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Disclaimer

Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding.

Thoracic surgery

Chapter:
Thoracic surgery
DOI:
10.1093/med/9780199584048.003.0015

  • Nicki Ross and Bruce McCormick

    General principles [link]

  • Analgesia [link]

  • Isolation of the lungs [link]

  • Management of one lung ventilation [link]

  • Rigid bronchoscopy and stent insertion [link]

  • Superior/cervical mediastinoscopy [link]

  • Lung surgery: wedge resection, lobectomy, and pneumonectomy [link]

  • Thoracoscopy and video-assisted thoracoscopic surgery (VATS) procedures [link]

  • Lung volume reduction surgery and bullectomy [link]

  • Drainage of empyema and decortication [link]

  • Repair of bronchopleural fistula [link]

  • Pleurectomy/pleurodesis [link]

  • Oesophagectomy [link]

  • Chest injury [link]

  • See also:

    • Thoracoscopic sympathectomy [link]

    • First rib resection [link]

    • Tracheo-oesophageal fistula [link]

    • Inhaled foreign body [link]

    • Chest injuries [link]

General principles

Successful thoracic anaesthesia requires the ability to control ventilation of the patient's two lungs independently, skilful management of the shared lung and airway, and a clear understanding of planned surgery. Good communication between surgeon and anaesthetist is essential.

Patients undergoing thoracic surgery are commonly older and less fit than other patients (30% >70yr, 50% >ASA 3). Long-term smoking, bronchial carcinoma, pleural effusion, empyema, oesophageal obstruction, and cachexia are all common and can significantly reduce cardiorespiratory physiological reserve.

General considerations

  1. Discuss planned procedure and any potential problems with the surgeon.

  2. Optimise lung function before elective surgery—try to stop patients smoking, arrange preoperative physiotherapy and incentive spirometry. Optimise bronchodilator therapy and consider a course of oral steroids.

  3. The lateral decubitus position with operating table ‘broken’ to separate ribs is used for the majority of procedures.

  4. Postoperative mechanical ventilation stresses pulmonary suture lines and increases air leaks and the risk of chest infection, so avoid if possible.

  5. Minimise postoperative respiratory dysfunction by providing good analgesia and physiotherapy.

  6. Prescribe postoperative oxygen therapy routinely to compensate for increased V/Q mismatch. Warmed humidified 40% oxygen via a facemask is recommended after pulmonary surgery. Nasal cannulae delivering oxygen at 3 l/min are better tolerated and satisfactory for most other patients.

Preoperative assessment

  1. Patients require a standard assessment with particular emphasis on cardiorespiratory reserve.

  2. Examine most recent CXR and CT scans. Check for airway obstruction and tracheal or carinal distortion/compression which can cause difficulties with double lumen tube placement. Discuss scans with surgeon—tumours impinging on chest wall, crossing fissures, or in proximity to major vessels have implications for surgery performed.

  3. Patients with significant cardiac disease form a high-risk group.

Lung resection1

Based on history, examination, and simple pulmonary function tests (PFTs), patients may be classified as:

  1. Clinically fit with good exercise tolerance and normal spirometry—accept for surgery.

  2. Major medical problems, minimal exercise capacity, and grossly impaired PFTs—high risk for surgery, consider alternative treatment.

  3. Reduced exercise capacity (short of breath on climbing two flights of stairs) and abnormal spirometry with or without moderate co-existing disease—require careful evaluation of risks/benefits of surgery.

Pulmonary function (see [link] and [link]) tests are often used to determine suitability for lung resection surgery by estimating postoperative lung function. Always consider the results in context of patient's general health and proposed resection.

  1. Spirometry reflects the ‘bellows’ function of the respiratory system while tests of diffusion capacity (e.g. carbon monoxide transfer factor, DLCO) assess the ability to transfer oxygen to the circulation. It is important to realise that patients with diffuse alveolar lung disease can have severely impaired gas transfer with relatively normal spirometry (see also [link]).

  2. Generally accepted minimum preoperative values of FEV1 for the following procedures are: pneumonectomy >55%, lobectomy >40%, wedge resection >35% of patient's predicted value.

