Anaesthesia for Pneumonectomy

Dr. Akinjola O.E

Dr Ajefolakemi J.

Dept. of Anaesthesia and Intensive Care

OAUTHC
 Outline
• Introduction

• Basic Anatomy and Physiology

• Anaesthesia Management

• Complications

• Literature Review

• Conclusion
Introduction

• Pneumonectomy is the surgical removal of the entire lung.

• First performed by Evarts A. Graham in 1933 on a patient with lung
carcinoma.
• There are various types of pneumonectomy (standard, intrapericardial,
extrapleural, completion, and carinal pneumonectomy).
• Overall, malignant lung diseases is the leading indication worldwide.
Common Indications

Malignant indications Non Malignant indications

1. Advanced bronchogenic 1.Trauma to the lung with uncontrolled

cancer haemorrhage

2. Mesothelioma 2.Chronic Infection e.g Tuberculosis,

3. Extensive thymomas Necrotizing pneumonia, lung abscess,

bronchiectasis

3.Fungal infection resulting in lung

destruction
Introduction contd

• Pneumonectomy is associated with high mortality and a significant reduction

in quality of life compared to other lung reduction surgeries. As such, it’s
often a last resort.
• Mortality is further increased for right pneumonectomy due to the diversion of
entire cardiac output through the smaller left lung results, leading to
increased pulmonary vascular resistance and right ventricular failure.
• There is also a higher incidence of bronchopleural fistula (BPF) with right
pneumonectomy
Our experience at OAUTHC

• A 7-year review of cases done from 2016 - 2022

• A total of 17 patients had lung reduction surgery done in this facility
• 7 cases of Pneumonectomy were done
S/N Indication for Pneumonomy Pneumonectomy Others
(Lobectomy, Sleeve
resection)
1 Lung Bronchiectasis I I
2 Destroyed Lung 20 TB III I
3. Lung Cancer/ lung mass III
4. Recurrent bronchopleural fistula I
5. Lung abcess I II
6. Recurrent massive haemoptysis I II
7. Aspergilloma I
Total 7 10
 Basic Anatomy of the lung

• The lungs are paired intrathoracic

pyramidal shaped organ that play a
vital role in gas exchange.
• They also play crucial roles in
maintainance of body physiologic
homeostasis, emzyme production and
host immune defense mechanism.
Basic Anatomy of the lung

Bronchopulmonary Segments

• Functionally, the lung is divided

into a series of bronchopulmonary
segments each with its own
bronchus and blood supply and
distinct parenchyma

• The right lung has 10 segments

while the left has 9 segments
Physiologic Effect of Pneumonectomy

• Respiratory

– ↑ Negative pleura pressure on the affected side

– ↓ Diffusion capacity from reduced alveolar area

– ↑ Resp rate and depth of breathing as a form of compensation

– ↑ Work of breathing

• Cardiovascular

– ↑ Blood flow to the residual lung

– ↑ Pulmonary artery pressure and right ventricular pressure

– ↓ Affect gas exchange leading to hypoxemia

Physiologic changes during lateral decubitus position

• Optimal access for most thoracic surgery

• Awake state
– Dependent lung receives more perfusion than non-
dependent due to the influence of gravity
– Dependent lung also receives more ventilation due to
• More efficient hemidiaphragm contraction
• More favorable part of the compliance curve
• Ventilation/perfusion matching is preserved
Physiologic changes in LDP…

• Induction of anaesthesia
– Reduction in FRC moves non-dependent lung to a more favourable part of
compliance curve than dependent lung
– Non-dependent lung is ventilated more than the dependent lung
– Dependent lung is more perfused than the non-dependent
– Ventilation/perfusion mismatch occurs
PHYSIOLOGIC CHANGES IN LDP…
• Open pneumothorax which can cause:
– Mediastinal shift
– Paradoxical respiration
• These phenomena can result into progressive hypoxaemia
• These effects are overcome by use of positive pressure ventilation
Anaesthesia Management
Anaesthetic Considerations

• Patient-related

– Comorbid condition especially underlying lung disease e.g COPD, Cor-

pulmonale, CAD
– Current medication

• Pathology-related

1. Indication for Surgery

• Malignant vs Non-Malignant

2. Type of Malignancy and extent of disease

Anaesthetic Considerations

• Procedure related

– Open Thoracotomy

– Lateral Positioning

– Possible Haemorrhagic Surgery

– Challenges of one lung ventillation

– Possible difficult airway

Anaesthesia Technique

• General Anaesthesia with

Endotracheal intubation using one
of the following:
– double-lumen endobronchial tubes

