Anesthesia for Pneumonectomy : Anesthesia for Pneumonectomy Dr Gagan Pal Singh Slide 2: Preoperative assessment
Lung isolation techniques
One lung Ventilation
Complications Preoperative Assessment : Preoperative Assessment Aim
Identify patients at high risk
Use that risk assessment to stratify perioperative management and focus resources on the high-risk patients to improve their outcome. Assessment of Respiratory function : Assessment of Respiratory function Detailed history
Lung parenchymal function
Cardiopulmonary interaction Respiratory mechanics : Respiratory mechanics For example, after a right lower lobectomy a patient with a preoperative FEV1 (or DLCO) 70% of normal would be expected to have a postoperative
FEV1 = 70% × (1 - 29/100) = 50% ppoFEV1% = preop FEV1% ×
(1- %Functional lung tissue removed/100) Slinger PD, Johnston MR: Preoperative assessment: an anesthesiologist's perspective. Thorac Surg Clin 15:11, 2005. Ppo FEV1
>40% -Low risk
30-40%- mod risk
< 30% - high risk Lung Parenchymal Function : Lung Parenchymal Function Diffusing capacity for CO (DLCO)
Useful predictor of perioperative mortality but not long term survival.
ppoDLco <40% predicted correlates with both increased respiratory and cardiac complications and is independent of the FEV1. Cardiopulmonary Interaction : Cardiopulmonary Interaction Maximum oxygen consumption (Vo2max)
Most useful predictor of post-thoracotomy outcome.
Morbidity and mortality is unacceptably high- Vo2max <15 mL/kg/min.
Few patients with a Vo2max >20 mL/kg/min have respiratory complications
5 flights - Vo2max >20 mL/kg/min
2 flights - Vo2max of 12 mL/kg/min
6-minute test (6MWT)
<2000 ft (610 m) - Vo2max <15 mL/kg/min
Patients with a decrease of Spo2 greater than 4% during exercise are at increased risk for morbidity and mortality. Ventilation-Perfusion Scintigraphy : Ventilation-Perfusion Scintigraphy Pneumonectomy patient who has a preoperative FEV1 and/or DLCO less than 40%.
Split Function Tests
Unilateral exclusion of a lung or lobe with an endobronchial tube/blocker or by pulmonary artery balloon occlusion of a lung or lobe artery, or by both. Comorbid Conditions : Comorbid Conditions Cardiovascular Diseases
“intermediate risk” procedure in terms of perioperative cardiac ischemia.
Documented incidence is 5% and peaks on 2 to 3 POD.
History, physical examination, and electrocardiogram.
Noninvasive testing is indicated in patients with
Active cardiac conditions (unstable coronary syndromes, Decompensated CHF, severe valvular disease, significant arrhythmia)
Therapeutic options for patients with significant cad
optimization of medical therapy
coronary artery bypass, either before or at the time of lung resection. Timing of lung resection surgery : Timing of lung resection surgery ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery . Age >70 Yrs : Age >70 Yrs Respiratory complications – 40%
(double than expected)
Cardiac complications – 40%
(3 times than expected). Age : Age Renal Dysfunction : Renal Dysfunction Mortality – 18-20%
H/o of previous renal impairment
Blood transfusion Chronic Obstructive Airway Disease : Chronic Obstructive Airway Disease Emphysema
Peripheral Airway Disease
Impairement of Expiratory Airflow
stage I - >50% predicted
stage II - 35% 50%
stage III - <35% Respiratory Drive : Respiratory Drive Earlier concept
COPD pts relied on a hypoxic stimulus for ventilatory drive and became insensitive to Paco2.
Hypercapnic coma by the administration of a high Fio2.
Minute ventilation is basically unchanged.
Relative decrease in alveolar ventilation and an increase in alveolar dead space
Redistribution of perfusion away from lung areas of relatively normal V/Q matching to areas of very lowV/Q ratio.
