluate PET positive mediastinal nodes by
further mediastinal sampling. [C]
9. Confirm the presence of isolated distant
metastases/synchronous tumours by biopsy or
further imaging in patients being considered for
radical treatment. [C]
10. Consider MRI or CT scanning of the head in
patients selected for radical treatment, especially in
stage III disease. [C]
11. Evaluate patients with features suggestive of
intracranial pathology by an initial CT scan of the
head followed by MRI if normal or MRI as an
initial test. [C]
12. Biopsy adrenal lesions that show abnormal
uptake on PET-CT scanning before radical treatment.
[D]
13. RR The role of PET-CT scanning in patients
with small cell lung cancer considered suitable for
radical treatment should be evaluated in clinical
trials.
1.1.2 Endoscopic procedures for diagnosis and staging
14. When obtaining diagnostic and staging samples,
consider the adequacy of these in the context of
selection of patients for targeted therapy. [D]
15. Ensure biopsy samples are taken in adequate
numbers and size where there is negligible additional
risk to the patient. [D]
16. Use transbronchial needle aspiration (TBNA)
and endobronchial ultrasound/endoscopic ultrasound
(EBUS/EUS)-guided TBNA as an initial
diagnostic and staging procedure according to
findings on CT or PET-CT scans. [C]
17. Consider EBUS/EUS-guided TBNA to stage the
mediastinum. [C]
18. Confirm negative results obtained by TBNA
and EBUS/EUS-guided TBNA by mediastinoscopy
and lymph node biopsy where clinically appropriate.
[C]
19. RR The use of narrow band and autofluorescence
imaging should be investigated in clinical
trials.
1.1.3 7th Edition of TNM for lung tumours
20. The 7th edition of the TNM classification of
lung cancer should be used for staging patients
with lung cancer. [B]
21. The IASLC international nodal map should be
used in the assessment and staging of lymph node
disease. [C]
1.2 Management of specific disease subsets
1.2.1 T3 disease
22. Offer patients with T3N0e1M0 disease radical
treatment. [D]
1.2.2 T4 disease
23. Consider selected patients with T4N0e1M0 disease for
radical multimodality treatment. [D]
24. RR Consider clinical trials of radical treatment for T4
disease.
1.2.3 N2 disease
25. Consider radical radiotherapy or chemoradiotherapy in
patients with T1e4N2 (bulky or fixed) M0 disease. [B]
26. Consider surgery as part of multimodality management in
patients with T1e3N2 (non-fixed, non-bulky, single zone) M0
disease. [B]
27. RR Consider further randomised trials of surgery added to
multimodality management in patients with multi-zone N2
disease to establish if any subgroups of patients might benefit
more from the addition of surgery.
1.2.4 N3 disease
28. RR Consider clinical trials of radical treatment for patients
with T1e4N3M0 disease.
1.2.5 M1 disease
29. RR Consider clinical trials of radical treatment for patients
with M1a and M1b disease.
1.2.6 Bronchioloalveolar carcinoma
30. Offer suitable patients with single-site bronchioloalveolar
carcinoma anatomical lung resection. [C]
31. Consider multiple wedge resections in suitable patients with
a limited number of sites of bronchioloalveolar carcinoma. [C]
1.2.7 Open and close thoracotomy
32. Surgical units should have an open and close thoracotomy
rate of around 5%. [D]

SECTION 2: SURGERY
2.1 Assessment of the risks of surgery
2.1.1 Risk assessment for operative mortality
33. Consider using a global risk score such as Thoracoscore to
estimate the risk of death when evaluating and consenting
patients with lung cancer for surgery. [C]

2.1.2. Risk assessment for cardiovascular morbidity
34. Use the American College of Cardiology guidelines 2007 as
a basis for assessing perioperative cardiovascular risk. [C]
35. Avoid lung resection within 30 days of myocardial infarction.
[B]
36. Seek a cardiology review in patients with an active cardiac
condition or $3 risk factors or poor cardiac functional capacity.
[C]
37. Offer surgery without further investigations to patients with
#2 risk factors and good cardiac functional capacity. [B]
38. Begin optimisation of medical therapy and secondary
prophylaxis for coronary disease as early in the patient
pathway as possible. [C]
39. Continue anti-ischaemic treatment in the perioperative
period including aspirin, statins and b blockade. [B]
40. Discuss management of patients with a coronary stent
with a cardiologist to determine perioperative antiplatelet
management. [C]
41. Consider patients with chronic stable angina and conventional
ACC/AHA indications for treatment (coronary artery
bypass grafting and percutaneous coronary intervention) for
revascularisation prior to thoracic surgery. [C]

