Pneumonectomy

Pneumonectomy

Anesthesia type	General
Airway	DL ETT
Lines and access	2x PIV, A-line typically
Monitors	Standard
Primary anesthetic considerations
Preoperative	Patients often smokers with COPD, may have poor reserve Fiberoptic cart should be available prior to induction
Intraoperative	Consider PC to limit peak pressures during one-lung ventilation
Postoperative	+/- chest tubes postoperatively
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A pneumonectomy is the surgical removal of an entire lung. It can be performed via VATS or thoracotomy.

Overview

Indications

• Lung cancer
• TB
• Severe COPD
• Bronchiectasis
• Lung abscess

Surgical procedure

• After a pneumonectomy, air fills the space previously occupied by the lung. This postpneumonectomy space (PPS) will change over time, as the body compensates with elevation of the hemidiaphragm, mediastinal shift towards the PPS, and hyperinflation of the remaining lung. At the same time, there is progressive resorption of the air in the PPS which is replaced with fluid.
• Postoperatively, a chest tube is NOT always inserted, and the air is not always evacuated.

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary	May have poor reserve to begin. Many patients are smokers with COPD
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Operating room setup

• Have DLT (39F for males, 37F for females typically) available, as well as equipment to place it (video scope, fiberoptic bronchoscope to confirm placement)
• Have large hemostat or Kelly clamp to clamp DLT and drop or deflate the operative lung

Regional and neuraxial techniques

• Thoracic epidurals are common. Bolusing prior to incision helps with intraoperative and postoperative pain. (consider 5-8cc of 0.25% bupivacaine)

Intraoperative management

Monitoring and access

• 2 large bore PIV, usually 18G
• A-line ideally placed on dependent upper extremity

Induction and airway management

• Double lumen tube (usually left regardless of lung being resected) placed with DL or video scope and confirmed with fiberoptic bronchoscopy

Positioning

• Lateral decubitus with surgical lung up.
• Axillary roll is needed
• Bed will be flexed
• Pillows between abducted arms (or specialty sling)

Maintenance and surgical considerations

• Generally it is preferred to keep them dry intraop/post-op. Volume can be replaced with albumin or blood rather than crystalloid

• Open chest cases are particularly prone to hypothermia, so consider 2 warming blankets if possible
• When lung is deflated, ventilator settings need to be adjusted to avoid hyperinflation of remaining lung.
  • Consider switching to PCV and limiting peak inspiratory pressure to 30cm H2O, then titrate based on ETCO2.
  • An alternative is halving the tidal volumes and increasing respiratory rate
  • Adding 3-5 cmH2O of PEEP is common
  • Increase FiO2 to 100%. This will not only increase your oxygenation, but it will help resorb the clamped lung and provide better surgical access

Decreasing O2 sat management:

• This is a very common complication with one lung ventilation.
• First attempt should be to manually ventilate the dependent lung by applying more PIP with inspiratory holds (recruitment maneuver)
• Consider applying CPAP to the surgical lung for passive oxygenation
• If failed, inform the surgeon and consider reinflating the surgical lung. Once the saturation returns to the desired baseline, you may drop the surgical lung again.

Postoperative management

Potential complications

• Pulmonary edema
• Right heart failure
• Vagus nerve damage
• Vocal cord damage from DLT insertion
• Hemorrhage
• Trauma to surrounding organs
• Cardiac herniation postop (compression of SC and IVC decreasing venous return, large pressure drops)
  • Avoid patient lying laterally with postoperative side down

Procedure variants

	Open	VATS
Unique considerations		Advantages: shorter hospital stay, smaller postop scars, earlier return to work
Indications
Position	Lateral with operative side up	Lateral with operative side up
Surgical time	2-4 hours	2-4 hours
EBL	200-750
Postoperative disposition
Pain management	Higher postop pain	Decreased postop pain
Potential complications