Anaesthesia for lung volume reduction surgery

Abstract

SummaryLung volume reduction surgery is a surgical treatment for severe emphysema that is increasing in popularity. The aim is to reverse the hyperexpansion of the lungs that leads to expiratory airflow limitation, compromises the diaphragm and chest wall mechanics, and tamponades the right ventricle. Optimal patient selection has not yet been established, but it has become clear that those patients with the most severe disease have an unacceptably high surgical mortality. The anaesthetic management of patients undergoing lung volume reduction surgery requires a good understanding of both the pathophysiology of the disease and the surgical procedure. It is important for the anaesthetist and the surgeon to work closely, supported by a large multidisciplinary team. Excellent analgesia is essential to a successful outcome; whether this is best provided by thoracic epidural is as yet unclear.

Anesthetic Considerations in Candidates for Lung Volume Reduction Surgery

“…If the patient is calm and cooperative, sedative premedication is not necessary (19). However, small doses of a benzodiazepine may be beneficial for those treated chronically with benzodiazepines, or if heightened anxiety about the anticipated surgery contributes to dyspnea.…”

“…A variety of inhalation agents have been used, but no agent has emerged as clearly superior. Use of nitrous oxide has been avoided in all published reports (19). Due to the severity of the bullous disease, and the associated large dead space, uptake and distribution of inhalational agents is unpredictable (19) and delayed awakening may be seen.…”

“…Thoracic epidural analgesia is considered mandatory by some practitioners (19), and is the most commonly recommended form of regional pain control for LVRS. Indeed, in some centers, if acceptable placement of a thoracic epidural catheter cannot be confirmed before induction of anesthesia, the surgery will be postponed.…”

“…Repositioning of the patient after placement of the flow-directed PA catheter may contribute to inaccurate measurement of cardiac filling pressures. If more definitive intraoperative assessment of right or left heart function is required, the TEE will likely provide greater value (13,19).…”

“…An arterial monitoring line will allow rapid titration of these agents. Central venous catheters may be employed (19,21), and are useful for rapid delivery of pharmacologic agents to the central circulation, but are not absolutely necessary. Placement of a central catheter is usually performed after induction of anesthesia due to the discomfort that the patient may experience in the Trendelenberg position and the possibility of oxygen desaturation.…”