BACKGROUND:The effect of flow-controlled ventilation (FCV) as compared with volume-controlled ventilation (VCV) on oxygenation and respiratory system mechanics in patients undergoing one-lung ventilation (OLV) is unknown. OBJECTIVE:To test the hypothesis that FCV would improve oxygenation and respiratory system mechanics compared with VCV during OLV. DESIGN:Two-centre, two-arm, randomised controlled clinical trial. SETTING:University hospital and speciality hospital for pulmonary diseases in Germany. PATIENTS:A total of 78 thoracic surgery patients undergoing OLV for more than 30 min. INTERVENTIONS:Patients were randomly assigned to OLV with FCV ( n  = 39), or VCV ( n  = 39). In both groups, OLV was conducted with tidal volume of 5 ml kg -1 , positive end-expiratory pressure of 5 cmH 2 O, respiratory rate to normocapnia, and inspiratory oxygen fraction of 1.0. MAIN OUTCOME MEASURES:The primary outcome was the arterial partial pressure of oxygen (PaO 2 ) 20 min after initiation of OLV. The secondary outcomes included respiratory system mechanics, the need for rescue due to hypoxaemia, and clinical outcome variables. RESULTS:The partial pressure of arterial oxygen did not differ between FCV and VCV at 20 min after starting OLV (PaO 2 : 24.8 ± 14.8 kPa vs. 26.1 ± 15.9 kPa, mean difference -1.2 (95% confidence interval -8.2 to 5.7), P  = 0.721), while mechanical power was lower during FCV compared with VCV. Other variables did not differ at any time thereafter, except for the compliance of the respiratory system at end of surgery. The need for rescue manoeuvres due to hypoxemia or hypercapnia during OLV did not differ between the groups. The incidence of postoperative pulmonary and extrapulmonary complications, as well as the number of hospital-free days at day 30 after surgery, did not differ between FCV and VCV. CONCLUSIONS:Compared with VCV in thoracic surgery patients, FCV did not improve oxygenation or respiratory system mechanics during OLV, nor was it associated with improved outcomes.

BACKGROUND:Mechanical ventilation with variable tidal volumes (V-VCV) has the potential to improve lung function during general anesthesia. We tested the hypothesis that V-VCV compared to conventional volume-controlled ventilation (C-VCV) would improve intraoperative arterial oxygenation and respiratory system mechanics in patients undergoing thoracic surgery under one-lung ventilation (OLV). METHODS:Patients were randomized to V-VCV (n = 39) or C-VCV (n = 39). During OLV tidal volume of 5 mL/kg predicted body weight (PBW) was used. Both groups were ventilated with a positive end-expiratory pressure (PEEP) of 5 cm H2O, inspiration to expiration ratio (I:E) of 1:1 (during OLV) and 1:2 during two-lung ventilation, the respiratory rate (RR) titrated to arterial pH, inspiratory peak-pressure ≤ 40 cm H2O and an inspiratory oxygen fraction of 1.0. RESULTS:Seventy-five out of 78 Patients completed the trial and were analyzed (dropouts were excluded). The partial pressure of arterial oxygen (PaO2) 20 min after the start of OLV did not differ among groups (V-VCV: 25.8 ± 14.6 kPa vs C-VCV: 27.2 ± 15.3 kPa; mean difference [95% CI]: 1.3 [-8.2, 5.5], P = 0.700). Furthermore, intraoperative gas exchange, intraoperative adverse events, need for rescue maneuvers due to desaturation and hypercapnia, incidence of postoperative pulmonary and extra-pulmonary complications, and hospital free days at day 30 after surgery did not differ between groups. CONCLUSIONS:In thoracic surgery patients under OLV, V-VCV did not improve oxygenation or respiratory system mechanics compared to C-VCV. Ethical Committee: EK 420092019. TRIAL REGISTRATION:at the German Clinical Trials Register: DRKS00022202 (16.06.2020).

Background Mediastinal paragangliomas are rare. Their dangerousness may unfold during surgery, especially if hormonal activity was previously unknown. We report our experience with this case in context to the incidence and localization of atypically located mediastinal paragangliomas in the literature.Case presentation A 69-year-old female patient who was scheduled for thoracoscopic resection due to a posterior mediastinal tumor that had been progressing in size for several years and increasing symptoms. The induction of anesthesia, the ventilation of the lungs and the gas exchange after lung separation was uneventful. After initially stable circulatory conditions, there was a sudden increase in blood pressure up to 300/130 mmHg and tachycardia up to 130/min. This hypertensive phase was difficult to influence and required a rapid and consistent use of antihypertensive medication to bring down the blood pressure to reasonable values. The patient stabilized after tumor resection. The postoperative course was unremarkable. During the intraoperative blood pressure crisis, blood was drawn for analysis. These samples showed elevated concentrations of normetanephrine and metanephrine. The tumor subsequently presented as a catecholamine-secreting paraganglioma.Conclusion In order to avoid life-threatening blood pressure crises, hormone activity should be ruled out preoperatively in the case of mediastinal tumor, in which a paraganglioma could be considered in the differential diagnosis, especially if there are indications of hypertension in the medical history. Robotic-assisted thoracoscopic resection of the posterior mediastinal tumor was a feasible surgical method, even in the case of unexpected functional paraganglioma.

