The problem of efficient gas exchange maintenance is always actual in anesthetic management of thoracic surgery and determines the selection of appropriate method of anesthesia. The article presents an experience of anesthesia during operations on lungs, trachea, bronchi and mediastinal structures performed from 1963 to 2015. Current concept of safety and efficacy of anesthetic management in thoracic surgery is presented. The role of actual current respiratory technologies and methods of anesthesia per se to maximize the efficiency of gas exchange in all stages of thoracicsurgery is emphasized. Absolute coherence of anesthesiologist and surgeon based on correct interaction is the most important condition of successful surgery. Effectiveness of special respiratory technologies for thoracic surgery associated with one-lung ventilation and prolonged wide dissection of airways is described. The research results and pathophysiological rationale for the use of special respiratory technologies including different variants of differentiated independent lung ventilation especially important for patients with concomitant cardiorespiratory pathology are presented. We reported experience of effective gas exchange maintenance in reconstructive surgery of trachea and main bronchi including traditional mechanical ventilation with "shunt-breath" system, use of jet high-frequency ventilation and relatively new respiratory technology such as flow apnoeic oxygenation.

Ключевые слова: рубцовый стеноз трахеи, трахеомаляция, МСКТ, МРТ, резекция трахеи, трахеопластика, диагностика трахеи. Evolution of diagnostic methods for cicatrical tracheal stenosis and tracheomalaciaAim. to analyze the role of ray functional computerized diagnostic technologies in assessment of the state of tracheal wall in cicatricial stenosis. Material and methods. We examined 45 patients with cicatricial tracheal stenosis during August 2013 -march 2015. Fibrobronchoscopy, multislice computerized tomography, magnetic resonance imaging and lungs function examination were performed. For the first time dynamic (functional) Ct and mRi were included in research algorithm. these techniques have not been used for cicatricial stenosis and tracheomalacia in our country until this moment. Circular resection with anastomosis was made in 38 patients and stage reconstructions were preferred in 7 cases. Last ones had advanced tracheomalacia on the background of cicatrical stenosis that forced to abandon from tracheal resection. so time to treatment and incidence of complications and recurrences were reduced and the results were improved. Conclusion. endoscopy remains the main method of diagnosis of tracheal stenosis despite its invasiveness. Data of cicatrical transformation of tracheal wall per se can be obtained non-invasively using dynamic Ct and mRi. these techniques help to identify or exclude tracheomalacia. they potentially complement fibrobronchoscopy and may be preferable to assess perioperative intramural pathological changes of the trachea.

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Treatment of patients with recurrent cicatrical tracheal stenosis after previous circular tracheal resection is one of the most difficult problems in thoracic surgery at present time. In most cases repeated radical surgery as new resection is declined in favour of palliative treatment. It is often associated with lingering or perpetual preserving of T-shape or tracheostomy tube and respiratory tract stenting. Development of thoracic surgery last years permits to perform repeated tracheal resections with restoration of respiratory tract integrity by using of new tracheal anastomosis. For the last 4 years 6 such operations were performed with satisfactory immediate and remote results. Diagnostic algorithm before repeated surgery is similar to those before primary intervention. Special attention should be attended to state of remained parts of respiratory tract, degree and length of stenosis and tracheomalacia which may be result of divergence of edges of the primary anastomosis. Preserving of not less than 1/4 primary length of intact trachea with its satisfactory mobility is main condition for this surgery because it will permit to perform new anastomosis without high tension. Risk of postoperative complications after repeated operations is not higher than those after primary resection. But at present time these operations are in competence of small number of specialists and medical institutions with serious experience in thoracic surgery.