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
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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.

Background. Paravertebral regional anaesthesia is used to treat pain after several surgical
procedures. This study aimed to improve on our first published ultrasound-guided approach
to the paravertebral space (PVS) and to investigate a possible discrepancy between the
needle, catheter, and contrast dye position.
Methods. In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches
combined with loss of resistance (LOR) and after an interim analysis performed 36 novel,
pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was
controlled by a first computed tomography (CT) scan. After placement of the catheters,
the tips were assessed by a second CT and the spread of injected contrast dye was
assessed by further CT scans. The part of the PVS near the intervertebral foramen was
defined as the primary target to reach.
Results. The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34
(94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches
were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed:
three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of
LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected
in the epidural space. In two cases, insertion of the catheter was not possible. In cases
with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (SD)]
vertebral segments.
Conclusions. Our new PUSG technique has a high success rate for paravertebral needle
placement. Although needles were correctly positioned, catheters were usually found
distant from the needle-tip position.
Keywords: anatomy, regional; intercostal nerv

Background: Protective ventilation strategy has been shown to reduce ventilator-induced
lung injury in ARDS patients. In this study, we questioned whether protective ventilatory
settings would attenuate lung impairment during one lung ventilation (OLV) compared to
conventional ventilation in patients undergoing lung resection surgery.
Methods: One hundred ASA 1-2 patients scheduled for an elective lobectomy were
enrolled in the study. During OLV, two different ventilation strategies were compared. The
conventional strategy (CV group, n=50) consisted of FiO2 1.0, VT 10 ml/kg, ZEEP, and
volume-controlled ventilation, while the protective strategy (PV group, n=50) consisted of
FiO2 0.5, VT 6 ml/kg, PEEP 5 cm H2O, and pressure-controlled ventilation. The composite
primary endpoint included, PaO2/FiO2 < 300 mmHg and/or the presence of newly developed lung lesions (lung infiltration and atelectasis) within 72 hours of the operation. To monitor safety during OLV, SpO2, PaCO2, and PIP were repeatedly measured. Results: During OLV, although 58% of the PV group needed elevated FiO2 to maintain an SpO2 above 95%, PIP was significantly lower than in the CV group whereas the mean PaCO2 values remained at 35-40 mmHg in both groups. Importantly, in the PV group, the incidence of the primary endpoint of pulmonary dysfunction was significantly lower than in the CV group (the incidence of PaO2/FiO2 < 300 mmHg, lung infiltration, or atelectasis : 4% vs. 22%, P < 0.05). Conclusion: Compared with the traditional large VT and volume-controlled ventilation, the application of small VT and PEEP through pressure-controlled ventilation was associated with a lower incidence of postoperative lung dysfunction and satisfactory gas exchange.

Background. The need to compromise between surgical
and anesthetic access in airway surgery is an important
clinical problem. We wanted to determine the feasibility
of performing upper airway surgery under awake anesthesia
and spontaneous respiration.
Methods. This was a prospective, clinical feasibility
study. Patients with upper tracheal stenosis were managed
through cervical epidural anesthesia and conscious
sedation, and atomized local anesthetic. No intraoperative
intubation or jet ventilation was required. Outcome
measures were ease of surgery, observer-rated functional
result, early (less than 30 days) complications, and patient-
reported satisfaction.
Results. Twenty consecutive patients with idiopathic
(n
4) or postintubation (n
16) complete (n
3) or
severe (>80%, n
17) subglottic (n
12) or upper trachea
(n
8) stenosis were enrolled. Operations included 12
subglottic and 8 segmental resections with primary anastomosis.
Permissive hypercapnia was well tolerated. Median
length of resection was 4.5 cm (range, 2 to 6 cm), and
12 releases (8 thyrohyoid, 4 suprahyoid) were required.
One patient required a nasotracheal tube for 36 hours. All
but 1 were able to cough and talk immediately, and to
swallow fluids and solids, and were fully mobilized at 6
hours. There were no early complications. Median hospitalization
was 3.1 days (range, 2 to 15). Patients had
excellent (n
16) or good (n
4) functional (n
20)
outcomes, with no early relapse of stenosis. Median
self-reported satisfaction at median 12 months was 9.5 
1.0 (scale, 0 to 10). All patients indicated that they would
be happy to repeat the procedure.
Conclusions. Awake and tubeless upper airway surgery
is feasible and safe, and has a high level of patient
satisfaction. If supported by randomized controlled trial,
this method will change the way airway stenosis surgery
is approached by both surgeons and anesthesiologist.

Bangalore Lung Protectupload,10,10

Bangalore Preop 20,10,10