Anaesthesia

concerns in
patient posted
for Lobectomy
Presenter: Dr. Nisha M P
Moderator: Dr. Bharat Paliwal
Introduction
• Thoracic surgery at the beginning of the last century was primarily for infectious
indications (lung abscess, bronchiectasis, empyema).

• Now the most common indications are related to malignancies (pulmonary, esophageal,
and mediastinal).
• Lobectomy: standard operation for the management of lung cancer as
local recurrence of tumor is reduced compared to lesser resections.

• Commonly performed via open thoracotomy or VATS.

• Posterolateral thoracotomy is the classic incision for lobectomies,

anterolateral and muscle-sparing lateral incisions have also been
used.
 Benign

• Infectious: Tuberculosis and sequelae

• Non Infectious: Congenital bronchial atresia,

pulmonary sequestration, bronchogenic cyst,
congenital cystic adenomatous malformation, Massive
hemoptysis (aspergilloma, cavity, AV Malformation)
Indications Malignant

• Non small cell lung cancer

• Mucoepidermoid tumors
• Adenoid cystic tumors
• Sarcomas
• Localized pulmonary metastasis.
Preoperative evaluation

• Main aim is to identify patients at elevated risk and to stratify perioperative management
and focus resources on the high-risk patients to improve their outcome.

• Also should assess the suitability for lung resection.

 Three-Legged Stool of
Respiratory assessment

Pulmonary
Lung mechanical Cardiopulmonary
parenchymal
function reserve
function
Lung mechanical function

• Most valid single test for postthoracotomy

respiratory complications is the Predicted
postoperative FEV1 (ppoFEV1 %)
 Most useful test of the gas exchange capacity
of the lung is the Diffusing capacity for
carbon monoxide (DLCO).

DLCO correlates with the total functioning

Pulmonary
surface area of alveolar-capillary interface.
parenchymal
function
ppoDLCO less than 40% correlates with both
increased respiratory and cardiac
complications and is, to a large degree,
independent of the FEV1.
 Exercise capacity is commonly described in
units of metabolic equivalent of task (MET).

Cardiopulmonary Sitting quietly requires an oxygen

interaction consumption of 3.5 mL/kg /min (1 MET).
Climbing one flight of stairs is 4 METs.

Ability to climb two flights of stairs without

stopping is a minimum to be considered for
pulmonary resection evaluation
• 6 - minute walk test: most valid simple exercise test.

• Maximal distance that a patient can walk in 6 minutes

• Excellent correlation with maximal oxygen consumption (vo2max)
• Requires no laboratory equipment
• VO2max = 6MWT distance/30
• The risk of morbidity and mortality is high if the preoperative VO2max is < 15
mL/kg/min (corresponds to 6MWT distance of 450)
• Other simple exercise tests include:

• Shuttle Walking: Patient walks at a fixed, and gradually increased, rate between 2
markers 10 meters apart. Distance of < 250 meters correlates with a VO2max of
less than 10 mL/kg/min.

• Exercise-oximetry: patients with a decrease of SpO2 > 4% during exercise are at

increased risk.
Concomitant Medical Conditions

• Cardiac disease • Chronic Obstructive Pulmonary Disease

(COPD)
• Ischemia
• Arrhythmia • Expiratory flow limitation
• Congestive heart • Auto-Positive End-Expiratory Pressure
failure
• Dynamic hyperinflation
• Pulmonary
Hypertension

• Renal Dysfunction
Cardiac disease: Ischemia
• Elective pulmonary resection surgery is regarded as an “intermediate-risk” procedure in terms
of perioperative cardiac ischemia.

• Noninvasive testing indicated in patients with major (i.e., unstable ischemia, recent infarction,
severe valvular disease, significant arrhythmia) or intermediate (i.e., stable angina, remote
infarction, previous congestive failure, diabetes) clinical predictors of myocardial risk.

• Appropriate delay after coronary stenting is conventionally 4 to 6 weeks after bare metal
stents and 6 months after drug-eluting stents.

• Surgery should be delayed until it is safe to temporarily discontinue major antiplatelet drugs
(except aspirin).
Thoracic revised cardiac index

Class Mortality
Class A(score 0-1) 1.5%
Class B(score 1.5-2.5) 7%
Class C(>2.5) 13%
Arrhythmias
• 30-50% patients develop arrhythmias in the 1st week postoperatively; 60-70% are Atrial
fibrillation.