– Single lumen tubes plus bronchial

blockers
– Conventional ETT into a mainstem
bronchus
Preoperative Assessment
• Goals

– Determine resectability & operability

– Identify patient at risk of adverse intraoperative event

– Prepare for post-op management

– Optimize patient

– Counsel patient on anaethesia technique

– Get Informed Consent

Preoperative Assessment

a. Detailed History
– History of presenting symptom- cough, hemoptysis, weight loss,
productive sputum, dyspnea, pleuritic chest pain
– Comorbid conditions

– Drugs history

– Previous anaesthesia experience

Preoperative Assessment

b. Examination
– General Examination

– Airway Examination

– System Examination

• Respiratory system

• Cardiovascular Status
Investigations
Diagnostic Others

•Plain Radiograph •Full Blood Count

•Chest CT •Electroyte, Urea and creatinine

•Chest MRI •Clotting profile
•Positron emission tomographic •GxM
(PET) scan
•ECG
•Ventilation perfusion scan
•Transthoracic Echocardiography
Pulmonary Function Assessment

• Bed-side test • Instrumental

– Respiratory Rate – Peak flow meter

– Saberasez Breath holding test – De Bono whistle blowing test

– Snider's Match blowing Test – Pulse Oximeter

– Cough test – ABG

– Spirometry
Preoperative Assessment

• Determine resectability & operability

– Resectability is determined by the anatomic stage of the
tumor
– Operability on the other hand is dependent on the
interaction between the extent of the procedure versus
the overall physiological status of the patient.
Preoperative Assessment
• Thoracoscore
• Thoracoscore is used to estimate the
postop mortality for patients undergoing
thoracic surgery.
• It incorporates nine factors
• Not accurate in predicting mortality in
thoracic surgery.
• Consequently, preoperative assessment
should be focused more on the patient’s
exercise capacity and physiological reserve.
Predicted postoperative lung function

• Calculating the predicted postoperative FEV1 (ppoFEV1)

• Ppo FEV1 =Preoperative FEV1 x No.of segments left after resection
19

• Mortality and morbidity are significantly increased if postoperative FEV1 is

less than 40% of preoperative FEV1

• Example
• A 57-year-old man for Rt Pneumonectomy pre-op FEV1 = 60

• Ppo FEV1 = 70* 9/19 =33

Gas Exchange Function

• Diffusion lung capacity for carbon monoxide (DLCO)

• Predictive postoperative DLCO can be calculated in the way as postoperative

FEV1
• Ppo DLCO =Preoperative DLCO x No.of segments left after resection

19

• Ppo DLCO of less than 40% also correlates with increased postoperative
respiratory and cardiac complications.
Cardiopulmonary Function

1. Stair climbing

– > 5 flight of stairs suggest FEV1> 2L and VO2 >20ml/kg/min

– 3 stairs > 15ml/kg/min

– 2 stairs > 12ml/kg/min

– Predict low mortality post-pneumonectomy

2. 6-minute walk test

– Distance covered in meters divided by 30 equal approximately the VO 2
• e.g. 450m/30 = 20ml/kg/min
3. Cardiopulmonary Exercise Testing (CPET)

The gold standard for evaluating cardiopulmonary

– Anaerobic threshold (> 11 ml/kg/min)

– Maximum oxygen utilization VO2 (>20ml/kg/min)

– Ventilatory equivalent of O2 (< 35L)

– Ventilatory equivalent of CO2 (<42L)

– Oxygen pulse (4‐6ml/heart beat)

 Perioperative Cardiac Event

• Cardiologist review is necessary for all patients with an active cardiac disease
for optimisation of medical condition
• Patients without no active cardiac condition should be assessed using the
Revised Cardiac Risk Index
– Score of 3 or more with poor functional status should be referred for exercise
stress testing and a cardiologist’s opinion.