A minor fraction of the increase in Paco2 is due to a diminished respiratory drive.
Supplemental oxygen must be administered postoperatively to prevent the hypoxemia associated with the unavoidable fall in FRC.
The attendant rise in Paco2 should be anticipated and monitored. Nocturnal Hypoxemia : Nocturnal Hypoxemia Rapid/shallow breathing pattern during REM sleep.
This tendency to desaturate, combined with the postoperative fall in FRC and opioid analgesia, places these patients at high risk for severe hypoxemia postoperatively during sleep. Right ventricular dysfunction : Right ventricular dysfunction 50% of COPD patients.
poorly tolerant of sudden increases in afterload, such as the change from spontaneous to controlled ventilation.
Cor pulmonale - 40% in pts with an FEV1 <1 L
70% with an FEV1 <0.6 L.
Pneumonectomy candidates with a ppoFEV1 less than 40% should have transthoracic echocardiography to assess right-sided heart function. Elevation of right-sided heart pressures places these patients in a very high-risk group.
The only therapy that has been shown to improve long-term survival and decrease right-sided heart strain in COPD is oxygen.
COPD patients with resting PaO2 <55 mm Hg & <44 mm Hg with usual exercise should receive supplemental home oxygen. The goal of supplemental oxygen is to maintain a PaO2 of 60 to 65 mm Hg. Bullae : Bullae Chances of Bullae rupture, tension pneumothorax and bronchopleural fistula with positive-pressure ventilation
Keep low airway pressures
Equipment should be available to insert a chest drain and obtain lung isolation if necessary. Flow Limitation : Flow Limitation Risk for hemodynamic collapse with the application of positive-pressure ventilation owing to dynamic hyperinflation of the lungs. Difficult Endobronchial Intubation : Difficult Endobronchial Intubation History
Prior pulmonary or airway surgery
Written bronchoscopy report with detailed description of anatomic features.
The most useful predictor is plain chest radiograph Prediction of Desaturation during OLV : Prediction of Desaturation during OLV High percentage of ventilation or perfusion to the operative lung on preoperative ventilation- perfusion scan
Poor PaO2 during two-lung ventilation, particularly in the lateral position intraoperatively
Restrictive lung disease
Supine position during one-lung ventilation Preoperative Optimization : Preoperative Optimization Stop smoking, avoid industrial pollutants
Airway hydration (humidifier/nebulizer)
Mucolytic and expectorant drugs
Chest physiotherapy (percussion and vibration) Adjunct medication
Antibiotics—if purulent sputum/bronchitis
Antacids, H2 blockers, or PPIs—if symptomatic reflux.
Increased education, motivation, and facilitation of postoperative care
Preoperative pulmonary care training
Secretion removal maneuvers
Stabilize other medical problems Summary of initial preoperative assessment : Summary of initial preoperative assessment All patients:
Assess exercise tolerance
estimate predicted postoperative FEV1%
discuss postoperative analgesia
Patients with predicted postoperative FEV1< 40%:
Ventilation perfusion Scan
Vo2 max Cancer patients:
consider the “4 Ms”:
Arterial blood gas analysis
Increased renal risk:
Measure creatinine and blood urea nitrogen Final Assessment : Final Assessment Review initial assessment and test results.
Assess difficulty of lung isolation: examine chest radiograph and computed tomography scan.
Assess risk of hypoxemia during one-lung ventilation. Intraoperative Monitoring : Intraoperative Monitoring Oxygenation
Arterial blood pressure
Pulmonary artery pressure
Temperature Transesophageal Echocardiography : Transesophageal Echocardiography Lung Isolation Techniques : Lung Isolation Techniques Double lumen tube
Endotracheal tube advanced into bronchus Double lumen tube : Double lumen tube Carlens tube
Quickest to place successfully
Repositioning rarely required
Bronchoscopy to isolated lung
Suction to isolated lung
CPAP easily added
Can alternate OLV to either lung easily
Placement still possible if bronchoscopy not available Disadvantages
Size selection more difficult
Difficult to place in patients with difficult airways or abnormal tracheas
Not optimal for postoperative ventilation
Potential laryngeal trauma
Potential bronchial trauma Size selection : Size selection Depth of insertion
12 + (patient height/10) cm Method of insertion : Method of insertion Blind technique:
DLT is passed with direct laryngoscopy
Turn 90 ° counterclockwise (for a left-sided DLT placement) after the endobronchial cuff has passed beyond the vocal cords.