  3. Predicted postop (ppo) value of PFTs is preop value x (5 – number of lobes resected)/5. Goal is for ppoFEV1 and ppoDLCO >40% of predicted normal (FEV1 0.8–1.0 litre for average male).

  4. If preoperative DLCO <40% predicted normal, ppoFEV1 <800ml, or ppoFVC <15ml/kg it is likely that postoperative ventilation will be needed (poor cough with an FVC <1 litre).

  5. Ventilation scans may be used to account for non-functional lung (e.g. atelectasis beyond an obstructing tumour).

  6. Exercise testing or exercise pulse oximetry should be used to refine clinical assessment in borderline cases. Failure to cover at least 200m or a fall in SpO2 of more than 4% in a ‘6 min walk test’ indicates a very high risk.2

Important scenarios encountered by thoracic anaesthetists

  1. Sub-glottic obstruction of the trachea/carina from extrinsic compression (retrosternal thyroid, lymph node masses, etc.) or invasion of the lumen, usually by a bronchial or oesophageal carcinoma.

  2. Dynamic hyperinflation of the lungs following positive pressure ventilation in patients with severe emphysema, bullae, lung cysts, or in the presence of airway obstruction acting as a ‘flap valve’ resulting in gas trapping. Progressive lung distension creates the mechanical equivalent of a tension pneumothorax. The increase in intrathoracic pressure compromises venous return and right ventricular function, dramatically reducing cardiac output. ‘PEA arrest’ may follow. Emergency treatment is to disconnect the patient from the ventilator, open the tracheal tube to atmosphere, relieve any airway obstruction, and support right ventricular function. Remember, ‘if in doubt let it (the trapped gas) out!’3

  3. Significant mediastinal shifts can occur due to large pleural effusions, tension pneumothorax, and lateral positioning leading to a severe reduction in cardiac output. Prompt recognition and correction of the underlying cause is vital.

  4. Sudden falls in cardiac output presenting as acute severe hypotension can be caused by surgical manipulation within the chest, obstructing venous return or cardiac filling. The effects can be reduced by volume loading the patient, but the surgeon or assistant should be advised and requested to ‘stop squashing the heart!’

Analgesia

  1. Thoracotomy incisions are extremely painful. Inadequate pain relief increases the neurohumoral stress response and impairs mobilisation and respiration, leading to an increase in respiratory complications.

  2. Chronic pain syndrome after thoracic surgery occurs in 25–60% of patients.1 The multiple pathogenic mechanisms proposed include pre-, intra-, and postoperative factors.

  3. Effective analgesia is crucial and a technique combining paracetamol, NSAIDs, a regional block, intraoperative opioids, and regular or patient-controlled postoperative analgesia is recommended.

  4. Perioperative intercostal nerve blocks or percutaneous paravertebral blocks are useful for thoracoscopic procedures with oral or patient-controlled opioid analgesia postoperatively.

  5. Unless specifically contraindicated, patients undergoing thoracotomy or thoracoabdominal incisions should receive continuous thoracic epidural or paravertebral regional analgesia. These techniques have equivalent analgesic efficacy, and similar effects on the stress response and respiratory function. Paravertebral blockade is associated with fewer adverse events (hypotension, urinary retention, and PONV).2

  6. With either technique it is imperative to match the level of block to that of the incision—usually T5/6 or T6/7.

  7. Perioperative epidural blockade should be established cautiously (3–4ml of 0.25% bupivacaine) as an extensive thoracic sympathetic block can cause a major reduction in cardiac output and severe hypotension.

  8. Percutaneous paravertebral injection of 0.5% bupivacaine (0.3ml/kg) may be performed. A continuous postoperative infusion of bupivacaine (0.5% for 24hr, then 0.25% for 3–4d) at 0.1ml/kg/hr via a surgically placed paravertebral catheter provides excellent post-thoracotomy analgesia.

Isolation of the lungs

  1. Achieving independent ventilation of the lungs is not always straightforward.

  2. One lung ventilation (OLV) is associated with a number of complications and should be used only when the benefits outweigh the risks.