2.1.3 Assessment of lung function
42. Measure lung carbon monoxide transfer factor in all patients
regardless of spirometric values. [C]
43. Offer surgical resection to patients with low risk of
postoperative dyspnoea. [C]
44. Offer surgical resection to patients at moderate to high risk
of postoperative dyspnoea if they are aware of and accept the
risks of dyspnoea and associated complications. [D]
45. Consider using ventilation scintigraphy or perfusion
scintigraphy to predict postoperative lung function if a ventilation
or perfusion mismatch is suspected. [C]
46.Consider using quantitative CTorMRI to predict postoperative
lung function if the facility is available. [C]
47. Consider using shuttle walk testing as functional assessment
in patients with moderate to high risk of postoperative
dyspnoea using a distance walked of >400 m as a cut-off for
good function. [C]
48. Consider cardiopulmonary exercise testing to measure peak
oxygen consumption as functional assessment in patients with
moderate to high risk of postoperative dyspnoea using >15 ml/
kg/min as a cut-off for good function. [D]
49. RR Further studies with specific outcomes are required to
define the role of exercise testing in the selection of patients for
surgery.

2.1.4 Postoperative quality of life/dyspnoea
50. Avoid pneumonectomy where possible by performing
bronchoangioplastic resection or non-anatomical resection. [C]
51. Avoid taking pulmonary function and exercise tests as sole
surrogates for quality of life evaluation. [C]
52.Whenestimating quality of life, use a validated instrument.[D]

2.2 Surgical approach
2.2.1 Pulmonary resection
53. Employ segment counting to estimate postoperative lung
function as part of risk assessment for postoperative dyspnoea.
[D]
54. Consider patients with moderate to high risk of postoperative
dyspnoea for lung parenchymal sparing surgery. [D]
55. Consider bronchoangioplastic procedures in suitable patients
to preserve pulmonary function. [D]
56. Consider patients with limited pulmonary reserve for
sublobar resection as an acceptable alternative to lobectomy. [B]
57. RR Consider randomised trials of segmental resection versus
wedge resection.
58. Consider patients with concomitant lung cancer within
severe heterogeneous emphysema for lung resection based on
lung volume reduction surgery criteria. [B]
2.2.2 Lymph node management
59. Perform systematic nodal dissection in all patients undergoing
resection for lung cancer. [A]
60. Remove or sample a minimum of six lymph nodes or
stations. [D]

2.3 Chemotherapy
2.3.1 Preoperative chemotherapy
61. Patients with resectable lung cancer should not routinely be
offered preoperative chemotherapy. [B]
2.3.2 Postoperative chemotherapy
62. Offer postoperative chemotherapy to patients with TNM 7th
edition T1e3N1e2M0 non-small cell lung cancer. [A]
iii2 Thorax 2010;65(Suppl III):iii1eiii27. doi:10.1136/thx.2010.145938
Supplement
Downloaded from thorax.bmj.com on October 4, 2011 – Published by group.bmj.com
63. Consider postoperative chemotherapy in patients with TNM
7th edition T2e3N0M0 non-small cell lung cancer with tumours
>4 cm diameter. [B]
64. Use a cisplatin-based combination therapy regimen in
postoperative chemotherapy. [A]
65. RR Consider further trials of novel chemotherapeutic agents
in conjunction with surgical resection.

2.4 Postoperative radiotherapy
66. Postoperative radiotherapy (PORT) is not indicated after R0
complete resection. [A]
67. Consider PORT for patients with residual microscopic
disease at the resection margin where the benefit of reduction
in local recurrence outweighs the risk of mortality and
morbidity related to PORT. [C]
68. Use CT-planned three-dimensional conformal radiotherapy
for patients receiving PORT. [B]
69. Consider PORTafter completion of adjuvant chemotherapy.
[B]
70. RR Randomised trials looking at the effect of PORT in pN2
non-small cell lung cancer are recommended.

SECTION 3: RADICAL RADIOTHERAPY
3.1 Assessment of the risks of radiotherapy
3.1.1 Risks of radical radiotherapy
71. Perform three-dimensional treatment planning in patients
undergoing radical thoracic radiotherapy. [B]
72. A clinical oncologist specialising in lung oncology should
determine suitability for radical radiotherapy, taking into
account performance status and comorbidities. [D]
73. RR Clinical trials of radical radiotherapy should include
measures of lung function, outcome and toxicity.

3.2 Radiotherapy and chemoradiotherapy regimens
3.2.1 Early stage disease
74. Offer radical radiotherapy to patients with early stage
non-small cell lung cancer who have an unacceptable risk of
surgical complications. [B]
75. Consider CHART as a treatment option in patients with
early stage non-small cell lung cancer and unacceptable risk of
surgical complications. [A]
76. Consider stereotactic body irradiation in patients with early
stage non-small cell lung cancer and unacceptable risk of surgical
complications. [C]
3.2.2 Locally advanced disease
77. Offer chemoradiotherapy to patients with locally advanced
non-small cell lung cancer and good performance status who are
unsuitable for surgery. [A]
78. Offer selected patients with good performance status
concurrent chemoradiotherapy with a cisplatin-based chemotherapy
combination. [A]
79. Offer patients unsuitable for concurrent chemoradiotherapy
sequential chemoradiotherapy. [A]
80. Consider CHART as a treatment option for patients with
locally advanced non-small cell lung cancer. [A]