• Two factors in the early post-thoracotomy period interact to produce atrial

arrhythmias:

• 1. Increased flow resistance through the pulmonary vascular bed because of

permanent (lung resection) or transient (atelectasis, hypoxemia) causes, with
attendant strain on the right side of the heart.

• 2. Increased sympathetic stimuli and oxygen requirements, which are maximal on

the second postoperative day as patients become more mobile.
Congestive heart failure
• During one-lung ventilation (OLV) for thoracotomy or thoracoscopy there is an
obligate 20% to 30% shunt through the nonventilated lung.
• Patients with a history of congestive heart failure and/or cardiomyopathy may
tolerate OLV poorly.
Pulmonary
hypertension
• Patients with pulmonary
hypertension are at
increased risk of
respiratory complications
and may need prolonged
intubation after
noncardiac surgery
 Occurs in as many as 50% of COPD patients

Dysfunctional right ventricle is poorly tolerant of

sudden increases in afterload as in change from
RV spontaneous to controlled ventilation.
Chronic recurrent hypoxemia is the cause of the RV
Dysfunctio dysfunction and the subsequent progression to cor
pulmonale.
n
Renal Dysfunction
• Perioperative mortality of 19% has been reported in post thoracotomy patients
with a significant increase in Serum creatinine.

• Predictive factors for renal dysfunction include preoperative hypertension,

angiotensin II receptor blockers, use of hydroxyethyl starch, and open
thoracotomies.
 • Most common concurrent illness in the thoracic
surgical population

• Severity of COPD made on the basis of the FEV1%

of predicted values
COPD
• American Thoracic Society Classification:
• Stage I : >50% predicted FEV1
• Stage II: 35-50% predicted FEV1
• Stage III: <35% predicted FEV1
Many patients with stage II or III COPD have an elevated PaCO2 at
rest.
High FiO2 blunts HPV

There is redistribution of perfusion away from lung areas of

relatively normal V/Q matching to areas of very low V/Q ratio
 Many COPD patients develop cystic air spaces in lung
parenchyma called bullae

Often asymptomatic unless they occupy > 50% of

hemithorax

Bullae In PPV, pressure inside bulla becomes positive in relation to

adjacent lung tissue and will expand with risk of rupture,
tension pneumothorax, and bronchopleural fistula

So care should be taken to keep airway pressures low as

well as keep ICD accessible in the event of pneumothorax
 Occurs when an equal pressure point (EPP) develops in
the intrathoracic airways during expiration.

Present in normal patients only during a forced

expiratory maneuver.

Flow
limitation Flow limitation occurs particularly in emphysematous
patients, who primarily have a problem with loss of lung
elastic recoil and have marked dyspnea on exertion

Severely flow-limited patients are at risk for

hemodynamic collapse with the application of PPV due
to dynamic hyperinflation of the lungs.
 Flow limitation, increased work of respiration,
and increased airway resistance leads to
elevation of end-expiratory lung volume above
the FRC.
This positive end-expiratory pressure (PEEP) in
the alveoli at rest is called auto-PEEP or intrinsic-
PEEP
Auto PEEP Auto PEEP is directly proportional to tidal volume
and inversely proportional to expiratory time.

Measured by end-expiratory flow interruption in

ventilator
LUNG
CANCER
 Risk of postoperative pulmonary complications
A. Nunn and Milledge C. Based on patient criteria
criteria B. Based on spirometry:
and type of surgery:

a)FEV1 < 1L, normal PaO2 a) Predicted FVC < 50% • Patient dependent factors:
PaCO2: Low risk of POPC b) Predicted FEV1 < 50% or < 2 L Current smoker, reduced
c) Predicted MVV < 50% or < 50 health status (ASA grade > 2),
b) FEV1 < 1L, low PaO2 and L/min old age (> 70 years in COPD
normal PaCO2 : Will need d) Predicted DLCO < 50% patients), COPD with exercise
prolonged O2 predicted intolerance
supplementation e) Predicted RV/TLC > 50%
• Surgery dependent factors:
c) FEV1 < 1L, low PaO2, and Abdominal surgery (open >
high PaCO2: May need minimal invasive), thoracic
postoperative ventilation. surgery, long duration of
anesthesia (> 4 hrs), general
anesthesia (vs regional
anesthesia).
Investigations
• Polycythemia: COPD patients
Complete blood count • Leucocytosis: Active pulmonary infection

LFT
• Creatinine>2mg/dl has increased risk
KFT
• Tracheal deviation or obstruction, mediastinal mass,
Chest X-Ray pleural effusion, consolidation

ECG • Left or Right heart dysfunction

2D Echo • To r/o pulmonary hypertension

• diagnose obstructive or restrictive abnormalities

PFT
Final
Preoperative
Assessment
 • GA with controlled ventilation is method of choice.