Background Airway management in case of acute tracheal injury is a challenging situation where the use of Extracorporeal Membrane Oxygenation (ECMO) has recently gained more importance.Case Description We report the case of a 60-year old women with aspiration of a large blister pack tablet causing acute tracheal obstruction with asphyxia as well as tracheal perforation with tension pneumothorax. As bronchoscopy failed to retrieve the blister pack, emergency tracheal reconstruction with Extracorporeal Membrane Oxygenation (ECMO) support was carried out.Conclusion The application of ECMO instantly alleviated the acute situation and provided excellent conditions for technically demanding emergency tracheal repair.

Abstract Background  Not much is known about the results of nonelective anatomical lung resections in coronavirus disease 2019 (COVID-19) patients put on extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyze the outcome of lobectomy under ECMO support in patients with acute respiratory failure due to severe COVID-19. Methods  All COVID-19 patients undergoing anatomical lung resection with ECMO support at a German university hospital were included into a prospective database. Study period was April 1, 2020, to April 30, 2021 (first, second, and third waves in Germany). Results  A total of nine patients (median age 61 years, interquartile range 10 years) were included. There was virtually no preexisting comorbidity (median Charlson score of comorbidity 0.2). The mean interval between first positive COVID-19 test and surgery was 21.9 days. Clinical symptoms at the time of surgery were sepsis (nine of nine), respiratory failure (nine of nine), acute renal failure (five of nine), pleural empyema (five of nine), lung artery embolism (four of nine), and pneumothorax (two of nine). Mean intensive care unit (ICU) and ECMO days before surgery were 15.4 and 6, respectively. Indications for surgery were bacterial superinfection with lung abscess formation and progressive septic shock (seven of nine) and abscess formation with massive pulmonary hemorrhage into the abscess cavity (two of nine). All patients were under venovenous ECMO with femoral-jugular configuration. Operative procedures were lobectomy (eight) and pneumonectomy (one). Weaning from ECMO was successful in four of nine. In-hospital mortality was five of nine. Mean total ECMO days were 10.3 ± 6.2 and mean total ICU days were 27.7 ± 9.9. Mean length of stay was 28.7 ± 8.8 days. Conclusion  Emergency surgery under ECMO support seems to open up a perspective for surgical source control in COVID-19 patients with bacterial superinfection and localized pulmonary abscess.

Pediatric sarcomas are rare entities. Bone sarcomas and rhabdomyosarcoma are most common, whereas primary sarcoma of the lung is extremely uncommon. Pneumonectomy is only very infrequently performed in the pediatric population. We report on a 16-year-old girl with an undifferentiated high-grade pleomorphic sarcoma of the left lung. There was no comorbidity and no history of previous malignant disease. The huge tumor originated from the left lower lobe and had spread to the left pleura. As part of a multimodal approach, she underwent extrapleural pneumonectomy with en bloc resection of the pleura, lung, pericardium, and diaphragm.

Objective Extracorporeal membrane oxygenation (ECMO) support for elective cardiothoracic surgery is well established. In contrast, there is not much data regarding the usefulness and outcome of ECMO in non- elective major lung resections for infectious lung abscess.

OBJECTIVES:Extracorporeal membrane oxygenation (ECMO) support for elective cardiothoracic surgery is well established. In contrast, there are not much data regarding the usefulness and outcome of ECMO in non-elective major lung resections for infectious lung abscess.METHODS:All patients undergoing non-elective major lung surgery for infectious lung abscess at 5 centres in Germany, UK and Spain were enrolled in a prospective database. Malignant disorders and intrathoracic complications of other procedures were excluded.RESULTS:There were 127 patients. The median age was 59 years (interquartile range 18.75). The mean Charlson index of comorbidity was 2.83 (standard deviation 2.57). Surgical procedures were lobectomy (89), pneumectomy (20) and segmentectomy (18). ECMO was used for 10 patients (pneumectomy 2, lobectomy 8) and several more received pre-ECMO treatment. Mortality was 17/127. Intraoperatively no ECMO-associated complications were encountered. EMCO [1/10 vs 16/117; odds ratio (OR): 0.70, 95% confidence interval (CI) 0.08-5.91, P = 0.74] and the extent of pulmonary resection were not associated with higher mortality. Preoperative sepsis (OR: 17.84, 95% CI 2.29-139.28, P < 0.01), preoperative air leak (OR: 13.12, 95% CI 4.10-42.07, P < 0.001), acute renal failure (OR: 7.00, 95% CI 2.19-22.43, P < 0.01) and Charlson index of comorbidity ≥3 (OR: 10.83, 95% CI 2.36-49.71, P < 0.01) were associated with significantly higher mortality.CONCLUSIONS:The application of ECMO is widening the possibilities for successful surgical management of infectious, non-malignant lung abscesses. Particularly, patients with marginal functional operability benefit from the availability and readiness to use ECMO. Mortality is determined by the burden of pre-existent comorbidity, severe sepsis and septic shock.