The DLT should pass the glottis without any resistance.
Tip of the endobronchial lumen is guided into the correct bronchus after the DLT passes the vocal cords using direct vision with a flexible fiberoptic bronchoscope Confirmation of tube placement : Confirmation of tube placement Auscultation “three-step” method:
Step 1. During bilateral ventilation, the tracheal cuff is inflated to the minimal volume that seals the air leak at the glottis. confirm bilateral ventilation.
Step 2. The tracheal lumen is clamped proximally and the port distal to the clamp opened. During ventilation via the bronchial lumen the bronchial cuff is inflated to the minimal volume that seals the air leak from the open tracheal lumen port. Auscultate to confirm correct unilateral ventilation.
Step 3. The tracheal lumen clamp is released and the port closed. Auscultate to confirm resumption of bilateral breath sounds. Fiberoptic bronchoscopy : Fiberoptic bronchoscopy Tracheal View
Confirm endobronchial portion in the left bronchus
Bronchial cuff herniation over the carina after inflation.
identify the takeoff of the right upper lobe bronchus through the tracheal view.
Going inside this right upper lobe with the bronchoscope should reveal three orifices (apical, anterior, and posterior).
check for patency of the tube
Determination of margin of safety
The orifices of both the left upper and lower lobes must be identified to avoid distal impaction in the left lower lobe and occlusion of the left-upper lobe Slide 37: view from the distal bronchial lumen Tracheal view Right-Sided Double-Lumen Endobronchial Tubes : Right-Sided Double-Lumen Endobronchial Tubes Distorted Anatomy of the Entrance of Left Mainstem Bronchus
External or intraluminal tumor compression
Descending thoracic aortic aneurysm
Site of Surgery Involving the Left Mainstem Bronchus
Left lung transplantation
Left-sided tracheobronchial disruption
Left-sided sleeve resection Bronchial blockers : Bronchial blockers Pts with previous oral or neck surgery who present with a challenging airway
Pts with previous contralateral pulmonary resection
when postoperative mechanical ventilation is being considered after prolonged thoracic or esophageal surgery. Cohen Blocker : Cohen Blocker Wheel in the proximal part of the unit deflects the tip of the distal part of the blocker into the desired bronchus.
Distal tip is preangled to facilitate insertion into a target bronchus.
Arrow on the distal shaft above the balloon
To position the Cohen blocker, the arrow is aligned with the bronchus to be intubated, the proximal wheel is turned to deflect the tip toward the desired side and then the blocker is advanced with fiberoptic guidance. Arndt Blocker : Arndt Blocker Disadvantages of Bronchial Blockers : Disadvantages of Bronchial Blockers More time consuming
Repositioning needed more often
Bronchoscope essential for positioning
Nonoptimal right lung isolation due to RUL anatomy
Bronchoscopy to isolated lung impossible
Minimal suction to isolated lung
Difficult to alternate OLV to either lung Univent Bronchial blockers : Univent Bronchial blockers Enclosed bronchial blocker is fully retracted into the standard lumen of the tube.
Conventional endotracheal tube intubation technique is used.
Then a fiberoptic bronchoscope is passed into the main lumen through a bronchoscopy adaptor.
Under direct vision the enclosed bronchial blocker is advanced into the targeted bronchus Positioning : Positioning Position Change
Secure all lines and monitors
Make an initial “head-to-toe” survey
Check oxygenation, ventilation, hemodynamics, lines, monitors, and potential nerve injuries.
