Severe reperfusion lung injury after double lung transplantation

AIM: To demonstrate the effects of combined inhaled nitric oxide and surfactant replacement as treatment for acute respiratory distress syndrome. This treatment has not previously been documented for reperfusion injury after double lung transplantation. METHOD: A 24-year-old female with cystic fibrosis underwent double lung transplantation. During implantation of the second lung a marked increase in pulmonary artery pressure associated with systemic hypotension, hypoxemia and low cardiac output were observed. Notwithstanding the patient received support from cardiovascular drugs and pulmonary vasodilators cardiopulmonary by-pass was necessary. In the intensive care unit the patient received the same drug support, inhaled nitric oxide and two bronchoscopic applications of bovine surfactant. RESULTS: A rapid improvement in PaO(2)/FiO(2) within 2–3 hours of administration of surfactant was seen. The patient is well at follow-up 1 year post-transplant. CONCLUSION: There is a potential role for a combined therapy with inhaled nitric oxide and surfactant replacement in reperfusion injury after lung transplantation

Acute hemodynamic effects of inhaled nitric oxide, dobutamine and a combination of the two in patients with mild to moderate secondary pulmonary hypertension

INTRODUCTION: The use of low-dose dobutamine to maintain hemodynamic stability in pulmonary hypertension may have a detrimental effect on gas exchange. The aim of this study was to investigate whether inhaled nitric oxide (INO), dobutamine and a combination of the two have beneficial effects in patients with end-stage airway lung disease and pulmonary hypertension. METHOD: Hemodynamic evaluation was assessed 10 min after the administration of each drug and of their combination, in 28 candidates for lung transplantation. RESULTS: Administration of INO caused a reduction in mean pulmonary arterial pressure (MPAP), an increase in PaO(2) with a significant reduction in venous admixture effect (Q(s)/Q(t)).Dobutamine administration caused an increase in cardiac index and MPAP, with a decrease in PaO(2) as a result of a higher Q(s)/Q(t). Administration of a combination of the two drugs caused an increase in the cardiac index without MPAP modification and an increase in PaO(2) and Q(s)/Q(t). CONCLUSION: Dobutamine and INO have complementary effects on pulmonary circulation. Their association may be beneficial in the treatment of patients with mild to moderate pulmonary hypertension

Fluorescence-guided lung nodule identification during minimally invasive lung resections

In the last few years, minimally invasive surgery has become the standard routine practice to manage lung nodules. Particularly in the case of robotic thoracic surgery, the identification of the lung nodules that do not surface on the visceral pleura could be challenging. Therefore, together with the evolution of surgical instruments to provide the best option in terms of invasiveness, lung nodule localization techniques should be improved to achieve the best outcomes in terms of safety and sensibility. In this review, we aim to overview all principal techniques used to detect the lung nodules that do not present the visceral pleura retraction. We investigate the accuracy of fluorescence guided thoracic surgery in nodule detection and the differences among the most common tracers used

Decurarization After Thoracic Anesthesia using sugammadex compared to neostigmine (DATA trial): a multicenter randomized double-blinded controlled trial

Abstract Background Thoracic surgery is a high-risk surgery especially for the risk of postoperative pulmonary complications. Postoperative residual paralysis has been shown to be a risk factor for pulmonary complications. Nevertheless, there are few data in the literature concerning the use of neuromuscular blocking agent antagonists in patients undergoing lung surgery. Methods Seventy patients were randomized in three Italian centers to receive sugammadex or neostigmine at the end of thoracic surgery according to the depth of the residual neuromuscular block. The primary outcome was the time from reversal administration to a train-of-four ratio (TOFR) of 0.9. Secondary outcomes were the time to TOFR of 1.0, to extubation, to postanesthesia unit (PACU) discharge, postoperative complications until 30 days after surgery, and length of hospital stay. Results Median time to recovery to a TOFR of 0.9 was significantly shorter in the sugammadex group compared to the neostigmine one (88 vs. 278 s — P < 0.001). The percentage of patients who recovered to a TOFR of 0.9 within 5 min from reversal administration was 94.4% and 58.8% in the sugammadex and neostigmine groups, respectively (P < 0.001). The time to extubation, but not the PACU stay time, was significantly shorter in the sugammadex group. No differences were found between the study groups as regards postoperative complications and length of hospital stay. The superiority of sugammadex in shortening the recovery time was confirmed for both deep/moderate and shallow/minimal neuromuscular block. Conclusions Among patients undergoing thoracic surgery, sugammadex ensures a faster recovery from the neuromuscular block and earlier extubation compared to neostigmine

