Key Points

Anesthetic management is guided by preoperative assessment of the perioperative risk.
■ Primary differences between thoracic anesthesia and other types of anesthesia are the requirement for lung isolation and the management of one-lung anesthesia.
■ There are two basic methods of lung isolation: double-lumen endobronchial tubes and bronchial blockers.
■ Anesthetic management for specific procedures is determined by the patient’s underlying disease and by the physiologic effects of the surgery.
■ Lung isolation is mandatory for complex surgeries to avoid soiling of the lung, tension pneumothorax, or air leak through a bronchopleural fistula.
■ Patients with large, anterior mediastinal masses may experience life-threatening lower airway obstruction or cardiovascular collapse with the induction of general anesthesia.
■ Patients with myasthenia gravis are very sensitive to nondepolarizing muscle relaxants; optimization and maintenance of the patient’s medical regimen perioperatively is crucial.
■ Patients having esophageal surgery may be prone to reflux of gastric contents and aspiration.
■ Patients with severe emphysema are prone to gas trapping and cardiovascular instability during positive-pressure ventilation.
■ In patients undergoing lung transplantation, the patient’s underlying lung condition influences the ventilation parameters required during surgery and the need for extracorporeal support.

General thoracic surgery encompasses a wide breadth of varied procedures; we have had the privilege of practicing anesthesia in institutions where these procedures are performed with regularity. The practice of thoracic anesthesia requires a firm understanding of pulmonary anatomy and physiology in addition to technical knowledge and experience. The bulk of this chapter describes the authors’ experiences in airway management, lung separation and management of one-lung ventisltion for pulmonary resection. The chapter ends with an overview anesthetic considerations germane to other procedures performed by general thoracic surgeons. Management issues discussed include those related to mediastinal surgery, esophageal surgery, pulmonary vascular surgery, whole lung lavage and surgical procedures that improve quality of life in end-stage lung disease through lung volume reduction and pulmonary transplantation.