Reassess after repositioning
Recheck Endobronchial tube/blocker position and the adequacy of ventilation by auscultation and fiberoptic bronchoscopy after repositioning. Neurovascular Complications : Neurovascular Complications Brachial Plexus Injury
Dependent Arm (Compression Injuries)
Arm directly under thorax
Pressure on clavicle into retroclavicular space
Caudal migration of thorax padding into the axilla
Nondependent Arm (Stretch Injuries)
Lateral flexion of cervical spine
Excessive abduction of arm (>90%)
Semiprone or semisupine repositioning after arm fixed to a support “Head-to-Toe” Survey : “Head-to-Toe” Survey Dependent eye
Dependent ear pinna
Cervical spine in line with thoracic spine
Dependent and nondependent suprascapular nerves
Nondependent leg: sciatic nerve
Circulation Lateral decubitus position for thoracotomy : Lateral decubitus position for thoracotomy Awake Vs Anaesthetized In Lateral position : Awake Vs Anaesthetized In Lateral position Non dependent lung moving from a flat, noncompliant portion to a steep, compliant portion
Dependent lung moving from a steep, compliant part to a flat, noncompliant part.
Thus, an anesthetized patient in a lateral decubitus position has more of the tidal ventilation in the nondependent lung (where
perfusion is the least) and less of the tidal ventilation in the dependent lung Open paralyzed Chest in lateral position : Open paralyzed Chest in lateral position Opening the chest increases nondependent lung compliance
Paralysis also reinforces or maintains the larger part of tidal ventilation going to the nondependent lung because the pressure of the abdominal contents (PAB ) pressing against the upper part of the diaphragm is minimal compliance of a single lung during position changes in an anesthetized, paralyzed patient during controlled mechanical ventilation : compliance of a single lung during position changes in an anesthetized, paralyzed patient during controlled mechanical ventilation One Lung Ventilation : One Lung Ventilation Determinants of pulmonary blood flow : Determinants of pulmonary blood flow Hypoxic Pulmonary Vasoconstriction : Hypoxic Pulmonary Vasoconstriction Decrease the blood flow to the nonventilated lung by 50%.
Primary stimulus is Pao2
↓ Pao2 stimulates precapillary vasoconstriction redistributing pulmonary blood flow via a pathway involving NO and/or cyclooxygenase synthesis inhibition
Rapid onset over the first 30 minutes and then a slower increase to a maximal response at approximately 2 hours.
response to a second hypoxic challenge will be greater than to the first challenge One-Lung Ventilation… : One-Lung Ventilation… Thoroughly de-nitrogenate the operative lung, before collapse
Recruitment maneuver (holding the lung at an end-inspiratory pressure of 20 cm H2O for 15 to 20 sec) immediately after the start of OLV to decrease atelectasis Hypoxemia during OLV : Hypoxemia during OLV Incidence
1950-1980 -20% to 25%
1990s - <10%
Improved lung-isolation techniques such as routine fiberoscopy to prevent lobar obstruction from DLTs
Improved anesthetic techniques that cause less inhibition of HPV
Better understanding of the pathophysiology of OLV Treatment of Hypoxemia : Treatment of Hypoxemia Severe or precipitous desaturation:
Resume two-lung ventilation (if possible).
Ensure that delivered FIO2 is 1.0
Check position of DLT or blocker with fiberoptic bronchoscopy
Ensure cardiac output is optimal; decrease volatile anesthetics to < 1 MAC
Apply a recruitment maneuver to the ventilated lung
Apply PEEP 5 cm H2O to the ventilated lung
Apply CPAP 1-2 cm H2O to the nonventilated lung (apply a recruitment maneuver to this lung immediately before CPAP)
Intermittent reinflation of the nonventilated lung
Partial ventilation techniques of the nonventilated lung:
Lobar collapse (using a bronchial blocker)
Mechanical restriction of the blood flow to the nonventilated lung Anesthetic Management : Anesthetic Management Fluid Management
First 24-hour perioperative total positive fluid balance should not exceed 20 mL/kg.
crystalloid administration should be limited to < 3 L in the first 24 hours.