Advantages of OLV

  1. Protects dependent lung from blood and secretions.

  2. Allows independent control of ventilation to each lung.

  3. Improves surgical access and reduces lung trauma.

Disadvantages of OLV

  1. Inevitably creates a shunt and usually causes hypoxia.

  2. Acute lung injury occurs in 2–5% of cases.

  3. Increases technical and physiological challenge.

Indications for isolation and separation of the two lungs

  1. To avoid contamination of a lung in cases of infection, massive pulmonary haemorrhage, or bronchopulmonary lavage.

  2. Control the distribution of ventilation in massive air leaks or severe unilateral lung disease (e.g. giant bullae and lung cysts).

  3. Improving access for surgery is a relative indication for OLV. If isolation of the lung proves difficult the need to pursue OLV should be discussed with the surgeon since satisfactory access can often be achieved by careful lung retraction.

Techniques

  1. Double lumen endobronchial tubes (DLTs) are the commonest and most versatile approach.

  2. Bronchial blockers (Univent tube or Arndt endobronchial blocker). Useful in experienced hands, especially in patients who are difficult to intubate or have distorted tracheobronchial anatomy/tracheostomy.

  3. DLT and bronchial blockers have been shown to be clinically equivalent in the provision of OLV.2

  4. Single lumen endobronchial tubes are rarely used.

Double lumen endobronchial tubes

  1. Traditional reusable red rubber DLTs are still used in some specialist centres, but disposable plastic (polyvinyl chloride—PVC) tubes are in wider general use.

  2. Described as ‘right’ or ‘left’ according to main bronchus they are designed to intubate.

  3. Right-sided tubes have a hole or slit in the wall of the endobronchial section to facilitate ventilation of the right upper lobe.

  4. Sizes of plastic DLTs are given in Charriere (Ch) gauge (equivalent to French gauge), which is the external circumference of the tube in millimetres. Thus a 39Ch tube has an external diameter of about 13mm. Note that diameter of the bronchial segment of the tubes varies between manufacturers (for the same tube gauge).

  5. The lumens of DLTs are small compared with standard single lumen tubes used in adults. The internal diameters of the lumens of the 39 and 35Ch ‘Broncho-Cath’ DLTs are only 6.0 and 4.5mm, respectively.

  6. Bronchoscopic placement and checking requires a narrow scope (<4mm diameter) ideally with an integral battery light source for ease of manipulation.

  7. A major contraindication to use of a DLT is very distorted tracheobronchial anatomy or an intraluminal lesion—placement is likely to be difficult and possibly dangerous.

Types of DLT

  1. Carlens (left-sided): has a carinal ‘hook’ to aid correct placement.

  2. White's (right-sided): has a carinal hook and slit in the tube wall for right upper lobe.

  3. Robertshaw (right- and left-sided): D-shaped lumens; traditionally a red rubber reusable tube, now available as a single-use version in small, medium, and large sizes.

  4. Single-use PVC (right- and left-sided): high-volume, low-pressure cuffs; bronchial cuff and pilot tube coloured blue; radiopaque marker stripe running to tip of bronchial lumen; available in sizes 28–41Ch, e.g. ‘Broncho-Cath’ (Mallinckrodt) and ‘Sheribronch’ (Sheridan).

Selection of DLT

  1. Use the largest DLT that will pass easily through the glottis. 41Ch or 39Ch gauge PVC tube (large or medium Robertshaw) for males, 37Ch gauge PVC tube (medium Robertshaw) for females. Small individuals may need a 35Ch gauge or small Robertshaw tube.

  2. It is common practice to choose a left-sided tube unless the surgery involves proximal left lobar resection or left pneumonaectomy, or abnormal bronchial anatomy is likely to obstruct intubation of the left main bronchus. A left-sided tube is less likely to block a lobar bronchus and gives a greater tolerance to shifts in tube position, which inevitably occur when the patient is moved.

  3. Where indicated use a right-sided tube. Placement is generally straightforward if bronchoscopically guided.

Placement of DLT

  1. Assess the risks/benefits of using a DLT. Examine the X-rays, CT scans, and any previous bronchoscopy reports for tracheobronchial anatomy and lung pathology—is there distortion or narrowing which will interfere with bronchial intubation?

