1482
CASE REPORTS
5. McCollum WB, Mattox KL, Guinn GA, Beall AC Jr: Immediated
operative treatment for massive hemoptysis. Chest 1975; 67:152–5
6. Garzon AA, Gerrute M, Gourin A, Karlson KE: Pulmonary resec-
tion for massive hemoptysis. Surgery 1970; 67:633– 8
7. Scott NB, Mogensen T, Bigler D, Lund C, Kehlet H: Continuous
thoracic epidural bupivicaine 0.5 percent with and without morphine:
Anesthesiology
2000; 92:1482– 4
© 2000 American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc.
Thoracic Epidural Anesthesia for Thoracoscopy, Rib Resection,
and Thoracotomy in a Patient with a Bronchopleural Fistula
Postpneumonectomy
Alexander Williams, M.D., F.R.C.P.C.,* Joseph Kay, M.D., F.R.C.P.C.†
THE induction of anesthesia in a patient with a broncho-
pleural fistula (BPF) postpneumonectomy can be quite
difficult. This is because positive pressure ventilation can
force gas through the fistula and lead to inadequate
ventilation. The choice of endotracheal tube and inser-
tion technique are important considerations in these
patients. The placement of a double lumen tube or a
single lumen tube inside the normal main stem bronchus
may be technically difficult after a lung resection and is
at risk of being malpositioned through the bronchial
stump. A single lumen tube can be placed above the
carina in a patient breathing spontaneously (awake or
asleep); however, positive pressure ventilation, if
needed, may impair ventilation. Also, it will not prevent
contamination of the remaining lung. A bronchial
* Lecturer.
† Assistant Professor.
Received from the Department of Anesthesia, Sunnybrook & Wom-
en’s College Health Sciences Centre, University of Toronto, Toronto,
Canada. Submitted for publication September 1, 1999. Accepted for
publication December 22, 1999. The Department of Anesthesia pro-
vided the necessary working space and office supplies to prepare the
manuscript.
Address reprint requests to Dr. Williams: Department of Anesthesia,
Sunnybrook & Women’s College Health Sciences Centre, Sunnybrook
Campus 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5.
Address electronic mail to:
sandyw12@hotmail.com
The authors thank Dr. Peter Slinger for reviewing the manuscript.
Key words: Bronchial stump; empyema; neuraxial block; thoracic
surgery; pneumonectomy.
Anesthesiology, V 92, No 5, May 2000
Effect on quality of blockade, lung function and the surgical stress
response. Br J Anaesth 1989; 62:253–7
8. Reiz S, Balfors E, Sorensen M: Coronary haemodynamic effects
of general anesthesia and surgery: Modification by epidural anesthe-
sia in patients with ischemic heart disease. Reg Anesth T 1982;
14:8 –18
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blocker proximal to the fistula risks perforating the bron-
chial stump if it migrates distally.
We report a case of a patient with a BPF postpneumo-
nectomy who had a thoracoscopy, mini thoracotomy,
and rib resection performed under thoracic epidural
anesthesia and intravenous sedation without instrument-
ing the airway and without positive pressure ventilation.
Case Report
A 68-yr-old male was readmitted to hospital 1 week after discharge
after an uneventful right pneumonectomy for squamous cell carci-
noma. He presented with worsening dyspnea, hemoptysis, and pro-
ductive cough. Examination revealed a respiratory rate of 22, heart rate
of 100, and blood pressure of 130/78. The trachea was midline and
there was good air entry to the left lung with some rales in the left
lower lobe. Oxygen saturation was 83% on room air and 91% on 2 l of
nasal prong oxygen. The chest x-ray revealed a right hydropneumo-
thorax, a midline trachea and mediastinum, and no air space disease.
The patient was started on intravenous ampicillin and gentamicin.
On the third day, a right-sided chest tube was inserted that drained 250
ml of fluid in the first 24 h and demonstrated a persistent air leak.
Follow-up chest x-rays revealed persistent loculated air fluid levels on
the right hemithorax and a clear left lung field. The chest tube was left
open to air to drain any remaining empyema. Throughout this period,
the patient did not show signs of sepsis.
Bronchopleural fistula caused by a persistent bronchial stump leak
was diagnosed. The patient was scheduled to undergo a thoracoscopy
and rib resection to allow for the insertion of a large caliber drainage
tube. The surgeon preferred that the patient’s airway not be instru-
mented. After reviewing the anesthetic options with the surgeon and
patient, the decision was made to proceed using a thoracic epidural for
anesthesia and postoperative analgesia.
A thoracic epidural catheter was inserted at the T7-8 interspace
using the paramedian approach in the sitting position. Carbonated
lidocaine (equivalent to 2%) was titrated in 2 ml aliquots to a total dose

CASE REPORTS
of 8 ml to which 25 ␮g fentanyl was added. The patient had loss of pin
prick sensation from T2-T10 within approximately 15 min. As a pre-
caution, an additional 15 ml of 0.5% bupivacaine was injected locally
by the surgeon to the skin and subcutaneous tissue covering the
surgical site immediately before initiating the surgery. A total of 2.5 mg
midazolam and 50 ␮g fentanyl was given intravenously for sedation
and 200 ␮g phenylephrine was given intravenously to treat epidural
induced hypotension.