• All patients considered for pneumonectomy should have transthoracic

echocardiography done.
– The presence of pulmonary hypertension is a relative contraindication
Optimising patient

• Cessation of smoking
• Treat any co-existing Infection
• Treat and optimize the co-morbid condition
• Correct electrolyte derangement, anaemia & malnutrition
• Incentive spirometry
• Bronchodilator therapy
• Sputum drainage
• Chest physiotherapy, lung expansion techniques, and breathing
exercises
Intraoperative Management
Intraoperative management

a. Monitoring

1. O2 Saturation

2. Capnography

3. ECG

4. Temperature

5. Invasive and non-invasive blood pressure monitoring

6. Central venous pressure monitoring

7. Hourly urine output

Intraoperative management
a. Induction
a. Position Supine

b. Pre-oxygenation

c. Intravenous Induction e.g Propofol can be used

d. Preoperative rigid bronchoscopy is often performed to confirm length of

bronchus free of tumour before proceding with sugery

e. Endotracheal Intubation using a DLT preferred (Type opposite to site of

operation)

f. Confirm correct placement

Intraoperative management

b. Maintenance Anaesthesia
– TIVA can be used to maintain especially during bronchoscopy
– Propofol alone or in combination with remifentanyl

– Inhalation anesthesia e.g Isoflurane or sevoflurane at MAC < 1%

– Avoid Halothane- it inhibit the hypoxic pulmonary vasoconstriction

Intraoperative management

c. Secure Arterial line and Central Venous (Access preferably on the side of
thoracotomy)

d. Venous thromboembolism prophylaxis - Application of TED stockings

e. Positioning
– Usually lateral decubitus position

– Pad pressure point

– Reconfirm tube position after positioning

Intraoperative management
f. Neuromuscular Blockage
– Recommended
g. Prophyactic antibiotics
h. Analgesic (Multimodal)
– Opioids e.g Morphine 0.1-.0.2mg/kg ( reduce dose if epidural opioid is in use)
– Non-opioids such as paracetamol, NSAIDs, clonidine, magnesium, ketamine, glucocorticoids
– Epidural Analgesia
– High Lumbar vs Thoracic
– Opioid vs LA

– Paravertebral and Intercostal nerve block

– Perineural catheters and regional analgesia into the serratus anterior or erector spinae plane
Intraoperative management
i. Lung Isolation
•Surgical access necessitates collapse of the operative lung.

•This is most commonly achieved using a DLT

•Alternatively, a bronchial blocker may be used where it is not possible to place

a DLT (e.g. in the presence of a ‘difficult’ airway)
•Commence ventilation of dependent lung
Intraoperative management

Alternatives to One-Lung Ventilation

a.Apnoeic Oxygenation
– Involves stopping ventilation for short periods with 100% oxygen insufflated at a
rate greater than oxygen consumption into an unobstructed tracheal tube
– Adequate oxygenation can often be maintained for prolonged periods, but
progressive respiratory acidosis limits the use of this technique to 10–20 min in
most patients.

– Arterial PCO2 rise of 6mmHg in the first minute, followed by a rise of 3–4mmHg
during each subsequent minute is expected.
Intraoperative Management

Alternatives to One-Lung Ventilation

b.High-frequency positive-pressure ventilation and high-frequency jet ventilation

have also been used

c.High frequency Oscillatory Ventilation (HFOV )

A standard tracheal tube may be used with small tidal volumes (<2 mL/kg) allowing
reduced lung excursion during surgery while still ventilating both lungs
Intraoperative management

j. Ventilatory Strategies
•Acute lung injury complicates as high as 7.9% of all pneumonectomies and
increases mortality to as high as 40%
•Ensuring lung protection strategies is therefore very important
1. Use of lower tidal volumes (5–6 mL/kg)