  2. Check the Y connector and ensure that 15mm connectors are inserted into proximal ends of the DLT (‘Broncho-Caths’ come with these connectors separately wrapped).

  3. Most plastic DLTs are supplied with a malleable stylet which can be used to adjust the curve of the tube to facilitate intubation.

  4. Commence intubation with the concavity of the endobronchial section of the DLT facing anteriorly—once the tip is past the glottis, partially withdraw the stylet and rotate the tube 90° to bring the oropharyngeal curve into the sagittal plane. Turn the patient's head to the side opposite to the bronchus to be intubated (i.e. to the right for a left-sided DLT) and gently slide the tube down the trachea until resistance is felt to further advancement.

  5. At this stage treat DLT as an ordinary ETT—inflate only the tracheal cuff to achieve a seal and confirm ventilation of both lungs.

  6. It is easy to push plastic DLTs in too far. The patient's height is the main determinant of correct insertion depth—the usual insertion depth to the corner of the mouth in a patient 170cm (5’ 7’’) tall is 29cm [depth changes by 1cm for every 10cm (4’’) change in the patient's height].1

  7. The diameter of a DLT makes intubation more difficult than with a standard tube, even with a good view of the larynx. The Airtraq optical laryngoscope is useful in this situation, but prior experience and generous lubrication are required. Alternative strategies in difficult intubation include intubation over an airway exchange catheter (AEC), intubation with a standard tube followed by change to a DLT over an AEC, or use of a bronchial blocker (see below).

Clinical confirmation of DLT position

  1. Check the tube position and establish isolation of lungs. Beware of pathology affecting clinical signs—compare with preoperative clinical examination findings and radiology. It is easy to get confused, so check tube position by achieving the lung isolation required for the surgery.

  2. Check that you can achieve ventilation on the non-operative lung. Clamp off the gas flow to the operative lung at the Y connector and allow the lung to deflate by opening the sealing cap on this lumen.

  3. Look for chest movement—is there appropriate unilateral expansion on the non-operative side?

  4. Listen—auscultate both lungs and listen over the end of the open tube. A leak indicates air passing around the deflated bronchial cuff. Listen whilst inflating the bronchial cuff 1ml at a time (use a 5ml syringe) until the leak stops. If a reasonable seal cannot be obtained with <4 ml of air, the tube is either incorrectly placed or too small for the patient. Check specifically that all lobes are ventilated, especially the right upper if using a right-sided DLT.

  5. Feel—assess compliance by ‘bagging’ right, left, and both lungs. Very poor compliance (high inflation pressures) which is not explained by the patient's pathology suggests malposition—peak pressure on OLV should be <35cmH2O.

  6. Close the sealing cap and remove the Y connector clamp. Some anaesthetists then confirm it is possible to isolate and achieve OLV of the opposite lung via the tracheal lumen.

  7. Remember that the operative lung will only partially collapse until the pleural cavity is opened.

  8. Endobronchial tubes often move when the patient is placed in the lateral position. Recheck isolation and OLV once the patient is in position and before surgery starts.

Fibreoptic bronchoscope

  1. Ideally the position of every DLT should be checked bronchoscopically. At the very least a suitable bronchoscope must be immediately available to assess DLT placement if there are clinical problems with the tube or with OLV.

  2. This is invaluable where bronchial intubation is difficult and can be used to ‘railroad’ the tube into the correct main bronchus. Insert the bronchoscope via the bronchial lumen, partially withdraw the DLT so its tip lies in the trachea, and locate the carina. Left–right recognition is aided by looking for the longitudinal muscle that runs along the posterior wall of the trachea. Advance scope into the appropriate main bronchus, then slide the tube into position.

  3. Several bronchoscopic studies have shown that up to 80% of DLTs are malpositioned to some extent even when clinical signs are satisfactory. The upper surface of the bronchial cuff (blue) should lie just below the carina when visualised via the tracheal lumen.

