Cohen’s Comprehensive Thoracic Anesthesia

Edmund Cohen, M.D., F.A.S.A., longtime professor of anesthesiology at the Icahn School of Medicine at Mount Sinai (New York, New York), has made a monumental contribution to the field of thoracic anesthesiology with the publication of the new textbook Cohen’s Comprehensive Thoracic Anesthesia. He has assembled an international team of experts who take the reader on a journey through the history of operating in the thorax from the days of the first-century Roman author Celsus to the latest in minimally invasive techniques, enhanced recovery principles, protective ventilation strategies, lung transplantation, and lung isolation tools of all kinds.

The book’s utility is enhanced by its link to an electronic version, which enables the reader to access it on any electronic device, search topics, enlarge images, highlight content, and take notes. This electronic feature is equally invaluable for the resident or fellow who needs immediate clinical answers, for the academic faculty member who has just been asked a question that he or she cannot readily answer, or for the occasional thoracic anesthesiologist in the community setting who seeks a quick refresher in troubleshooting a double-lumen endotracheal tube or guidance in how to handle an urgent thoracic problem.

As might be expected from Dr. Cohen, who is internationally recognized for his expertise in lung isolation and the development of the Cohen endobronchial blocker (Cook Medical, USA), there is ample information about selection of lung isolation devices, including double-lumen tubes and endobronchial blockers. Co-author Javier Campos, M.D., provides a thorough and unbiased review of the advantages and disadvantages of commercially available devices, with excellent illustrations including diagrams, photographs, radiographic and ultrasound imaging, and bronchoscopic views. We concur with the assessment of indications and guide to positioning for right-sided double-lumen tubes. A separate and very helpful chapter, also by Dr. Campos, is devoted to the practical real-world scenarios of the patient with a difficult airway for intubation, the need for tube exchange from single- to double-lumen tube and vice versa, and the problem of lung isolation in the patient with a tracheostomy tube.

The chapter on mediastinal mass and superior vena cava syndrome is well referenced and provides a case presentation that illustrates many of the problems with this frightening clinical challenge. In our opinion, the goal in these scenarios more often is to avoid giving general anesthesia (at least for the adult patient) than to do it and to obtain a tissue diagnosis with as minimal intervention as possible. Many of the most severe cases result from lymphoma and are treated with chemotherapy and/or radiation therapy rather than by surgical resection once a tissue diagnosis has been established. The anesthesiologist’s role may be primarily to counsel against the choice of a general anesthetic in a severely compromised patient as the referring physicians may be unaware of the risks. Lesions such as thymomas typically are smaller and less likely to cause respiratory or circulatory compromise, so the anesthetic challenges are correspondingly less. However, the two authors perform a valuable service in outlining every step that should be considered and planned for, including rapid implementation of cardiopulmonary bypass, if general anesthesia cannot be avoided in the patient who is symptomatic from a large mediastinal mass.

True to its title, the textbook focuses on noncardiac anesthesiology, but it acknowledges the overlap into the cardiac subspecialty with chapters on extracorporeal ventilatory therapies, thoracic aneurysm repair, the management of lung transplantation, and the application of transesophageal echocardiography in the thoracic setting. The chapter on lung resection in patients with pulmonary hypertension succinctly reviews the management of right ventricular failure, although more attention might have been given to discussing the utility of transesophageal echocardiography as a monitor and inhaled pulmonary vasodilators as therapy. The discussion of thoracic aneurysms is confined to the ascending aorta, with no mention of cannulation and partial bypass techniques for repair of the descending aorta. Cerebral protection is discussed, but spinal cord protection and neurologic monitoring are not.

There are instances in this overall outstanding textbook where the reader would wish for fewer platitudes and more precision, as in this sentence, which could be applicable to any case: “Therefore, perioperative hypotension, tachyarrhythmias, or anemia should be avoided to reduce the incidence of serious adverse cardiovascular events.” The use of thoracic epidural analgesia is endorsed more than once as the “gold standard” for analgesia with scant mention of the sympathetic blockade and hypotension that may lead our surgical colleagues to object to it. In the chapter on the postoperative management of acute pain, there is no mention of the use of intrathecal narcotics, which may be a valid option in selected circumstances for analgesia that can reduce total systemic opioid consumption with less relative risk of hypotension. (Intrathecal opioids are listed as an option in the chapter on thoracic trauma management.) The chapter on tracheal resection and reconstruction describes the use of a superglottic airway in an excellent discussion on the need for smooth emergence and extubation but fails to mention the laryngeal mask airway as a useful option during the initial stage of resecting a high tracheal or cricothyroid lesion before cross-table ventilation has been instituted.

These minor criticisms aside, Dr. Cohen and his colleagues have contributed enormously to the armamentarium of teaching thoracic anesthesiology. This book lives up to its claim of being comprehensive and detailing the highest standards of thoracic anesthesia care as they exist in 2022. This is indeed a book that no academic center should be without and that everyone who administers thoracic anesthesia may wish to add to their personal libraries.