Technique • GA with thoracic epidural analgesia, intercostal

block, paravertebral block.

of • Aim is to :
Anaesthesia • Suppress airway reflexes, irritability,
• Decrease inhibition of HPV,
• Maintain the cardiovascular status.
• Maintain both lung ventilation as far as
possible
 Pulse oximetry
Capnometer
Intra
operative Arterial line
monitoring CVP
Fibre optic bronchoscope
 • To separate one lung from prevent spillage or
contamination (bronchopulmonary lavage, lung
abscess)
Lung
• To control distribution of ventilation
isolation (bronchopleural fistula)

• For surgical exposure

ANATOM
Y
IMPLICATIONS
• Tracheal diameter: 14-24mm
• Length of right main bronchus: 0.5cm-2.5cm
• Length of left main bronchus: 4-6cm

Tracheal width DLT size

14mm 35
15mm 37
16mm 39
18mm 41
Patient age(years) DLT Size
13-14 35
12 32
10 28
8 26
Maintain two-lung ventilation as long as possible.

Prior switching to OLV give 100 % oxygen.

Start OLV with 100% O2 then start backing off the FiO2 if
saturations are OK
Manual ventilation for the first few minutes of OLV to get a sense of pulmonary
compliance / resistance

Be attentive to inspiratory pressures and tidal volumes and adjust the ventilator
to optimize oxygenation and alveolar ventilation, with minimal barotrauma

Look at the surgical field to see if the non-dependent lung is collapsed

VENTILATION STRATEGY FOR OLV
INTRAOP
COMPLICATI
ON
• PREDICTORS OF
DESATURATION IN
OLV
• After the lobe and blood vessels have been dissected, a test
maneuver is performed with the surgeon clamping the surgical
bronchus to confirm that the specific lobe is extirpated.

• Done by unclamping the limb of the DLT connector of the respective

side, or in the case of a bronchial blocker, by deflating the blocker
balloon, and re expanding the lung with manual ventilation.
• During VATS lobectomy, the anesthesiologist may be asked to
fiberoptically inspect the bronchial tree to confirm patency of the
bronchus of the noninvolved lobe(s).

• Post lobectomy, bronchial stump is usually tested with 20 cm H2O

positive pressure in the anesthetic circuit to detect air leaks.

• If uncomplicated lobectomy, patient can be usually extubated in the

operating room provided preoperative respiratory function is adequate
Fluid management in Pulmonary resection
Total positive fluid balance in the first 24-h perioperative period should not
exceed 20 mL/kg

For an average adult patient, crystalloid administration to be limited to <3 L in

the first 24 h

No fluid administration for third-space fluid losses during pulmonary resection

  Ischemia, nerve damage, or compartment
syndrome to the dependent arm

Concerns in Postoperative shoulder discomfort

lateral
 Lateral angulation of the neck leading to
decubitus jugular venous obstruction
position
Hyperextension of the non-dependent arm
leading to traction or compression of the
brachial and axillary neurovascular bundles.
 • Before resuming both lung ventilation do
suction and fully inflate lungs.

• Postoperative x-ray is advised to rule out

pneumothorax, haemothorax, collapse,
misplaced drains.
Postoperative
period • Adequate pain relief, ability to cough,
moisturised air/ oxygen therapy, breathing
exercises , physiotherapy are essential to
prevent complications.

• Judicious fluid therapy

PROSPECT
• PROCEDURE SPECIFIC
POSTOPERATIVE PAIN
MANAGEMENT
ERATS
 Oedema of operative site

Collapse

Consolidation.
POSTOPERATIV
E Retention of sputum, Inadequate pain relief limiting
adequate chest expansion
COMPLICATION Chronic post operative pain(CPP)
S
May need diuretics , high peep, higher fiO2,

Post pneumonectomy syndrome

NIVATS OR AVATS
• Awake video-assisted thoracic surgery (VATS) has been increasingly employed in a
variety of procedures involving pleura, lungs, and mediastinum.
• Adequate anesthesia and analgesia obtained from thoracic epidural anesthetic (TEA)
allow VATS to be performed in awake patients.
• The potential general anesthesia-related adverse effects, such as intubation-related
trauma, pneumonia, ventilator-associated lung injury, effects of neuromuscular
blocking agents, and postoperative nausea and vomiting, can thus be avoided.
Thank You