No fluid administration for third space fluid losses during pulmonary resection.
Urine output > 0.5 mL/kg/hr is unnecessary.
If increased tissue perfusion is needed postoperatively, it is preferable to use invasive monitoring and inotropes rather than to cause fluid overload.
Avoid N2O - more prone to cause atelectasis in poorly ventilated lung regions
Maintenance of body temperature
Prevention of Bronchospasm Ventilation Strategies : Ventilation Strategies Postoperative mangement- Analgesia : Postoperative mangement- Analgesia Systemic Analgesia
Nonsteroidal Anti-inflammatory Drugs
Local Anesthetics/Nerve Blocks
Intercostal Nerve Blocks
Paravertebral Block Thoracic Epidural Analgesia : Thoracic Epidural Analgesia Better preservation of the functional residual volume
Efficient mucociliary clearance
Alleviation of the inhibiting reflexes acting on the diaphragm
prevention of atelectasis and secondary infections Postoperative Complications : Postoperative Complications Early Major Complications
Torsion of a remaining lobe after lobectomy
Dehiscence of a bronchial stump
Hemorrhage from a major vessel
Cardiac Herniation Respiratory Failure : Respiratory Failure Acute onset of
hypoxemia (PaO2 < 60 mm Hg)
hypercapnia (PaCO2 > 45 mm Hg)
use of postoperative mechanical ventilation for >24 hours
Reintubation for controlled ventilation after extubation
Incidence - 2% - 18% Respiratory Failure… : Respiratory Failure… Predictors
Preoperatively decreased respiratory function
Presence of coronary artery disease
Extent of lung resection
Prolonged mechanical ventilation postoperatively Respiratory Failure… : Respiratory Failure… Chest physiotherapy, incentive spirometry, and early ambulation are crucial
Early extubation is desirable for an uncomplicated lung resection.
Current therapy to treat acute respiratory failure is supportive therapy to provide better oxygenation, treat infection, and provide vital organ support without further damaging the lungs. Cardiac Herniation : Cardiac Herniation If the pericardium is incompletely closed or the closure breaks down
immediately or within 24 hours after chest surgery
Clinical presentation after a right pneumonectomy
Impairment of the venous return to the heart
Increase in central venous pressure
Acute SVC syndrome due to the torsion of the heart.
Clinical presentation after a left pneumonectomy
There is less cardiac rotation but the edge of the pericardium compresses the myocardium
ventricular outflow tract obstruction. Cardiac Herniation - management : Cardiac Herniation - management consider as dire emergent surgery.
The differential diagnosis
massive intrathoracic hemorrhage
mediastinal shift from improper chest drain management.
Early diagnosis and immediate surgical treatment by relocation of the heart to its anatomic position with repair of the pericardial defect or by the use of analogous or prosthetic patch material is key to patient survival. Arrhythmias : Arrhythmias Incidence - 30% to 50%
60% to 70% are atrial fibrillation
Extent of lung resection
Pneumonectomy – 60%
Lobectomy – 40%
Nonresection thoracotomy - 30%)
Intraoperative blood loss
Age of the patient.
Extrapleural pneumonectomy Slide 69: Antiarrhythmic Prophylaxis
Thoracic epidural analgesia
Due to increasing myocardial refractory period, decreasing ventricular diastolic pressures, and improving endocardial/epicardial blood flow ratios. Oka T, Ozawa Y, Ohkubo Y: Thoracic epidural bupivacaine attenuates supraventricular tachyarrhythmias
after pulmonary resection. Anesth Analg 2001; 93:253. Slide 70: THANK YOU