Transesophageal Endoscopic Ultrasound Fine Needle Biopsy for the Diagnosis of Mediastinal Masses: A Retrospective Real-World Analysis

Background: Endoscopic ultrasound (EUS) plays an important role in the diagnosis and staging of thoracic disease. Our report studies the diagnostic performance and clinical impact of EUS fine needle aspiration (FNA) in a homogenous cohort of patients according to the distribution of the enlarged MLNs or pulmonary masses. Methods: We retrospectively reviewed the diagnostic performance of 211 EUS-FNA in 200 consecutive patients with enlarged or PET-positive MLNs and para-mediastinal masses who were referred to our oncological center between January 2019 and May 2020. Results: The overall sensitivity of EUS-FNA was 85% with a corresponding negative predictive value (NPV) of 56% and an accuracy of 87.5%. The sensitivity and accuracy in patients with abnormal MLNs were 81.1% and 84.4%, respectively. In those with para-mediastinal masses, sensitivity and accuracy were 96.4% and 96.8%. The accuracy for both masses and lymph nodes was 100%, and in the LAG (left adrenal gland), it was 66.6%. Conclusions: Our results show that, in patients with suspected mediastinal masses, EUS-FNA is an accurate technique to evaluate all reachable mediastinal nodal stations, including station 5

Is very early extubation after lung transplantation feasible?

OBJECTIVE: To evaluate donor graft function, intraoperative blood consumption, and oxygenation and hemodynamic stability in patients undergoing lung transplantation. DESIGN: Prospective pilot study. SETTING: University hospital. PARTICIPANTS: Forty-three patients undergoing lung transplantation from January 1999 to June 2001. INTERVENTIONS: Hemodynamic monitoring, early extubation, and noninvasive ventilation criteria. MEASUREMENTS AND MAIN RESULTS: The 31 nonearly extubated patients showed a lower PaO(2)/fraction of inspired oxygen (F(I)O(2)), a higher mean pulmonary arterial pressure, extravascular lung-water index (EVLWI) and vasoactive drug support (norepinephrine), and more blood products consumption than 12 early extubated patients at the end of surgery. Seven of 12 early extubated patients did not show any signs of respiratory failure after tracheal extubation; they were alert and able to perform deep breathing exercise and coughing. In the other 5 patients, hypoxemia, hypercapnia, and an increase of respiratory rate &gt;30 breaths/min were observed. The intermittent application of noninvasive pressure ventilation by face mask avoided endotracheal intubation. CONCLUSION: The use of a short-acting anesthetic drug, appropriate intraoperative extubation criteria, epidural analgesia, and postoperative noninvasive ventilation make early extubation of lung-transplanted patients possible and effective

[Hemodynamic changes during continuous infusion with dobutamine in candidates for lung transplantation. Lung Transplantation Group].

The aim of this study is to analyze the effects of dobutamine (DBT) on pulmonary and systemic hemodynamics and oxygenation in lung transplant candidates. Forty-five patients (21M, 24F) to be introduced in waiting list for lung transplantation were studied (14 pulmonary fibrosis, 15 COPD, and 16 cystic fibrosis). They were studied awake, while spontaneously breathing in two different phases: baseline--O2 100%; DBT phase--O2 100% after 10 minutes of DBT continuous infusion (10 mcg/Kg/min). Blood gas samples and hemodynamic data were collected during right heart catheterization. Data were statistically analyzed with Student's "t" test and values for p < 0.05 were considered as significant. During DBT phase, a significant increase of cardiac output with a decreasing in systemic and pulmonary vascular resistance was observed. Since the fall in pulmonary vascular resistance (PVRI) was not proportional to the increase of cardiac output, mean pulmonary artery pressure and transpulmonary gradient increased. The prevalent role of vascular recruitment as mechanism in PVRI reduction during DBT is supported by the concomitant fall in PaO2/FiO2. This strongly suggests a worsening of regional Va/Qc due to an increased perfusion of poorly ventilated areas. DBT reduces PVRI through a recruitment of vessels due to an increase of pulmonary flow. Dobutamine has a favorable hemodynamic effect in mild-to-moderate pulmonary hypertension in lung transplant candidates