3.3 Other radical treatment
81. RR Randomised controlled trials are recommended
comparing conventional radical treatment (surgery, radical
radiotherapy) with other radical treatments where there is
evidence of efficacy in case series.
82. Consider alternative radical treatment in early stage lung
cancer in patients at high risk of morbidity and mortality with
conventional radical treatment. [D]
83. Consider radical brachytherapy in patients with early
invasive mucosal or submucosal non-small cell lung cancer. [D]

SECTION 4: SMALL CELL LUNG CANCER
4.1 Chemoradiotherapy
84. Offer selected patients with T1e4N0e3M0 limited stage
small cell lung cancer both chemotherapy and radiotherapy. [A]
85. Offer patients with T1e4N0e3M0 limited stage small cell
lung cancer and good performance status concurrent chemoradiotherapy.
[A]
86. Recommended treatment options for concurrent chemoradiotherapy
are twice daily thoracic radiotherapy (45 Gy in
3 weeks) with cisplatin and etoposide and 40 Gy once daily
delivered in 3 weeks. [A]
87. Offer patients unsuitable for concurrent chemoradiotherapy
sequential chemoradiotherapy. [A]
88. Offer prophylactic cranial irradiation to patients with
response to treatment and stable disease. [A]

4.2 Surgery
89. Consider patients with T1e3N0e1M0 small cell lung cancer
for surgery as part of multi-modality management. [D]
90. Surgical management of patients with T1e3N2M0 small cell
lung cancer should only be considered in the context of a clinical
trial. [C]

SECTION 5: PROVISION OF TREATMENT OPTIONS91. All available treatment options, including those that are the
subject of research, should be discussed with patients and their
carers and the risks and benefits presented so that they may
make an informed choice. [D]

Background. Meta-analysis and systematic reviews of epidural compared with paravertebral
blockade analgesia techniques for thoracotomy conclude that although the analgesia is
comparable, paravertebral blockade has a better short-term side-effect profile. However,
reduction in major complications including mortality has not been proven.
Methods. The UK pneumonectomy study was a prospective observational cohort study in
which all UK thoracic surgical centres were invited to participate. Data presented here
relate to the mode of analgesia and outcome. Data were analysed for 312 patients
having pneumonectomy at 24 UK thoracic surgical centres in 2005. The primary endpoint
was a major complication.
Results. The most common type of analgesia used was epidural (61.1%) followed by
paravertebral infusion (31%). Epidural catheter use was associated with major
complications (odds ratio 2.2, 95% confidence interval 1.1–3.8; P¼0.02) by stepwise
logistic regression analysis.
Conclusions. An increased incidence of clinically important major post-pneumonectomy
complications was associated with thoracic epidural compared with paravertebral
blockade analgesia. However, this study is unable to provide robust evidence to change
clinical practice for a better clinical outcome. A large multicentre randomized controlled
trial is now needed to compare the efficacy, complications, and cost-effectiveness of
epidural and paravertebral blockade analgesia after major lung resection with the
primary outcome of clinically important major morbidity.

Background: The increased tidal volume (VT) applied tothe ventilated lung during one-lung ventilation (OLV) enhancescyclic alveolar recruitment and mechanical stress. It isunknown whether alveolar recruitment maneuvers (ARMs)and reduced VT may influence tidal recruitment and lungdensity. Therefore, the effects of ARM and OLV with differentVT on pulmonary gas/tissue distribution are examined.Methods: Eight anesthetized piglets were mechanically ventilated(VT 10 ml/kg). A defined ARM was applied to thewhole lung (40 cm H2O for 10 s). Spiral computed tomographiclung scans were acquired before and after ARM.Thereafter, the lungs were separated with an endobronchialblocker. The pigs were randomized to receive OLV in thedependent lung with aVT of either 5 or 10 ml/kg. Computedtomography was repeated during and after OLV. The voxelswere categorized by density intervals (i.e., atelectasis, poorlyaerated, normally aerated, or overaerated). Tidal recruitmentwas defined as the addition of gas to collapsed lung regions.Results: The dependent lung contained atelectatic (5610 ml),poorly aerated (18310 ml), and normally aerated (18729 ml)regions before ARM. After ARM, lung volume and aeration increased(42635 vs. 52669 ml). Respiratory compliance enhanced,and tidal recruitment decreased(95%vs.79%of the wholeend-expiratory lung volume).OLVwith10ml/kgfurther increasedaeration (atelectasis, 152 ml; poorly aerated, 9424 ml; normallyaerated, 580 98 ml) and tidal recruitment (81% of thedependent lung). OLV with 5 ml/kg did not affect tidal recruitmentor lung density distribution. (Data are given as meanSD.)Conclusions: The ARM improves aeration and respiratorymechanics. In contrast to OLV with high VT, OLV withreduced VT does not reinforce tidal recruitment, indicatingdecreased mechanical stress.