Peter Slinger Editor

Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger

Randal S. Blank · Javier Campos

Jens Lohser and Karen McRae
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Associate Editors

Principles and Practice

of Anesthesia for
Thoracic Surgery

Second Edition

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 Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger

Principles and Practice of Anesthesia for Thoracic

Surgery
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 Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger

Peter Slinger
Editor
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Randal S. Blank · Javier Campos
Jens Lohser · Karen McRae
Associate Editors

Principles and Practice

of Anesthesia for Thoracic
Surgery
Second Edition

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 Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger
Editor
Peter Slinger
Department of Anesthesiology
University of Toronto
Toronto, ON
Canada
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ISBN 978-3-030-00858-1 ISBN 978-3-030-00859-8 (eBook)

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The Editor would like to thank the members of his family for their never-
ending support and patience.
Photo Left to right:
Back row: Colin (son-in-law), Eric (baby, grandson), Lee (daughter), Peter
(editor), Rusty (wife), Robyn (daughter-in-law), Luke(son).
Front row: Reagan (grand-daughter,) Jake (grandson), Bruce (Luke’s dog)

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 Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger

Preface

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It has been 8 years since the Associate Editors (Randall Blank, Javier Campos, and Karen
McRae) and I assembled the first edition of Principles and Practice of Anesthesia for Thoracic
Surgery. In this time period, there has been considerable evolution in the anesthetic manage-
ment of patients requiring anesthesia for non-cardiac intrathoracic diagnostic and therapeutic
procedures. We felt that it would be useful to update and expand the original text for practitio-
ners of thoracic anesthesia at all levels including Staff Anesthesiologists, Residents, Fellows,
Nurse Anesthetists, Nurse Practitioners, Anesthesia Assistants, and other Allied Health
Professionals. We welcome the addition of Jens Lohser, from the University of British
Columbia, as an Associate Editor for this second edition.
Among the major advances that we address in this new edition, we include the expanded
role of ultrasound beyond transesophageal echocardiography (Chap. 30): Lung ultrasound has
evolved from a curious pattern of artifacts to an essential clinical role in chest trauma and
management of pleural effusions (Chap. 28). Ultrasound is now an established tool for the
placement of many types of central and peripheral vascular access (Chap. 29). And, ultrasound
has permitted the development of several new regional anesthetic blocks (e.g., serratus anterior
and erector spinae, Chap. 59) that are useful modalities for management of postoperative pain.
Also new in this edition is the role of extracorporeal membrane oxygenation (ECMO)
(Chap. 27) in thoracic anesthesia. Veno-venous ECMO is becoming an established therapeutic
option for management of intraoperative hypoxemia in complex types of lung and airway sur-
gery and in whole lung lavage. Venoarterial ECMO is rapidly replacing cardiopulmonary
bypass as the main method of extracorporeal lung support in lung transplantation (Chap. 47).
There have been major advances in postoperative pain management for thoracic surgery in
this decade. In addition to the new blocks mentioned above, the book covers the expanded use
of paravertebral blocks and the use of long-acting local anesthetics (Chap. 60). Also, there have
been a variety of new bronchial blockers and modified double-lumen tubes developed that
facilitate lung isolation in patients with difficult airways (Chaps. 16, 17, and 18).
We would like to welcome the first Authors of new chapters.
Among these are:

• Daniel Sellers (University of Toronto, Intraoperative Extracorporeal Lung Support for

Pulmonary and Airway Surgery, Chap. 27)
• Rebecca Klinger (Duke University, Perioperative Fluid Management in Thoracic Surgery,
Chap. 21)
• Danielle Shafiepour (McGill University, Trouble-Shooting One-Lung Ventilation,
Chap. 26)
• Nathan Ludwig (University of Western Ontario, Lung Ultrasound, Chap. 28)
• Natalie Silverton (University of Utah, Ultrasound for Vascular Access, Chap. 29)
• Alexander Huang (University of Toronto, Pulmonary Resection in the Patient with
Pulmonary Hypertension, Chap. 34)
• Helen Lindsay (New Zealand, Anesthesia for Open Descending Thoracic Aortic Surgery,
Chap. 41)

