Prior to the 1930s the prognosis for survival after thoracic surgery was extremely poor. Once the chest of an anesthetized, spontaneously breathing patient was opened the operated lung collapsed. As the patient attempted to breathe respirations became “paradoxical”, that is, the operated lung became smaller on inspiration and larger on expiration. Within minutes the patient became hypotensive and unless the procedure was immediately discontinued and the chest quickly closed, the patient would die. This was the major obstacle for thoracic surgery. Thoracic surgery could not develop as a specialty until this “pneumothorax problem” was solved.

Airway Intubation and Positive-pressure Ventilation: In the 1930s infection was the usual indication for thoracic operations. General anesthesia was by open drop ether or chloroform, with the patient breathing spontaneously. Anesthesia was kept “light” because it was essential that the patient maintain a cough reflex to prevent contamination from the diseased to the healthy lung.

Guedel and Waters (1928)1 described the cuffed endotracheal tube. This tube combined with positivepressure ventilation provided a partial solution to the “pneumothorax problem”. Ventilation could be controlled by hand, the depth of anesthesia could be deepened, and the lungs could be protected from gastric (but not pulmonary) aspiration.

One-lung Ventilation: Three years later Gale and Waters (1931)2 solved the “pneumothorax problem” when they introduced a technique for one-lung ventilation. The trachea was intubated with a cuffed endotracheal tube using direct laryngoscopy. The tube was advanced into the bronchus of the healthy lung. The inflated cuff sealed the intubated bronchus and also extended into the carina where it obstructed ventilation to the diseased lung. The healthy lung was selectively ventilated while the operated lung collapsed. For the first time the thoracic surgeon was provided with an immobile surgical field, adequate ventilation of the healthy lung, absence of cardiovascular collapse from sudden pneumothorax, and the prevention of secretions from entering into the dependent healthy lung.

Archibald (1935)3 described a rubber bronchial blocker. It was inserted into the bronchus of the diseased lung, and lung tissue beyond its inflated balloon collapsed. A variety of balloon tipped catheters have been used as bronchial blockers. A combined endotracheal tube and bronchial blocker, the Univent tube (4), was introduced in the 1980s. Recently, several plastic blockers have become available; the most innovative is the Arndt wire-guided blocker.5

Double-lumen Tubes: In 1950 6 Bjork and Carlens were the first to use a double-lumen tube. These tubes allow one-lung ventilation, provide an immobile surgical field, and protect the healthy lung from aspiration. The operated lung can be safely collapsed and re-inflated at will, and the collapsed lung can be suctioned to remove blood and secretions before it is re-expanded. Robertshaw (1962)7 introduced a tube that lacked the carinal hook of the earlier double-lumen tubes. Disposable, plastic double-tubes of the Robertshaw design have been used since the 1980s.8

Flexible fiberoptic bronchoscopy (1980s) allows double-lumen tubes to be positioned under direct vision, which reduces the risks of trauma and hypoxemia.

Intraoperative Ventilation: The first ventilator, the “Spiropulsator” was described in 1934. However, controlled ventilation only became practical after the introduction of curare (1942).9 Widespread acceptance of intraoperative mechanical ventilation did not occur until the 1960s.

Anesthetic Agents: Halothane was introduced in 1956. In contrast to ether and cyclopropane, electrocautery could be safely used. Halothane was potent, eliminating the need for nitrous oxide and allowing high concentrations of oxygen during one-lung ventilation. Halothane was replaced by methoxyflurane and enflurane (1960-70s) and with isoflurane, sevoflurane, and desflurane (1980-present).

Intraoperative Monitoring: Invasive (arterial, central venous, pulmonary artery) monitoring became popular in the 1960s. Since the 1980s non-invasive capnography and oximetry have greatly improved the safety of one-lung ventilation.

Maximizing Oxygenation: Persistent “shunt” to the operated lung can produce low oxygen tensions during one-lung ventilation. Positive-end-expiratory pressure and continuous-positive airway pressure (CPAP) were applied during thoracotomy in the 1980s.

Postoperative Analgesia: Perhaps the most important factor reducing complications has been the management of post-thoracotomy pain. Behar (1979) reported the benefit of epidural morphine. Shulman (1984)10 was the first to compare thoracotomy patients receiving epidural and intravenous morphine. The epidural group had superior pain relief and better postoperative pulmonary function. Lumbar and thoracic epidural analgesia, with opioids alone or combined with local anesthetics, has revolutionized the management of thoracic surgical patients.

Conclusion: The specialty of thoracic surgery co-evolved with the practice of anesthesia. This relationship began in the 1930s and continues today. Modern anesthetic management allows complex procedures such as lung volume reduction and lung transplantation can be performed on the most severely compromised patient.

References

1. Guedel AE, Waters RM. A new intratracheal catheter. Anesth Analg 1928; 7: 238-239.

2. Gale JW, Waters RM. Closed endobronchial anesthesia in thoracic surgery. J Thorac Surg 1931; 1: 432-437.

3. Archibald E. A consideration of the dangers of lobectomy. J Thor Surg 1935; 4: 335-351.

4. Kamaya H, Krishna PR. New endotracheal tube (Univent tube) for selective blockade of one lung. Anesthesiology 1985; 63: 342-343.

5. Arndt GA, et al. Wire-guided endobronchial blockade in a patient with a limited mouth opening. Can J Anaesth 1999; 46: 87-89.

6. Bjork VO, Carlens E. The prevention of spread during pulmonary resection by the use of a double-lumen catheter. J Thorac Surg 1950; 20: 151-157.

7. Robertshaw FL. Low resistance double-lumen endobronchial tubes. Br J Anaesth 1962; 34: 576-579.

8. Burton NA, et al. Advantages of a new polyvinyl chloride double-lumen tube in thoracic surgery. Ann Thorac Surg 1983; 36: 78-84.

9. Stephens HB, et al. The use of curare in anesthesia for thoracic surgery. J Thorac Surg 1947; 16: 50-62.

10. Shulman M, et al. Post-thoracotomy pain and pulmonary function following epidural and systemic morphine.Anesthesiology 1984; 61: 569-575.