Regional anesthesia and pain management have experienced advances in recent years, especially with the advent of fascial plane blocks. The erector spinae plane block is one of the newest techniques to be described. In the past two years, publications referring to ESP block have increased significantly. The objective of this review is to analyze the articles about ESP block that have been published to date. We performed a search in the main databases and identified 368 articles. After a selection of the relevant articles, 125 studies were found eligible and were included in the review. The ESP block is performed by depositing the local anesthetic in the fascial plane, deeper than the erector spinae muscle at the tip of the transverse process of the vertebra. Many cases of its use have been described with satisfactory results in the treatment of both acute pain and chronic pain. The applicability of the technique covers many clinical scenarios. Of the 98 case reports reviewed, 12 and 87 articles, respectively described the technique as a treatment for chronic pain and acute pain. The single-shot was the most frequently used technique. As described in the articles published to date, the technique is easy to perform and has a low rate of complications. However, despite the effectiveness of the technique, further studies are necessary to obtain more evidence of its actions.

Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM. PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m2, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH2O with lung RM, or PEEP of 5 cmH2O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint. PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery. The trial was registered in clinicaltrials.gov ( NCT02963025 ) on 15 November 2016.

This article is the third in a series of articles prepared as part of a comprehensive, international and professional society-approved consensus project to advise on thoracic anesthesia. It represents the views and structured opinions of experts delegated to the Airway Management Task Force of the Thoracic Subcommittee of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC). This review highlights the main concepts and expert opinion of international leaders on the task of lung isolation and separation, as well as the current recommendations on the benefits and disadvantages of different devices in both routine and difficult airway scenarios. The consensus statement addresses the following main clinical topics and questions: (1) What are the overall goals and means of lung isolation and separation? (2) What are the best practices for using double-lumen tubes? (3) What is the role of alternative devices, specifically bronchial blockers? (4) What are the best practices for managing a difficult airway? (5) What are the recommendations for special cases? (6) What are the research priorities for thoracic anesthesia regarding airway management? The authors conclude with a brief reference to how these recommendations relate to the concepts of good clinical practice and enhanced recovery. The document was developed and formally evaluated by senior clinicians representing the core membership of the EACTAIC Thoracic Subcommittee from Europe, the United States, Africa, and the Middle East. Although the high-level evidence base is generally limited and significant controversies remain, all recommendations of the Task Force achieved an agreed (>60%), strong (>80%), or sometimes full (>95%) consensus. This consensus should serve as a consolidation of diverse practices of thoracic anesthesia and a starting point toward obtaining stronger evidence to further enhance our clinical practice in the future.

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

Airway management during the COVID-19 pandemic has been one of the most challenging aspects of care that anesthesiologists and intensivists face. This study was conducted to evaluate the management of tracheal intubation in patients with suspected or confirmed COVID-19 infection. This is a cross-sectional and international multicenter study based on a 37-item questionnaire. The survey was available to physicians who had performed intubations and tracheostomies in patients with suspected or confirmed COVID-19 and had provided informed consent to participate. The primary outcome is the preference to use a specific device for tracheal intubation. Secondary outcomes are clinical practice variables, use of video laryngoscopes, difficult airway management, and safety features to prevent cross-infection. This study included 2411 physicians who performed an average of 11.90 and 20.67 tracheal intubations in patients diagnosed or suspected of having COVID-19 disease, respectively. Physicians were mainly from the specialties of Anesthesiology (61.2%) and Intensive Care (7.4%). COVID-19 infection diagnosed by positive PCR or serology in physicians participating in intubation in this study was 15.1%. Respondents considered preoxygenation for more than three minutes very useful (75.7%). The preferred device for tracheal intubation was the video laryngoscope (64.8%). However, the direct laryngoscope (57.9%) was the most commonly used, followed by the video laryngoscope (37.5%). The preferred device to facilitate intubation was the Eschmann guide (34.2%). Percutaneous tracheostomy was the preferred technique (39.5%) over the open tracheostomy (22%). The predicted or unpredicted difficult airway management in these patients was preferably performed with a video laryngoscope (61.7% or 63.7, respectively). Intubation was mostly performed by two or more expert airway physicians (61.6%). The use of personal protective equipment increased the practitioners’ discomfort during intubation maneuvers. The video laryngoscope is the preferred device for intubating patients with COVID-19, combined with the Eschmann guide, flexible stylet within the endotracheal tube, or Frova guide to facilitate intubation. The sub-analysis of the two groups of physicians by the level of intubation experience showed a higher use of the video laryngoscope (63.4%) in the experts group and no significant differences between the two groups in terms of cross-infection rates in physicians, in their preference for the use of the video laryngoscope or in the number of intubations performed in confirmed or suspected COVID-19 patients.