ZusammenfassungEine CPAP-Therapie ist die häufigste Behandlungsform der obstruktiven Schlafapnoe.Schwerwiegende Komplikation dieser Behandlung sind sehr selten. Pneumothorax als Lungen-Barotrauma unter der CPAP-Therapie wird in Einzelfallberichten und ausschließlich bei vorbestehenden Lungen- und Thoraxerkrankungen beschrieben.Ein 68-jähriger, pulmonal nicht vorerkrankter Schlafapnoe-Patient mit einer langjährig etablierten CPAP-Therapie wird nach einem heftigen thorakalen Schmerzereignis mit anhaltender Luftnotsymptomatik stationär aufgenommen. Radiologisch und computertomografisch bestand ein ausgedehnter rechtsseitiger Pneumothorax mit rechts basal betontem bullösem Emphysem. Nach operativer Versorgung des sekundären Spontanpneumothorax konnte am 3. postoperativen Tag die nächtliche Überdruckatmung unter reduziertem CPAP-Druck mit zufriedenstellendem Schlafapnoe-Befund und ohne Pneumothorax-Rezidiv im Verlauf wiederaufgenommen werden.Als mögliche Pneumothorax-Ursache bei dem Patienten können alveoläre entzündliche Veränderungen infolge von Überdehnung und Drucksteigerung in Alveolen, die unter jahrelanger CPAP-Behandlung mit schrittweiser Drucksteigerung entstanden sind und folglich zu ausgedehnten Lungenveränderung mit Ruptur geführt haben, angenommen werden.Zusammenfassend und schlussfolgernd soll bei Patienten, die aufgrund einer Schlafapnoe über Jahre mittels Überdruckatmung behandelt werden, bei plötzlich einsetzenden thorakalen Schmerzen mit einer Luftnotsymptomatik an einen möglichen Spontanpneumothorax gedacht werden.

CPAP is the most common treatment for obstructive sleep apnea. Serious complications from this treatment are very rare. Pneumothorax following lung barotrauma under CPAP therapy has been described in case reports only in patients with pre-existing lung and thoracic diseases. A 68-year-old sleep apnea patient without pre-existing lung or thoracic diseases and with established CPAP therapy since many years was admitted to the hospital after a severe thoracic pain event with persistent shortness of breath. Chest radiograph and computed tomography showed an extensive right-sided pneumothorax with basal bullous emphysema. After surgical treatment of the secondary spontaneous pneumothorax, on the third postoperative day CPAP with reduced pressure was re-introduced with satisfactory sleep apnea findings and without pneumothorax recurrence. As possible cause of pneumothorax in the patient, alveolar inflammatory changes due to over-distention and increased pressure in the alveoli was assumed, which can occur after years of CPAP treatment with gradual pressure increase. In summary, in sleep apnea patients treated with CPAP for years, after sudden onset of thoracic pain and shortness of breath possible spontaneous pneumothorax should be considered.

Die häufigsten tumorassoziierten thoraxchirurgischen Notfälle sind Kompression oder Verlegung der Atemwege, endobronchiale Blutung, poststenotische infektiöse Komplikationen sowie die Fistelbildung zwischen den intrathorakalen Organen. Eine maligne Grunderkrankung ist in Europa in etwa 20 % der Fälle die Ursache für das Auftreten von Hämoptysen. Die vorliegende Arbeit gibt anhand der Literatur sowie Erfahrungen aus der eigenen Klinik einen Überblick über die Therapie solcher Notfälle. Die bronchoskopische Stentimplantation ist das Verfahren der Wahl bei tumorbedingter Kompression der zentralen Atemwege und zumeist auch bei malignen tracheoösophagealen Fisteln. Bei schweren Hämoptysen erfolgt die Sicherung des Atemwegs durch pulmonale Isolation, Methode der Wahl zur Therapie ist die Bronchialarterienembolisation. Lokalisierte Blutungen in den zentralen Atemwegen können mittels endoskopischer Verfahren beherrscht werden. Perakute, interventionell nicht beherrschbare endobronchiale Blutungen erfordern möglichst eine sofortige chirurgische Therapie. Bei der Behandlung der tumorbedingten poststenotischen Pneumonie steht die Therapie der Stenose im Mittelpunkt, bei Operabilität des Patienten ist Mittel der Wahl die Operation. Die endoskopische Stentimplantation führt zu einer umgehenden Verbesserung der Lebensqualität durch Verschluss der Fistel, Beendigung der Aspiration und Linderung einer evtl. vorhandenen Stenosesymptomatik. Die definitive chirurgische Therapie von Atemwegsblutungen sollte möglichst erst nach erfolgreicher interventioneller Blutstillung erfolgen, um die perioperative Mortalität zu senken.

