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The history of anesthesia for thoracic surgery encompasses much of the history of anesthesia because the modern practice of thoracic anesthesia relies on major advances in preoperative evaluation, airway management, intraoperative monitoring, pharmacological agents, and improvements in postoperative pain management and intensive care management. These advances equip the modern thoracic anesthesiologist with the tools and techniques to care for even the frailest patients undergoing complex surgical operations. Many patients who would have been deemed inoperable in the past are operative candidates today, because of improvements in both anesthetic and surgical techniques that have augmented safety for all patients undergoing thoracic surgery. The current practice of anesthesia for thoracic surgery represents a culmination of 100 years of advances in anesthesia techniques, and these techniques continue to evolve.

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The safe delivery of anesthesia for thoracic surgery is a relatively late development in the history of anesthesia because of the ingenuity needed to overcome the unique challenges of safely performing surgery in the thorax. It is easy to forget today that prior to advances in general anesthesia techniques, specifically positive pressure ventilation and controlled respiration with endotracheal intubation, surgery that trespassed the chest wall posed grave risks to patients. Although inhalational anesthesia was introduced in the 1840s, it took another 100 years before anesthesiologists made significant headway in providing safe care for patients undergoing operations in the chest. Improvements in anesthetic practice permitted thoracic surgery to flourish as a specialty; the growth of no other surgical subspecialty depended so heavily on the progress of anesthesia. Although intrathoracic procedures have become routine, thoracic surgeons and anesthesiologists retain a unique relationship; few areas of surgery require as much communication and cooperation between surgeon and anesthesiologist.

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As the scope of thoracic surgery has increased greatly, so has the scope of anesthetic practice for it. Today, knowledge of anesthesia techniques for thoracic surgery has become more important than ever. Greater numbers of and types of procedures for lung, esophageal, mediastinal, anterior and posterior spinal, thoracic aortic and cardiac surgery rely on thoracic approaches that require use of one-lung ventilation (OLV). Also, more intrathoracic procedures are being performed with minimally invasive approaches that rely on OLV for adequate surgical exposure. To safely provide the OLV that is universally favored by thoracic surgeons, anesthesiologists must be knowledgeable about the physiology of OLV, be familiar with the range of tools available for providing it, and be aware of techniques for preventing hypoxemia. A variety of double lumen endotracheal tubes and modern endobronchial blockers are now available to provide safe and reliable OLV for most patients.

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The Pneumothorax Problem

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The inherent danger of performing surgery within the thorax has been known since antiquity. Almost 2000 years ago, the Roman encyclopedia author Celsus, in De Medicina, described the problem succinctly by noting that when a knife penetrates the chest death ensues at once, even though the belly can be opened safely with the patient breathing spontaneously....

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