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 viii Preface
Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger
• Andrew Levin (Stellenbosch University, Cape Town, South Africa, Bronchopleural Fistula,
Chap. 43)
• Maureen Cheng (Cambridge University, Anesthesia for the Patient with a Previous Lung
Transplant, Chap. 48)
• Emily Teeter (University of North Carolina, Enhanced Recovery After Thoracic Surgery,
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Chap. 52)
• Hadley Wilson (University of North Carolina, Trouble-Shooting Chest Drains, Chap. 58)
• Wendell H. Williams III (MD Anderson Cancer Center, Long-Acting Local Anesthetics for
Post-Thoracotomy Pain, Chap. 60)

We would also like to welcome several new first Authors of previous chapters, including
Drs. Amanda Kleiman (University of Virginia, Non-respiratory Functions of the Lung, Chap.
7), Javier Lasala (MD Anderson Cancer Center, Intravenous Anesthesia for Thoracic
Procedures, Chap. 12), Lorraine Chow (University of Alberta, Anesthesia for Patients with
Mediastinal Masses, Chap. 14), Daniel Tran (Yale School of Medicine, Lung Isolation in
Patients with Difficult Airways, Chap. 18), Jennifer Macpherson (University of Rochester,
Intraoperative Ventilation Strategies for Thoracic Surgery, Chap. 22), Florin Costescu (McGill
University, Anesthesia for Patients with End-Stage Lung Disease, Chap. 31), George
Kanellakos (Dalhousie University, Thoracic Surgery for Morbidly Obese Patients and Patients
with Obstructive Sleep Apnea, Chap. 33), Valerie Rusch (Memorial Sloan Kettering Cancer
Center, Pancoast Tumors and Combined Spinal Resections, Chap. 37), Swapnil Parab (Tata
Memorial Hospital, Mumbai, India, Thoracic Anesthesia in the Developing World, Chap. 42),
Timothy Maus (UC San Diego, Anesthesia for Pulmonary Thromboendarterectomy, Chap.
49), Michael Hall (University of Pennsylvania, Anesthetic Management of Post-Thoracotomy
Complications, Chap. 53), and Wendy Smith (UC San Francisco, Postoperative Respiratory
Failure and Treatment, Chap. 54).
New to the second edition is the incorporation of video. Relevant video clips will be avail-
able online to readers of the print text. For the online text, streaming video clips will allow the
reader to point and click to see techniques as they are described. This is particularly useful for
ultrasound-guided procedures and lung isolation.
Personally, I would like to thank the returning Authors and Coauthors from the first edition
for the thorough updates of their previous chapters. Thank you to the Associate Editors for
their hard work and support. And, thank you to the Editors at Springer Clinical Medicine,
Daniel Dominguez and Becky Amos, for their encouragement.

Toronto, ON, Canada Peter Slinger

March 2018

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 Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger

Contents

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Part I Introduction
1 History of Thoracic Anesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ian Conacher

Part II Preoperative Evaluation

2 Preanesthetic Assessment for Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . 13
Peter Slinger and Gail Darling
3 Thoracic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Javier Campos and Kalpaj R. Parekh

Part III Thoracic Anatomy, Physiology, and Pharmacology

4 Essential Anatomy and Physiology of the Respiratory System
and the Pulmonary Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
J. Michael Jaeger, Brian J. Titus, and Randal S. Blank
5 Physiology of the Lateral Decubitus Position, Open Chest, and One-Lung
Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Sean R. McLean and Jens Lohser
6 Clinical Management of One-Lung Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . 107
Travis Schisler and Jens Lohser
7 Nonrespiratory Functions of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Amanda M. Kleiman and Keith E. Littlewood
8 Pharmacology of the Airways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Cassandra Bailey, Paul J. Wojciechowski, and William E. Hurford
9 Pharmacology of the Pulmonary Circulation. . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Cara Reimer and John Granton
10 Perioperative Lung Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Peter Slinger

Part IV Diagnostic and Therapeutic Procedures of the Trachea and Airways

11 Bronchoscopic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Gordon N. Finlayson, Tawimas Shaipanich, and Chris Durkin
12 Intravenous Anesthesia for Thoracic Procedures . . . . . . . . . . . . . . . . . . . . . . . 219
Javier D. Lasala and Ron V. Purugganan

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 x Contents
Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger
13 Tracheal Resection and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Karen McRae

Part V Diagnostic and Therapeutic Procedures of the Mediastinum

14 Anesthesia for Patients with Mediastinal Masses . . . . . . . . . . . . . . . . . . . . . . . 251
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Lorraine Chow
15 Thymic Surgery and Paraendocrine Syndromes . . . . . . . . . . . . . . . . . . . . . . . . 265
Daniel Sellers and Karen McRae