The chest tube was removed and a thoracoscopy performed through
this opening with the patient in the left lateral reverse Trendelenberg
position. Loculations of fibrinous exudate was suctioned out of the
thorax. The surgeon was unable to visualize the bronchial stump. Ten
milliliters of saline was introduced into the thorax which resulted in
immediate coughing up of the saline into the patient’s mouth, con-
firming the bronchial stump leak. A seventh rib resection was then
performed in the posterior axillary line in the most dependent position
of the cavity. This was performed by a mini thoracotomy incision with
removal of approximately 4 cm of rib and then dissection through the
pleura and into the cavity. A large permanent drainage tube was
inserted and sutured in place. A dry dressing was applied to the
drainage tube which was left open to air. The total operating room time
was 1 h and 20 min. The procedure was well tolerated, respiratory status
was stable, and oxygen saturation was maintained above 95%.
The patient was then transferred to the postanesthesia care unit,
awake, pain free, breathing oxygen by face mask and in stable condi-
tion. He was nursed in the right lateral semi-sitting position. In the
postanesthesia care unit, an epidural bolus of 4 ml 0.5% bupivacaine
was administered and an infusion of ropivacaine 0.2% was started at 4
ml/h. The epidural was discontinued on the third postoperative day, at
which time the patient’s oxygen saturation had improved to 95% on
room air. The patient was discharged home on the 14th postoperative
day and was doing well on his 6-month follow-up visit despite persis-
tence of the BPF.
Discussion
The incidence of postpneumonectomy BPF has been
reported to be 3.1 to 11%.1,2 Although initial manage-
ment includes chest tube insertion and parenteral anti-
biotics, these patients will often return to the operating
room for a more definitive procedure. Respiratory re-
serve is decreased in these patients because of their
underlying pulmonary disease, recent pneumonectomy,
BPF, and potential pneumonia from soiling by the con-
tralateral empyema.
Case reports describing the use of thoracic epidurals in
different types of thoracic procedures have been previ-
ously published. However, we could not find a docu-
mented case using this technique in a patient with a
bronchial stump leak postpneumonectomy undergoing a
thoracoscopy and rib resection. Kempen described the
use of a thoracic epidural and interpleural block for
pleurodesis in a patient with a recurrent pneumotho-
rax.3 Mukaida et al. described four cases of high-risk
patients undergoing video-assisted thoracic surgery
Anesthesiology, V 92, No 5, May 2000
1483
using a thoracic epidural.4 Three patients had severe
emphysema with bilateral bullae and recurrent pneumo-
thoraces and the fourth patient had pulmonary fibrosis
with a left pneumothorax.
When deciding the appropriateness of using a thoracic
epidural, awareness both of the innervation of the tho-
racic structures and the potential drawbacks of using an
epidural must be considered. The chest wall and parietal
pleura are innervated by the intercostal nerves. The
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lungs and visceral pleura are innervated by the anterior
and posterior pulmonary plexuses which contain both
vagal (parasympathetic) and sympathetic fibers. A tho-
racic epidural or a stellate ganglion block can block
sympathetic fibers thus decreasing the cough reflex from
manipulation of the hilum.5,6 The sympathetic fibers of
the thorax originate from the T1–T5 level.7 However,
the vagal fibers, which also supply afferent innervation
from the lungs and visceral pleura, will not be blocked.
The mediastinal pleura has sensory innervation from the
phrenic nerve which will not be blocked by a thoracic
epidural. Sensation to the diaphragm originates from
two different sources. The upper and lower surfaces of
the central portion of the diaphragm are supplied by the
phrenic nerve.8 Stimulation to this portion of the dia-
phragm will not be blocked by an epidural and will be
felt in the shoulder tip area as referred pain. The lower
six intercostal nerves innervate the peripheral parts of
the diaphragm and can be blocked by a thoracic epi-
dural. The pericardium has sensory fibers from the
phrenic nerve and vagus nerve, both of which will not
be blocked by a thoracic epidural.8,9
Therefore, the potential drawbacks of using a thoracic
epidural alone for anesthesia include limitation of block-
ade. If a complication arises intraoperatively requiring
more extensive surgery, then the epidural may not be
adequate in blocking the necessary structures including
visceral pleura, lung, airways, diaphragm, and pericar-
dium. Converting to a general anesthetic with a secure
airway plus or minus lung isolation may be difficult to
perform in the lateral position. The possibility of con-
taminating the remaining lung from the contralateral
empyema must also be considered in deciding on the
anesthetic technique.
In the case presented, the surgical plan consisted only
of visualizing the bronchus without any plans to repair it.
Stimulation arising from the vagus and phrenic nerves
therefore was minimized. Aggressive suctioning of the
remaining fluid from the patient’s hemithorax was done
at the beginning of the case to minimize the leakage of
empyema into the dependent lung. Supplemental local
1484
CASE REPORTS
infiltration of the skin and subcutaneous tissue was per-
formed by the surgeon just before incision. The benefit
of this is unclear as surgery started before the onset of
blockade from the 0.5% bupivacaine used. However, the
additional risk of supplementing with a field block is
quite low. A field block alone would not have adequately
anesthetized the ribs and parietal pleura to enable a rib
resection and thoracotomy. Similarly, to anesthetize the
right hemithorax using intercostal nerve blocks, a large
volume of anesthetic would have been required in this
case and would not have blocked the sympathetic sup-
ply to the lungs. In addition, this technique would have
provided a shorter duration of postoperative analgesia
compared to a continuous thoracic epidural.
In conclusion, we describe the use of a thoracic epi-
dural for a thoracoscopy, rib resection, and large drain-
age tube insertion in a patient with a BPF postpneumo-
nectomy. It is crucial to discuss the surgical plan with
the surgeon before deciding on the anesthetic. If the
empyema has been adequately drained and the surgery
does not involve the thoracic structures innervated by
vagal and phrenic nerves, then thoracic epidural anes-
thesia may be considered as an option.
Anesthesiology, V 92, No 5, May 2000
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