Anaesthesia for the surgery of emphysema

Abstract

Thoracic anaesthesia is now established in a third age. The first age related to surgery for infective conditions, predominantly tuberculosis, the second was defined by surgery for bronchogenic cancer and the third is surgery for respiratory failure. The anaesthetic imperatives of this latest age are epitomized by emphysema, with some variants treated with lung transplantation and, recently, surgery for the oxymoron, lung volume reduction. Small areas of emphysematous changes are common in the general population, occasionally resulting in pneumothoraces; a significant number of these patients require surgical intervention. The presence of large cystic areas or bullae, and bilateral, widespread diffuse areas of enlarged air spaces distal to terminal bronchioles 32 are much rarer and their management fraught with risk. Until the advent of lung volume reduction surgery, the anaesthetic literature was sparse, with mostly case reports and series involving small numbers. Personal experience of managing cases with moderate to severe respiratory failure, as a result of end-stage emphysematous disease, serves as an illustrative framework (table 1) and has much to teach about the dangers, how anaesthesia may contribute to morbidity and mortality, and where risks can be reduced. An early specimen of emphysema, purportedly the lung of Dr Samuel Johnson, is illustrated in Mathew Baillie's The Morbid Anatomy of Some of the Most Important Parts of the Human Body (London, Bulmer, 1812). 47 Laennec 42 described the clinical condition of dyspnoea, cyanosis, dry cough, over-inflated chest, cardiac hypertrophy and quiet respiratory sounds on auscultation. He recognized the continuum from the small areas of enlarged air cells, illustrated in his book, to the giant cyst or bulla. He foresaw pathognomonic features now so often seen on chest x-rays and CT scans, 74 noting that: "When this disease occupies only one side, or exists much more in one lung than the other, this side is evidently enlarged, and the intercostal spaces wider...........and instead of its natural compressed shape it (the chest)

Left Ventricular Performance and Dimensions in Patients with Severe Emphysema

“…However, our patient characteristics and lung function data were identical to those described by Tschernko et al (3). It would therefore seem reasonable that PEEP i levels were also high in the present study, particularly as our patients were studied during positive pressure ventilation, which further aggravates dynamic hyperinflation and PEEPi in patients with severe emphysema (20). In patients with normal lung function, and in volunteers, positive pressure-respiration with PEEP depletes the intrathoracic vascular bed and the heart, decreasing both pulmonary, right ventricular (RV) and LV end-diastolic dimensions (21)(22)(23)(24)(25)(26)(27).…”

Complete spontaneous resolution of a giant bulla without rupture or infection: a case report and literature review

“…Prolonged one lung ventilation for bilateral surgery can cause rupture of a giant bulla on contralateral lung. It can lead to potential life-threatening situations such as pneumothorax, pneumopericardium, hypoxemia, and death in spite of cardiopulmonary bypass (7).…”

Endobronchial tubes – a case for re‐evaluation

“…Episodic hypoxaemia and hypotension, temporarily corrected by this apnoea manoeuvre, are markers of dynamic hyperinflation affecting venous return and pulmonary blood flow [4, 5]. Despite direct visual confirmation of the correct positioning and function of the tube exchange catheter it was decided that the absence of a cuff and a poorly sealed left main bronchus were most likely contributory factors [6]. Later, it was shown that a haemothorax, due to blood loss into the dependant pleura throughout the surgery, had caused this life‐threatening event and 1500 ml of blood was drained during the recovery period.…”

“…A sterile uncut, 7.5 mm cuffed tracheal tube was passed over the tube exchange catheter into the left main bronchus and the position of the tube and cuff confirmed using the fibreoptic bronchoscope and under direct vision through the operative field. Anaesthetic management became a holding exercise – adaptive (low inflation pressure, prolonged expiration) and reactive (ventilator disconnection) until the trachea was repaired and ventilation of the second lung was re‐established [5–7]. After the tracheal tube was withdrawn into the trachea and both lungs were ventilated, the patient remained stable until the end of the procedure.…”