Lung transplantation (LTx) is the definitive treatment for end-stage pulmonary disease. About 4500 LTxs are performed annually worldwide. It is considered challenging and complex surgery regarding anaesthesia and pain management. While providing adequate analgesia is crucial for patient comfort, early mobilisation and prevention of postoperative pulmonary complications, standardising an analgesic protocol is challenging due to the diversity of aetiologies, surgical approaches and the potential use of extracorporeal life support (ECLS). Although thoracic epidural analgesia is commonly considered the gold standard, concerns regarding procedural safety and its potential for devastating consequences have led physicians to seek safer analgesic modalities such as thoracic nerve blocks. The advantages of thoracic nerve blocks for general thoracic surgery are well established. However, their utility in LTx remains unclear. Considering paucity of relevant literature, this review aims to raise awareness about the literature gap in the field and highlight the need for further high-quality studies determining the effectiveness of available techniques.

BACKGROUND: Cardiac surgery involving cardiopulmonary bypass induces a significant systemic inflammatory response, contributing to various postoperative complications, including pulmonary dysfunction, myocardial and kidney injuries. OBJECTIVE: To investigate the effect of Nitric Oxide delivery via the cardiopulmonary bypass circuit on various postoperative outcomes. DESIGN: A prospective, single-centre, double-blinded, randomised controlled trial. SETTING: Rabin Medical Centre, Beilinson Hospital, Israel. PATIENTS: Adult patients scheduled for elective cardiac surgery were randomly allocated to one of the study groups. INTERVENTIONS: For the treatment group, 40 ppm of nitric oxide was delivered via the cardiopulmonary bypass circuit. For the control group, nitric oxide was not delivered. OUTCOME MEASURES: The primary outcome was the incidence of hypoxaemia, defined as a paO ₂/FiO₂ ratio less than 300 within 24 h postoperatively. The secondary outcomes were the incidences of low cardiac output syndrome and acute kidney injury within 72 h postoperatively. RESULTS: Ninety-eight patients were included in the final analysis, with 47 patients allocated to the control group and 51 to the Nitric Oxide group. The Nitric Oxide group exhibited significantly lower hypoxaemia rates at admission to the cardiothoracic intensive care unit (47.1 vs. 68.1%), P = 0.043. This effect, however, varied in patients with or without baseline hypoxaemia. Patients with baseline hypoxaemia who received nitric oxide exhibited significantly lower hypoxaemia rates (61.1 vs. 93.8%), P = 0.042, and higher paO ₂/FiO₂ ratios at all time points, F (1,30) = 6.08, P = 0.019. Conversely, this benefit was not observed in patients without baseline hypoxaemia. No significant differences were observed in the incidence of low cardiac output syndrome or acute kidney injury. No substantial safety concerns were noted, and toxic methaemoglobin levels were not observed. CONCLUSIONS: Patients with baseline hypoxaemia undergoing cardiac surgery and receiving nitric oxide exhibited lower hypoxaemia rates and higher paO ₂/FiO₂ ratios. No significant differences were found regarding postoperative pulmonary complications and overall outcomes. TRIAL REGISTRATION: NCT04807413.

Pulmonary alveolar proteinosis (PAP) presents a significant challenge due to its progressive and potentially fatal nature. Whole lung lavage (WLL) is a key treatment for primary PAP with respiratory failure. Despite its efficacy, the lack of standardised protocols has led to diverse practice techniques across different institutions. Our study introduces a novel approach, employing a cardiopulmonary bypass (CPB) system for infusing lavage fluid, a method not previously utilised. This paper will share our pioneering experience with this technique at a tertiary referral centre, focusing on its implementation and safety profile. This retrospective study included patients aged ≥ 18 who underwent WLL for PAP or silicosis. Pre-lavage preparations included chest X-rays and pulmonary function tests (PFT). Preprocedural empiric antibiotics were administered. During lavage, warm saline was infused using a CPB, with cycles of normal saline infusion and degassing until fluid clarity was reached. Positioning techniques facilitated saline drainage. The procedure concluded with intravenous furosemide administration. Fifty-two WLLs were identified between 2010 and 2024; complete data was available for 33 procedures. Of these, 91% were due to PAP, and 9% to silicosis. Almost half of the patients did not require additional WLL, while 43% needed sequential contralateral WLL. Median operative and mechanical ventilation times were 65 [58.5, 67.5] and 118 [97, 195] minutes, respectively. The median length of hospital stay was two days [2, 3]. Although not statistically significant, O2 saturation and a 6-minute walk distance increase were observed after the WLL. This study outlines our novel approach to WLL, which incorporates rapid saline infusion via a CPB system. Our findings indicate reduced procedure time while maintaining safety and efficacy for treating PAP and silicosis. Despite promising results, the retrospective design and small sample size limit generalizability. Further high-quality studies are warranted to validate and refine this technique.