|Year : 2008 | Volume
| Issue : 5 | Page : 584
Anaesthesia for Lung Volume Reduction Surgery in Bilateral Bullous Lung Disease: A Case Report
Raj Sahajanandan1, Georgene Singh1, Manickam Ponniah2
1 Asst. Professor, Department of Anaesthesiology and Critical Care, Christian Medical College, Vellore, Tamil Nadu-632004, India
2 Professor and Head, Department of Anaesthesiology and Critical Care, Christian Medical College, Vellore, Tamil Nadu-632004, India
|Date of Acceptance||06-May-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anaesthesiology and Critical Care, Christian Medical College, Vellore, Tamil Nadu. 632004
Source of Support: None, Conflict of Interest: None
Lung Volume Reduction Surgery (LVRS) has become an accepted modality for chronic pulmonary emphysema. Bilateral involve excision of emphysematous alveoli, which results in a 20% to 30% reduction in the volume of each lung. The goal of LVRS is to improve the respiratory mechanics in severe emphysema by re-expanding functional lung tissue that has been compressed by over-distended emphysematous alveoli, thus restoring diaphragmatic mobility and improving the bellows function of the chest wall structures. Anaesthesia for LVRS is a significant challenge to the anaesthetist as a result of high risk patient population and the nature of surgery. Management requires good understanding of the pathophysiology of the disease and surgical procedure. Close co-ordination between the anaesthetist, surgeon and other support staff are of paramount importance.
Keywords: Lung Volume Reduction Surgery, Bullous emphysema, One lung ventilation, Inter costal drain
|How to cite this article:|
Sahajanandan R, Singh G, Ponniah M. Anaesthesia for Lung Volume Reduction Surgery in Bilateral Bullous Lung Disease: A Case Report. Indian J Anaesth 2008;52:584
|How to cite this URL:|
Sahajanandan R, Singh G, Ponniah M. Anaesthesia for Lung Volume Reduction Surgery in Bilateral Bullous Lung Disease: A Case Report. Indian J Anaesth [serial online] 2008 [cited 2020 Apr 10];52:584. Available from: http://www.ijaweb.org/text.asp?2008/52/5/584/60681
| Introduction|| |
Lung Volume Reduction Surgery (LVRS) has become an accepted method of treatment for severe emphysema. LVRS is a challenging procedure for the anaesthetist, as a result of high-risk patient population and the nature of surgery. It requires sound knowledge of anaesthesia for thoracic surgery, pain therapy and ventilatory mechanics of patients suffering from severe emphysema. Careful patient selection, preoperative optimization and good analgesia that will facilitate early extubation are essential to minimize perioperative morbidity  .
| Case report|| |
A 34-year-old gentleman presented with progressively worsening dyspnoea on exertion and recurrent lower respiratory tract infections for eight years. He could climb two flights of stairs at a moderate pace. He was a smoker. On examination he was 175 cm tall and weighed 79 kg. He was breathing comfortably at a rate of 16 breaths per minute. Respiratory examination revealed decreased air entry bilaterally in the upper and mid zones. Skiagram of his chest [Figure 1] and plain computerized tomogram of the chest [Figure 2] revealed severe bilateral bullous emphysema. Right side involvement was more severe. Arterial blood gas analysis done on room air revealed respiratory alkalosis (pH 7.44; pO 2 69.5 mm Hg; pCO 2 28.3 mm Hg; Base excess of 3.7 and saturation 94%).
Preoperative pulmonary function test revealed severe obstructive ventilatory defect [Table 1] with no significant reversibility on administering bronchodilators. Lung volumes revealed distal air trapping suggestive of chronic obstructive airway disease. The patient was diagnosed to have bilateral bullous emphysematous disease. Staged lung volume reduction surgery with initial right bullectomy was planned.
| Anaesthetic management|| |
Breathing exercises and incentive spirometry were begun preoperatively. Fourth hourly nebulisation with ipratropium bromide and salbutamol were started. He was premedicated with 10 mg diazepam. Anti-aspiration prophylaxis with omeprazole 20 mg on the night before and on the morning of surgery along with metoclopramide 10 mg, was given. In the preoperative holding area a peripheral line, a central line via the basilic vein and a radial arterial cannula were inserted. Standard monitoring with five lead ECG, SpO 2 , EtCO 2 , temperature and arterial blood pressure monitoring were established.
Patient was induced with titrated doses of propofol and fentanyl. With spontaneous breathing, deep plane of anaesthesia was established with sevoflurane 6%. Prophylactically, an intercostal drain (ICD) was placed on the left side and connected to an under water seal. Direct laryngoscopy was done and vocal cords were sprayed with 2 ml of 2% lidocaine. Patient was then intubated with a 39F left sided double lumen tube (DLT) and the position was confirmed clinically and by paediatric fiberscope. The tracheal lumen of the double lumen tube was then clamped and the patient was paralysed with vecuronium bromide 0.15 mg.kg -1 and intermittent positive pressure ventilation initiated maintaining the peak inspiratory pressure (PIP) below 25 cm H 2 O. The patient was then positioned in the left lateral position. The tube position was confirmed again clinically and with fibrescope. Anaesthesia was maintained with morphine 0.15 mg.kg -1 , 50% oxygen air mixure, 3% sevoflurane and intermittent doses of vecuronium 1 mg. Acceptable levels of saturation and EtCO 2 were maintained with oxygen 70 - 100% without positive end expiratory pressure (PEEP). 0.9 % normal saline was infused at the rate of 4ml.kg -1 .hour -1 for fluid replacement. Estimated blood loss was 600 ml. It was replaced with 500 ml of 6% hydroxyethyl starch. The bullae were excised, leaks sutured and hemostasis achieved. Intercostal blocks were given by the surgeons with 0.25% bupivacaine under direct vision and the chest was closed after inserting two intercostal drains. Duration of surgery and ventilation was three hours. The residual neuromuscular blockade was reversed. After ensuring adequate spontaneous ventilation and tracheobronchial toileting the trachea was extubated. Oxygen supplementation by facemask was given. He was shifted to the high dependency area for postoperative monitoring.
