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Lung Volume Reduction

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

Lung volume reduction surgery (LVRS) is a viable option for a select group of emphysema patients. Effective preoperative pulmonary rehabilitation and careful patient selection criteria promote favorable outcomes. Effective perioperative pain management and early extubation are significant factors that minimize postoperative complications and lead to better outcome. LVRS improves dyspnea and exercise tolerance and increases potential for patient survival in appropriately selected patients.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, UPMC Presbyterian Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Erin A. Sullivan

Authors
  1. Erin A. Sullivan
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Corresponding author

Correspondence to Erin A. Sullivan .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

Case: A 58-year-old female patient with end-stage emphysema is scheduled for bilateral LVRS using a video-assisted thoracoscopic approach (VATS). She has a past medical history that is significant for smoking (60 pack years; quit for the past 2 years), hypertension, and atrial fibrillation that is controlled with metoprolol. Her other medication includes an 81-mg aspirin that she takes once per day. She successfully completed a preoperative exercise program 8 weeks ago. The patient is very anxious and wishes to speak with the anesthesiologist who will provide her care prior to the date of surgery.

Questions

  • What additional preoperative preparation is necessary from a pulmonary standpoint?

  • How will you treat the patient’s anxiety?

  • What will you recommend for perioperative pain management?

  • What are your specific concerns regarding postoperative management?

Preoperative Pulmonary Preparation

  • Successful completion of a preoperative exercise program including a 6-min walk on a flat surface, bicycle ergometer, and weight lifting (see section “Preoperative Medical Management of Emphysema Patients”).

  • Continue supplemental oxygen use, bronchodilators, and mucolytics up to and including the day of surgery (see section “Pharmacologic Preparation”).

  • Gradually reduce the dose of steroids prior to surgery if they are being administered.

  • If the patient is receiving theophylline therapy and exhibiting symptoms of toxicity (nervousness, tremor, tachycardia) or if serum levels exceed 20 ng/mL, discontinue the drug.

  • Ensure that the patient is free from infection and does not require antibiotics for at least a 3-week period prior to surgery.

Treatment of Anxiety

  • Untreated anxiety may precipitate an episode of acute bronchospasm, an increase in dynamic pulmonary hyperinflation, and dyspnea (see section “Preoperative Medical Management of Emphysema Patients”).

  • An effective way to allay a patient’s anxiety is for the anesthesiologist to establish a good relationship with the patient prior to the date of surgery by scheduling a meeting in the anesthesia preoperative evaluation clinic.

  • Anxiolytic therapy may be necessary during the preoperative and perioperative period.

Perioperative Analgesia

  • The patient is at high risk for perioperative pulmonary complications if analgesia is insufficient or ineffective.

  • The risk of pulmonary complications may be improved with the use of thoracic epidural or paravertebral analgesia (see sections “Thoracic Epidural Analgesia” and “Paravertebral Nerve Block”).

  • TEA or paravertebral nerve block catheters should be maintained until the chest drains are removed and the patient is tolerating oral pain medications.

Postoperative Management (see sections “Early Extubation” and “Postoperative Management”)

  • Air leakage can be exacerbated by positive pressure ventilation. Therefore, the patient should be extubated as soon as it is safe to do so, preferably in the operating room. It is safe, however, to maintain mechanical ventilation for 1–2 h following surgery, and this is preferable to premature extubation and the subsequent development of arterial hypoxemia.

  • Fifty percent of LVRS patients develop a postoperative complication.

  • Reintubation and mechanical ventilation in the postoperative period are associated with a high morbidity and mortality.

  • Postoperative complications can be minimized by implementing judicious pulmonary toilet, bronchodilator therapy, effective pain management with thoracic epidural or paravertebral analgesia, and avoidance of systemic corticosteroids.

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Sullivan, E.A. (2019). Lung Volume Reduction. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_46

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_46

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-00858-1

  • Online ISBN: 978-3-030-00859-8

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