Part VI Anesthetic Management for Intra-Thoracic Surgery

16 Lung Isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Javier Campos
17 Fiberoptic Bronchoscopy for Positioning Double-Lumen Tubes and Bronchial
Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Javier Campos
18 Lung Isolation in Patients with Difficult Airways . . . . . . . . . . . . . . . . . . . . . . . 323
Daniel Tran and Wanda M. Popescu
19 Intraoperative Patient Positioning and Neurological Injuries . . . . . . . . . . . . . 337
Cara Reimer and Peter Slinger
20 Intraoperative Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Gabriel E. Mena, Karthik Raghunathan, and William T. McGee
21 Fluid Management in Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Rebecca Y. Klinger
22 Intraoperative Ventilation Strategies for Thoracic Surgery . . . . . . . . . . . . . . . 375
Jennifer A. Macpherson
23 Anesthesia for Open Pulmonary Resection: A Systems Approach . . . . . . . . . . 389
E. Andrew Ochroch, Gavin Michael Wright, and Bernhard J. C. J. Riedel
24 Anesthesia for Video-Assisted Thoracoscopic Surgery (VATS) . . . . . . . . . . . . 413
Edmond Cohen and Peter Slinger
25 Anesthesia for Non-intubated Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . 425
Peter Slinger
26 Troubleshooting One-Lung Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Danielle Sophia Shafiepour
27 Intraoperative Extracorporeal Life Support for Thoracic
and Airway Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Daniel Sellers, Karen Lam, and Karen McRae

Part VII Applications of Ultrasound in Thoracic Anesthesia

28 Pulmonary Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
Nathan Ludwig and Ahmed F. Hegazy
29 Ultrasound for Vascular Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
James P. Lee, Joshua M. Zimmerman, and Natalie A. Silverton
30 Intraoperative Transesophageal Echocardiography
for Thoracic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Massimiliano Meineri

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Principles and Practice of Anesthesia for Thoracic Surgery (2nd Edition) Slinger
Part VIII Specific Patient Consideration
31 Anesthesia for Patients with End-Stage Lung Disease . . . . . . . . . . . . . . . . . . . 509
Florin Costescu and Martin Ma
32
Thoracic Surgery in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
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Maria D. Castillo, Jeffrey Port, and Paul M. Heerdt
33 Thoracic Anesthesia for Morbidly Obese Patients and Obese Patients with
Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
George W. Kanellakos and Jay B. Brodsky
34 Pulmonary Resection in the Patient with Pulmonary Hypertension . . . . . . . . 561
Alexander Huang and Katherine Marseu

Part IX Complex Thoracic Surgical Procedures

35 Surgery of the Chest Wall and Diaphragm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Peter Slinger
36 Extrapleural Pneumonectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587
Ju-Mei Ng
37 Pancoast Tumors and Combined Spinal Resections . . . . . . . . . . . . . . . . . . . . . 597
Valerie W. Rusch, Ilya Laufer, Mark Bilsky, Alexandra Lewis,
and David Amar
38 Anesthesia for Esophageal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Randal S. Blank, Stephen R. Collins, Julie L. Huffmyer,
and J. Michael Jaeger
39 Anesthesia for Robotic Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651
Javier Campos
40 Anaesthesia for Combined Cardiac and Thoracic Procedures . . . . . . . . . . . . . 661
Marcin Wąsowicz
41 Open Thoracoabdominal Aortic Aneurysm Repair. . . . . . . . . . . . . . . . . . . . . . 675
Helen A. Lindsay, Coimbatore Srinivas, and Maral Ouzounian

Part X Anesthetic Management of Uncommon Pulmonary Procedures

42 Thoracic Anesthesia in the Developing World . . . . . . . . . . . . . . . . . . . . . . . . . . 699
Swapnil Yeshwant Parab and Sheila Nainan Myatra
43 Bronchopleural Fistulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
Andrew Ian Levin
44 Massive Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
Jean S. Bussières and Marili Frenette
45 Whole Lung Lavage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
Jean S. Bussières and Etienne J. Couture

Part XI Anesthesia for Surgical Procedures for End-Stage Lung Diseases

46 Lung Volume Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761
Erin A. Sullivan
47 Lung Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773
Andrew Roscoe and Rebecca Y. Klinger

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