2. Use of PEEP (5–10 cmH20)

3. Lower FiO2 (50% to 80%) targeting SpO2 of 94-98%

4. Lower ventilatory pressures: Consider pressure-controlled ventilation

• Plateau pressure < 25 cmH2O

• Peak airway pressure < 35 cmH2O

5. Permissive hypercapnia
Intra-op Management
k. Intravenous Fluid
•Intravenous fluid should be restricted. Excessive fluid administration has been
associated with acute lung injury in the postoperative period.
•Excessive fluid administration in the lateral decubitus position may promote a
“lower lung syndrome” thus ↑ Shunting and worsening hypoxemia during one-lung
ventilation
• Positive fluid balance within the first 24hr should not exceed 20ml/kg targeting
urine output of 0.5ml/kg/hr
•No supplementation for ‘third space’ losses
 Intraoperative Risk
1. Intra-op Hypoxemia
1. Administer 100% oxygen
2. Check ventilator, breathing circuit
3. Clear secretions by suctioning dependent lung
4. Check tube position using FOB
5. Apply CPAP or entrain oxygen to non-dependent lung
6. Apply PEEP to dependent lung
7. Revert to two lung ventilation
8. Clamp the non-dependent pulmonary artery
9. Periodic inflation of collapsed lung with O2
10. Continuous insufflation of O2 into the collapsed lung
Intra-Op risk Cont’d

2. Hypotension
– Haemorrhage must be excluded and corrected as appropriate

– Hypotension due to epidural infusion should be treated appropriately with

vasoactive drugs as opposed to i.v. fluid.
Extubation
–Stable patients with good pulmonary reserve can be extubated shortly after
surgery
– ↓ risk of pulmonary barotrauma (particularly rupture of the bronchial suture)

–Patients with marginal pulmonary reserve should remain intubated until

standard extubation criteria are met
– However, replace DDT with a regular single-lumen tube at the end of surgery
using a tube exchanger.

–Transfer the patient to the ICU for post-op management

 Post- op Management
• Need for Post op ICU care

• Nurse 30% Head up

• Adequate pain control - using multimodal approach continued from intra-op

period
• Ensure adequate oxygenation

• Close monitoring of vital signs,

• Monitor for ECG changes

Post- op managment cont’d

• I.V. fluids should be restricted to the previous hour’s urine output plus
20ml/hr within the immediate postoperative period.
• Commence incentive spirometry

• Immediate post-op CXR

Complications

1. Postoperative hypoxemia and respiratory acidosis - common.

Common causes
– Atelectasis,

– Hypoventilation.

– Gravity-dependent accumulation of transudation of fluid into the

dependent lung
– Pulmonary edema

– Re-expansion edema of the collapsed nondependent lung

Complications

2. Postoperative haemorrhage
– complicates about 3% of thoracotomies and may be associated with
up to 20% mortality.
– Signs of haemorrhage include increased chest tube drainage (>200
ml/h), hypotension, tachycardia, and a falling haematocrit.

3. Postoperative supraventricular tachyarrhythmias

– Common and requires immediate treatment e.g. Amiodarone
Complications

4. Bronchopleural fistula
– Present as a sudden large air leak from the chest tube

– Onset within 24–72 hr, often due inadequate surgical closure of the
bronchial stump.
– Delayed presentation is usually due to necrosis of the suture line
Complications

5. Cardiac herniation
•It is a rare complication resulting in the heart herniating through the pericardial
defect into the postpneumonectomy space.
•Mortality as high as 50%.

•Patients present with acute hypotension, shock, and cyanosis, with evidence of
superior vena cava obstruction,chest pain and shortness of breath, then cardiac
arrest.
•Immediate surgery is needed to return the heart to its correct position
Complications