  4. Always confirm positioning of the right-sided tube by bronchoscopy. The lateral ‘slit’ in the wall of the distal bronchial lumen should be aligned with the right upper lobe bronchus.

Bronchial blocker technique

  1. A balloon-tipped catheter (‘blocker’) is manipulated through a single lumen tracheal tube into the appropriate main (or lobar) bronchus with the aid of a narrow fibreoptic bronchoscope.

  2. Good lubrication of both bronchoscope and blocker is essential.

  3. The position of the blocker should be rechecked after the patient has been positioned for surgery.

  4. Placement is usually straightforward in the supine position, but can be awkward in the lateral position.

  5. The lung or lobe is isolated from ventilation by inflating the balloon within the bronchus. The isolated lung slowly collapses as the trapped gas is absorbed or escapes via the blocker's narrow central lumen.

  6. Collapse can be accelerated by ventilating with 100% oxygen for a few minutes and then inflating the blocker at end expiration when lung volume is at its minimum.

  7. Reinflation of the collapsed lung requires deflation of the blocker and consequently loss of isolation of the lungs. (A correctly positioned DLT will maintain separation of the airways to each lung until extubation.)

  8. During pneumonectomy or sleeve resection (bronchial reanastomosis) the blocker has to be withdrawn to allow surgical access to the bronchus.

There are two modern forms of bronchial blocker:

  1. Univent tube: a single lumen tube with an internal channel in its wall containing an adjustable blocker bearing a high-volume, low-pressure cuff.

  2. Arndt wire-guided endobronchial blocker (Cook): a stiff catheter with a cylindrical cuff and an adjustable ‘wire’ loop at its tip which guides the blocker along the outside of a fibreoptic bronchoscope into the required bronchus. Supplied with a special adapter which allows it to be deployed through a conventional single lumen or cuffed tracheostomy tube.

Indications for using a bronchial blocker1

  1. On the rare occasions when isolation of a lobar bronchus is required (localised bronchiectasis or haemorrhage, lung abscess, bronchopleural fistula, previous lung resection and poor tolerance of OLV).

  2. In patients who are difficult to intubate or have a permanent tracheostomy.

  3. To avoid the reintubation required to change to or from a DLT in patients receiving pre- or postoperative IPPV.

Management of one lung ventilation

The physiology is complex and some aspects remain controversial.1 One lung ventilation inevitably creates a shunt through the unventilated lung and the crucial factor in managing OLV is to minimise the effects of this shunt.

Initiating OLV

  1. Start with typical ventilator settings during two lung ventilation (FiO2 0.33, VT 9–10ml/kg, and PAW ≤25cmH2O).

  2. Increase FiO2 to 0.5 and decrease VT to 6–8ml/kg before initiating OLV. Note the PAW generated by this VT.

  3. Clamp Y connection to operative (non-dependent) lung and open sealing cap on that lumen of the DLT to allow the gas to escape.

  4. Observe the airway pressure closely. It will increase by 30–40% (about 7–10cmH2O) if OLV is achieved. If the operative lung was non-functioning prior to anaesthesia (collapse secondary to bronchial obstruction or massive effusion) the pressure may not change.

  5. If PAW is excessive (>35cmH2O) or rises abruptly with each inspiration exclude mechanical causes (e.g. kinked connector, clamp incorrectly placed) and DLT malposition or obstruction (e.g. ventilating lobe rather than lung, sputum plugs, opening of tracheal lumen against wall of trachea).

  6. Adjust VT and ventilation profile to limit PAW to ≤35cmH2O and ideally to ≤30cmH2O. Incidence of acute lung injury is reduced by employing a ‘protective ventilation strategy’-lower PAW, PEEP.

  7. Observe SpO2 and ETCO2 closely. If necessary increase ventilatory rate to maintain acceptable minute volume and carbon dioxide clearance.

  8. Check with surgeon that lung is collapsing (may take a few minutes in patients with obstructive airways disease) and that mediastinum has not ‘sunk’ into dependent hemithorax.

Failure to achieve OLV

  1. If inflation pressure does not increase when OLV is attempted be suspicious that OLV has not been achieved. DLT is likely not to be in far enough and should be advanced under fibrescopic guidance.