Postoperative analgesia was given with patient controlled analgesia- morphine (0.01 mg.kg -1 .hour -1 background infusion; lock out period of ten minutes; bolus dose 1 mg) and eight-hourly intramuscular diclofenac 75 mg/dose. Salbutamol nebulisation (5mg/ 5ml), steam inhalation and incentive spirometry were continued into the postoperative period for five days. Chest X-ray done on the second postoperative period revealed good expansion of the lung in the right side with no evidence of residual bullae. The patient had an uneventful recovery. He underwent left bullectomy three months later and was discharged home.
| Discussion|| |
Lung volume reduction surgery is the non anatomic resection of lung tissue. The most diseased part of the lung is targeted based on preoperative CT scans, with the aim of resecting 20-30 % of total lung volume. At surgery when the lung is isolated from ventilation, the parts of lung that are slowest to collapse are resected.  The improvement in lung function after bilateral LVRS is greater than that seen with unilateral LVRS, with no increase in morbidity and mortality. , However, the subsequent rate of decline of lung function is greater after bilateral surgery.  Therefore a staged bilateral procedure as was done in this patient may offer better result. When performing a bilateral surgery, consensus opinion is to operate on the worst lung first in order to improve its function before exposing it to one lung ventilation. ,
Patients with bullous emphysema usually have severe preexisting lung impairment and a thorough pre-operative assessment and preparation are necessary.  LVRS in patients with severe pulmonary impairment presents a particular anaesthesiological challenge. The anaesthesia technique needs to meet a number of specific requirements. (1) Problems due to severe pulmonary emphysema [risk of tension pneumothorax, intrinsic PEEP, hyperinflation, hypercapnoea, pulmonary hypertension, right heart failure]. (2) Problems of one lung ventilation such as increased intrapulmonary shunting and hypoxia, increased dead space ventilation and hypercapnoea, increased airway pressure which are more pronounced in patients with bilateral pulmonary impairment (3) Problems inherent to LVRS [post operative pain, respiratory depression, post operative lung function impairment, air leakage etc]. , Heavy premedication is generally avoided in these patients and bronchodilator therapy is continued. Although intravenous induction has been commonly used  , inhalational induction or awake intubation with meticulous topical anaesthesia has also been described  . We intubated our patient under deep sevoflurane anaesthesia with topical lidocaine with out abolishing spontaneous respiration, as he had bilateral severe bullous lung disease. Intraoperative rupture of the bulla in the left lung during right thoracotomy might result in complete inability to ventilate the patient as the right lung would be collapsed and the left would be compromised by pneumothorax.  So it was planned to insert an intercostal drain prophylactically on the left side. Lung isolation is mandatory for LVRS regardless of the surgical approach.  Most of the published case series have used a left sided DLT. ,, Fibreoptic confirmation after DLT placement is advisable as the rate of malposition after clinical confirmation is high (48- 78%).  Perfect positioning of DLT is necessary because these patients will not tolerate excessive airway pressures or ventilatory exclusion of one of the upper lobes.  As the patients are at risk of barotraumas and gas trapping, pressure controlled ventilation is preferred over volume controlled ventilation.  This is especially important if the intraoperative air leaks are more than 50% of the tidal volume.  When positive pressure ventilation is required during one lung ventilation, the patient should be carefully observed for pneumothorax and efforts made to limit the peak inspiratory pressures permitting hypercapnoea.  To avoid dynamic hyperinflation, a low ventilatory rate and a long inspiratory to expiratory ratio (I:E) are used.  This almost invariably results in hypercapnoea which is usually well tolerated by the patient and resolves within 24 - 48 hours postoperatively. For obvious reasons N 2 O has to be avoided. , Anaesthesia can be maintained by using a combination of propofol and fentanyl or inhalational agents. However, successful administration of inhalational anaesthetic can be affected by severe air leak during LVRS.  EtCO 2 may grossly underestimate the arterial PaCO 2 , so it may be advisable to perform serial blood gas measurements intraoperatively.  Early tracheal extubation, with avoidance of coughing on the tube is an important aim after LVRS in order to minimize the risk of developing or exacerbating an air leak. Hypercapnoea is almost invariable in the early postoperative period and should not be seen as a barrier for early extubation. It is important that the patient is warm, pain free, haemodynamically stable and has good respiratory pattern and cough.  Good postoperative analgesia is crucial to allow best ventilatory excursions as early as possible and to facilitate chest physiotherapy. Thoracic epidural anaesthesia with local anaesthetic and opioids would appear to be the ideal means of achieving optimal intra and postoperative analgesia with minimum central nervous system and respiratory depression. , Intercostal nerve block employed intraoperatively is a good alternative in unilateral surgical procedure.  Supplemental analgesia with NSAIDs is of proven benefit in these cases.  Nebulised bronchodilators and aggressive chest physiotherapy should begin in the immediate postoperative period to maximize pulmonary function. Narcotics, if used, should be titrated to the minimum to keep a balance between adequate analgesia and respiratory depression. 
To conclude, careful preoperative assessment and optimization is of paramount importance in LVRS for bilateral bullous emphysema. Anaesthetic technique aimed at minimizing air trapping, barotrauma and facilitating early extubation contributes to reduction of morbidity associated with LVRS.
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[Figure 1], [Figure 2]