• Others

1. Injury to the phrenic, vagus, and left recurrent laryngeal nerves from
extensive mediastinal dissection

2. Paraplegia from spinal cord compression from migrating debris along the
thoracic gutter into the spinal canal
Literature review
• Salami MA, Sanusi AA, Adegboye VO. Current Indications and
Outcome of Pulmonary Resections for Tuberculosis
Complications in Ibadan, Nigeria. Med Princ Pract. 2018;27(1):80-
85. doi: 10.1159/000485382.
• Objectives: To review the current indications and outcome of pulmonary
resections for tuberculosis (TB) at the Cardiothoracic Surgery Unit of the
University College Hospital, Ibadan, Nigeria.
• Subjects and Methods: A retrospective case series review of patients who
had lung resections from January 2014 to January 2017 was performed.
• Data obtained from medical records included demographics, presenting
symptoms, indication for surgery, preoperative evaluation and preparation,
operative procedure, postoperative complications, and follow-up.
• The presence of TB in the patients was confirmed by detecting pathological
changes suggestive of TB and/or past history of pulmonary TB associated
with its anatomical complications such as cavitation and bronchiectasis.
• Data were analysed using descriptive statistics.
• Results: Ten patients had pulmonary resections during this study period.
The median age was 33.5 years (range: 3–50). The indication for lung
resection was massive or persistent haemoptysis, and 2 patients also had
aspergilloma.
• Six patients (60%) had lobectomy, 1 had a bilobectomy, and the remaining 3
had pneumonectomy.
• Complications included partial wound dehiscence in 2 patients, 1 of whom
also had postoperative empyema thoracis. One patient died immediately due
to haemorrhage.
• Follow-up ranged from 6 to 37 months.
• Conclusion: This study showed that the factors for a good outcome in
patients presenting with massive or recurrent haemoptysis from TB
complications were initial stabilization and multidisciplinary care. Hence,
improved awareness of high-standard care to encourage the inclusion of
patients with TB complications in the surgical care protocol as part of national
control programmes is recommended.
Newington DF, Ismail S. Laparoscopic cholecystectomy in a patient
with previous pneumonectomy: a case report and discussion of
anaesthetic considerations. Case Rep Anesthesiol.
2014;2014:582078. doi: 10.1155/2014/582078.
• Ding W, Chen Y, Li D, Wang L, Liu H, Wang H, Zeng X.
Investigation of single-dose thoracic paravertebral analgesia for
postoperative pain control after thoracoscopic lobectomy - A
randomized controlled trial. Int J Surg. 2018 Sep;57:8-14.
doi:10.1016/j.ijsu.2018.07.006.
• Background: Thoracoscopic lobectomy is less painful than normal thoracotomy, but pain
management is still an issue in the postoperative period. Thoracic epidural analgesia (TEA)
is considered the gold standard for post-thoracotomy pain control but is associated with
numerous risks. Thoracic paravertebral block (PVB) is another method of analgesia for
postoperative pain relief after thoracic surgery but has been found to be only useful in the
early postoperative period.
• Therefore, there is a need for adjuvants that extend the duration of analgesia in one-time
PVB. Dexmedetomidine can prolong the duration of nerve block anaesthesia and
intravertebral anaesthesia when used with local anesthetic and has few side effects.

• Aim: the present study investigated the postoperative analgesic effect of TEA, PVB, and
PVB with dexmedetomidine in patients undergoing thoracoscopic lobectomy. The primary
efficacy endpoint of the study was the total dose of sufentanil used during the 48-h
postoperative period.
• Methods: it was a randomized, prospective, controlled study carried out
between March 2017 and December 2017
• A total of 114 patients, classified as American Society of Anesthesiology
Physical Status I/III, undergoing elective video-assisted thoracoscopic
lobectomy were enrolled in the study.
• The patients provided written, informed consent for their participation, and
were randomly assigned to three groups.
• Patients in the PVB-R group received a single-dose 0.5% ropivacaine PVB
before the operation combined with the PCIA (0.01 μg/kg demand dose and
15 min lockout period with 0.03 μg/kg/h background infusion) after extubation
during the 48-h postoperative period.
• Those in the PVB-RD group received a single-dose 0.5% ropivacaine and
dexmedetomidine (1 μg/kg) PVB before the operation combined with the
same PCIA scheme; and those in the TEA group received intraoperative
thoracic epidural anaesthesia with 0.5% ropivacaine and a single dose of
epidural morphine (0.03 mg/kg) after extubation, combined with the same
PCIA scheme.
• The dose and first time of postoperative analgesia, verbal rating score (VRS),
change in catecholamine, cortisol and cytokine levels, change in
hemodynamic parameters, and side effects during the postoperative period
were recorded.
• Results: Compared to the PVB-R group, the dose of postoperative
analgesia and VRS were lower and the first time of postoperative analgesia
was longer in the PVB-RD and TEA group. Patients in the PVB-RD group
had a lower incidence of side effects compared to those in the TEA group.
• Conclusions: Single-dose 0.5% ropivacaine combined with
dexmedetomidine (1 μg/kg) PVB provides satisfactory postoperative pain
control after thoracoscopic lobectomy and can reduce the incidence of
postoperative side effects.
Conclusion
• Pneumonectomy should only be performed as a last resort because of the
high mortality associated with the procedure.
• Appropriate preoperative assessment, risk stratification, and counselling
about the expected postoperative course are vital.
• A multidisciplinary approach helps to optimise the patient’s care in the
postoperative period, allowing for early recognition and treatment of
potentially fatal complications
Thank You