  2. If surgeon says lung has not collapsed, but DLT position appears satisfactory, suction down operative lumen, to clear secretions and hasten lung collapse (particularly in emphysematous lungs).

Hypoxia on OLV

  1. Hypoxia is a frequent complication of OLV, and is more common when the right lung is collapsed.

  2. It usually occurs after a few minutes of OLV (as oxygen in non-ventilated lung is absorbed).

  3. SpO2 dips but then often rises again a few minutes later as the non-ventilated lung collapses more completely and blood flow through it decreases.

  4. Increase FiO2 and try to ensure an adequate cardiac output.

  5. Confirm correct positioning of DLT—are all lobes ventilated? Check with fibreoptic bronchoscope if unsure.

  6. If partial collapse of the ventilated (dependent) lung is suspected (‘sinking’ mediastinum) try 5–10cmH2O PEEP on that lung—this may help, but the effect is unpredictable and PEEP may be limited by PAW. Peak PAW may be limited by changing from volume-controlled to pressure-controlled ventilation.

  7. If still hypoxic, warn surgeon, partially reinflate non-dependent lung, and then apply 5–10cmH2O CPAP via a simple reservoir bag/APL valve arrangement (CPAP System, Mallinckrodt) supplied with 100% oxygen from an auxiliary oxygen flowmeter or cylinder at 5l/min. This will reliably improve saturations—simply insufflating oxygen into the collapsed non-dependent lung will not.

  8. If hypoxia persists use intermittent inflation of non-dependent lung with oxygen breaths from the CPAP circuit—this needs to be co-ordinated with surgical activity.

  9. If these manoeuvres are not successful return to two lung ventilation.

  10. The surgeon may clamp the appropriate pulmonary artery, thus eliminating the shunt and improving oxygenation.

  11. Persisting with OLV in the face of continuing hypoxia (SpO2 <90%) is dangerous and can rarely be justified.

Returning to two lung ventilation1

  1. Gently suction the non-ventilated lung to clear any blood or pus—use the long suction catheters supplied with the DLT.

  2. Close sealing cap on lumen to non-ventilated lung and remove clamp on the Y connector.

  3. Switch to manual ventilation and reinflate the collapsed lung under direct vision. Long sustained ventilation breaths are effective, and inflation pressures up to 35–40cmH2O are often required to fully re-expand all areas of the lung.

  4. Return patient to mechanical ventilation and, unless significant volumes of lung have been resected, return to original two lung ventilator settings and FiO2.

  5. Adjust respiratory rate to maintain normocapnia.

  6. Always be prepared to return to OLV immediately should problems occur, e.g. large air leak from operated lung.

Rigid bronchoscopy and stent insertion

Procedure

Endoscopic inspection of tracheobronchial tree—± biopsy, stents, removal of foreign body

Time

5–20min

Pain

+

Position

Supine with head and neck extended

Blood loss

Usually minimal

Practical techniques

TIVA with propofol boluses/target-controlled infusion, alfentanil/ remifentanil, intermittent suxamethonium. IPPV through bronchoscope with oxygen via Venturi needle and Sanders injector

Preoperative

  1. Check for airway obstruction—stridor, tracheal tumour on CT scan, or foreign body.

  2. Suitable as day-case procedure in appropriate patients.

  3. Warn about postoperative coughing, haemoptysis, and suxamethonium myalgia.

  4. Often combined with mediastinoscopy to assess suitability for lung resection.

  5. The airway will be unprotected so patients at risk of regurgitation should be pretreated to reduce the volume and acidity of gastric secretions (omeprazole 40mg PO the night before and 40mg 2–6hr before procedure). Ranitidine is an alternative.

Perioperative

  1. Give full preoxygenation.

  2. Confirm surgeon is in the theatre before inducing the patient.

  3. Boluses of midazolam (2–3mg) and alfentanil (500–1000µg) facilitate induction and may reduce risk of awareness.

  4. A preinduction ‘taming’ dose of non-depolarising relaxant (e.g. vecuronium 0.5mg) can reduce suxamethonium pains.

  5. Normally induce in the anaesthetic room, transfer to theatre with a facemask, and give suxamethonium just prior to bronchoscopy.

