During bronchoscopy hypoxemia is commonly found and oxygen supply can be delivered by interfaces fed with high gas flows. Recently, the high-flow nasal cannula (HFNC) has been introduced for oxygen therapy in adults, but they have not been used so far during bronchoscopy in adults. Forty-five patients were randomly assigned to 3 groups receiving oxygen: 40 L/min through a Venturi mask (V40, N = 15), nasal cannula (N40, N = 15), and 60 L/min through a nasal cannula (N60, N = 15) during bronchoscopy. Gas exchange and circulatory variables were sampled before (FiO2 = 0.21), at the end of bronchoscopy (FiO2 = 0.5), and thereafter (V40, FiO2 = 0.35). In 8 healthy volunteers oxygen was randomly delivered according to V40, N40, and N60 settings, and airway pressure was measured. At the end of bronchoscopy, N60 presented higher PaO2, PaO2/FiO2, and SpO2 than V40 and N40 that did not differ between them. In the volunteers (N60) median airway pressure amounted to 3.6 cmH2O. Under a flow rate of 40 L/min both the Venturi mask and HFNC behaved similarly, but nasal cannula associated with a 60 L/min flow produced the better results, thus indicating its use in mild respiratory dysfunctions.

In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.

During low-flow manually-controlled anaesthesia (MCA) the anaesthetist needs constantly adjust end-tidal oxygen (EtO2) and anaesthetic concentrations (EtAA) to assure an adequate and safe anaesthesia. Recently introduced anaesthetic machines can automatically maintain those variables at target values, avoiding the burden on the anaesthetist. End-tidal-controlled anaesthesia (EtCA) and MCA provided by the same anaesthetic machine under the same fresh gas flow were compared. Eighty patients were prospectively observed: in MCA group (n = 40) target end-tidal sevoflurane (1%) and EtO2 concentrations (≥ 35%) were manually controlled by the anaesthetist. In EtCA group (n = 40) the same anaesthetic machine with an additional end-tidal control feature was used to reach the same targets, rendering automatic the achievement and maintenance of those targets. Anaesthetic machine characteristics, amount of consumed gases, oxygen and sevoflurane efficiencies, and the amount of interventions by the anaesthetist were recorded. In EtCA group EtAA was achieved later (145 s) than in MCA (71 s) and remained controlled thereafter. Even though the target expired gas fractions were achieved faster in MCA, manual adjustments were required throughout anaesthesia for both oxygen and sevoflurane. In MCA patients the number of manual adjustments to stabilize EtAA and EtO2 were 137 and 107, respectively; no adjustment was required in EtCA. Low-flow anaesthesia delivered with an anaesthetic machine able to automatically control EtAA and EtO2 provided the same clinical stability and avoided the continuous manual adjustment of delivered sevoflurane and oxygen concentrations. Hence, the anaesthetist could dedicate more time to the patient and operating room activities.

Recently, the FLOW-i anaesthesia ventilator was developed based on the SERVO-i intensive care ventilator. The aim of this study was to test the FLOW-i's tidal volume delivery in the presence of a leak in the breathing circuit. We ventilated a test lung model in volume-, pressure-, and pressure-regulated volume-controlled modes (VC, PC, and PRVC, respectively) with a FLOW-i. First, the circuit remained airtight and the ventilator was tested with fresh gas flows of 6, 1, and 0.3 L/min in VC, PC, and PRVC modes and facing 4 combinations of different resistive and elastic loads. Second, a fixed leak in the breathing circuit was introduced and the measurements repeated. In the airtight system, FLOW-i maintained tidal volume (VT) and circuit pressure at approximately the set values, independently of respiratory mode, load, or fresh gas flow. In the leaking circuit, set VT = 500 mL, FLOW-i delivered higher VTs in PC (about 460 mL) than in VC and PRVC, where VTs were substantially less than 500 mL. Interestingly, VT did not differ appreciably from 6 to 0.3 L/min of fresh air flow among the 3 ventilatory modes. In the absence of leakage, peak inspiratory pressures were similar, while they were 35-45 % smaller in PRVC and VC than in PC mode in the presence of leaks. In conclusion, FLOW-i maintained VT (down to fresh gas flows of 0.3 L/min) to 90 % of its preset value in PC mode, which was 4-5 times greater than in VC or PRVC modes.

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