Oesophageal perforation is a severe life-threatening clinical condition with high mortality and morbidity needing rapid interdisciplinary approach to be effectively managed. Recently, on the basis of multicentric retrospective data, we proposed a decision tree for the treatment of oesophageal perforations based on the Pittsburgh Perforation Severity Score (PSS). We now report the first case of a traumatic oesophageal perforation, which was successfully treated according to the application of the PSS decision tree.

BACKGROUND:Chest tubes are a valuable instrument and are used on a daily basis - not only by thoracic surgeons but also by a variety of medical specialists who treat pneumothorax or pleural effusions. The goal of the working group of the German Thoracic Society (DGT) was to achieve a consensus on the management of chest tube/drainage using the Delphi process. METHODS:The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres. Consensus was considered as rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics. RESULTS:Thirteen questions on the management of chest tubes were proposed and voted on. A consensus was reached for the following topics: conditions for chest tube insertion, size of drainage/tube, technique of insertion, diagnostic measures after insertion and prior to removal, post-interventional management, documentation, number of chest tubes after anatomical lung resection, use of fibrinolytic agents, type of negative pressure. No consensus was reached for the following topics: autologous blood pleurodesis, reduction of suction in cases of persistent air leakage. CONCLUSION:Our manuscript depicts the results of a Delphi process in 2017 - 1018 involving experts of the German Thoracic Society from high volume departments certified for thoracic surgery. A very high rate of consensus was documented for topics such as chest tube insertion, peri-interventional management and removal algorithm. The most important topic for which there was no consensus was the case of persistent air leakage. The resulting expert recommendations of the Delphi process could be used as a starting point for internal clinical procedures.

Cryoballoon ablation is a recently introduced treatment option for patients with symptomatic, drug-refractory atrial fibrillation. The rate of complications is low and comprises mainly vascular-access-site complications and phrenic nerve palsy. We report a case of life-threatening pulmonary haemorrhage occurring during the procedure.

Background Surgery for lung abscess is a challenging task. Timing and indications for surgery are not well established. Identification of predictors of outcome could help to clarify the role of surgery. Methods Patients who underwent major thoracic surgery for infectious lung abscess were identified at six centers for general thoracic surgery in Germany, Spain, the United Kingdom, and the United States. Study period was 2000 to 2016. Results There were 91 patients. Pulmonary sepsis (48), pleural empyema (43), persistent air leakage (25), acute renal failure (12), and respiratory failure with mechanical ventilation (25) were already preoperatively present. The mean Charlson index of comorbidity was 3.0 (median: 2.0; interquartile range: 3). Procedures were segmentectomy (18), lobectomy (58), and pneumonectomy (15). The 30-day mortality following surgery was 13/91.Preoperative sepsis (odds ratio [OR]: 13.69; 95% confidence interval [CI]: 1.86-610.53; p < 0.01), preoperative persistent air leak (OR: 13.46, 95% CI: 3.00-85.37, p < 0.01), respiratory failure (OR: 5.60; 95% CI: 1.41-24.84; p < 0.01), acute renal failure (OR: 6.15 ; 95% CI: 1.24-29.56 ; p = 0.01), and Charlson index of comorbidity ≥ 3 (OR: 7.19 ; 95% CI: 1.43-71.21 ; p < 0.01) are associated with higher mortality, whereas age > 70 years (p = 0.46) and the extent of pulmonary resection (segmentectomy, lobectomy, pneumonectomy) have no significant influence on mortality. Patients with fatal outcome have significantly higher Charlson index of comorbidity (p < 0.01). Conclusions Delayed referral for surgery is common. Significant predictors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥ 3). The extent of surgical resection shows no significant influence.

Hintergrund: Angesichts des demographischen Wandels sehen sich Thoraxchirurgen mit einer steigenden Anzahl von Notfalloperation bei sehr alten Patienten konfrontiert.