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Advanced therapy in thoracic surgery - part 5

Một nhóm khoa gây mê có kinh nghiệm làm việc trong hợp tác chặt chẽ với nhóm phẫu thuật là cần thiết. Thay thế tự thở với thông khí áp lực dương có thể chuyển đổi một tổn thương một phần cản trở thành một tắc nghẽn hoàn toàn. Khi bảo trì đường thở là một mối quan tâm, thở xuống với một tác nhân | 220 Advanced Therapy in Thoracic Surgery steriods. Tracheostomies may be useful in some patients as the only way to secure an airway. When possible they should be placed through the stenosis preserving the uninvolved trachea for future reconstruction. Anesthesia An experienced anesthesiology team working in close cooperation with the surgical team is essential. Replacement of spontaneous breathing with positive pressure ventilation can convert a partially obstructing lesion into a complete obstruction. When maintenance of the airway is a concern a breathe down with an inhalation agent is employed and paralytics given once the airway is secured.20 Anesthesia is maintained with total intravenous anesthesia TIVA using short-acting agents such as remifentanil and propofol. This allows immediate extubation at the completion of the procedure and maintains continuous anesthesia during periods when inhala-tional agents are interrupted by the procedure. When a thoracotomy incision is used epidural anesthesia significantly decreases thoracotomy pain. For lower tracheal and carinal resections endotracheal intubation is accomplished with an extra-long armored endotracheal tube. Its flexibility allows bronchoscopic placement into one of the main stem bronchi. After transecting the airway the orotracheal tube is pulled back into the trachea and intermittent ventilation is performed with sterile crossfield equipment. The orotracheal tube is again advanced once the anastomosis is completed. The anesthesiology team should be familiar with the techniques of high-frequency jet ventilation. Cardiopulmonary bypass is not helpful and only introduces unnecessary risks. Simple Tracheal Resection This section describes our technique for uncomplicated resections of the middle and upper trachea. Rigid bronchoscopy with dilation is performed at the time of planned resection and if the lesion appears amenable to surgery the patient is intubated positioned and prepared for incision. For most .