  6. If there is potential airway obstruction (foreign body or tracheal compression) inhalation induction in theatre with sevoflurane in oxygen is recommended until airway is secure.

  7. Co-ordinate ventilation with surgical activity.

  8. Observe or palpate abdomen to detect recovery of muscle tone.

  9. Suction upper airway and confirm adequate muscle power before removing the scope.

Postoperative

  1. Turn patient biopsied side down to avoid bleeding into normal lung.

  2. Sit fully upright as soon as awake.

  3. Blood clot can cause severe lower airway obstruction requiring immediate intubation, suction, and repeat bronchoscopy.

Special considerations

  1. The procedure is very stimulating and can generate a marked hypertensive response.

  2. Extreme cardiovascular responses need to be obtunded and profound relaxation provided, but with prompt return of laryngeal reflexes and spontaneous respiration.

  3. Vocal cords can be sprayed with local anaesthetic (4% topical lidocaine), but this will not prevent carinal reflexes and may impair postoperative coughing.

  4. Rarely, biopsy can precipitate a life-threatening airway bleed.

  5. Stent insertion can be technically difficult and may involve periodic loss of airway control.

  6. A short-acting non-depolarising muscle relaxant can be employed, but it is difficult to achieve the profound paralysis required using mivacurium. Some patients will also undergo superior mediastinoscopy and so longer-acting agents can be used.

  7. Bradycardias caused by repeat doses of suxamethonium are rarely seen during rigid bronchoscopy in adults. Atropine should be drawn up, but routine administration is not recommended since this will exacerbate any tachycardia.

  8. Use of rocuronium followed by reversal with sugammadex may be an alternative.

Superior/cervical mediastinoscopy

Procedure

Inspection and biopsy of tumours and lymph nodes in superior and anterior mediastinum via small suprasternal or anterior intercostal incision

Time

20–30min

Pain

+

Position

Supine or slightly head up, arms by sides and head ring with bolster under shoulders

Blood loss

Usually minimal but potential for massive haemorrhage, G&S

Practical techniques

IPPV via single lumen tube

Preoperative

  1. Suitable as day-case procedure in appropriate patients.

  2. Check for superior vena cava obstruction and tracheal deviation or compression due to large mediastinal masses.

  3. Often preceded by rigid bronchoscopy (‘Bronch & Med’).

Perioperative

  1. Tape eyes and check tracheal tube connectors as the head will be obscured by drapes.

  2. Give boluses of IV fentanyl during surgery.

  3. Insert 16G cannula in lower leg vein after induction (see below).

  4. Watch for surgical compression of trachea—monitor tidal volume and airway pressures.

  5. Monitor BP in left arm and put pulse oximeter on right hand (see below).

Postoperative

  1. Paracetamol and NSAID.

Special considerations

  1. There is the potential for massive haemorrhage from the great vessels—risk is increased in patients with SVC obstruction (hence cannula in leg)—may require immediate median sternotomy.

  2. The brachiocephalic artery can be compressed by mediastinoscope, restricting blood flow to the right arm and carotid artery, creating a risk of cerebral ischaemia. Place pulse oximeter on right hand to monitor perfusion.

  3. Mediastinotomy can cause a pneumothorax.

Lung surgery: wedge resection, lobectomy, and pneumonectomy

Procedure

Excision of pulmonary tissue either selectively (wedge resection or lobectomy) or a whole lung (pneumonectomy)

Time

2–4hr

Pain

+++++

Position

Lateral decubitus with table ‘broken’, elbows flexed to bring forearms parallel to face with upper arm in gutter support

Blood loss

200–800ml—occasionally significantly more; G&S, X-match 2U for lobectomy/pneumonectomy

Practical techniques

IPPV via DLT using OLV during resection phase. Epidural or paravertebral regional anaesthesia with catheter for postoperative analgesia, art line for pneumonectomy and less fit patients

Preoperative

  1. Cancer is the commonest indication for lung resection—others include benign tumours, bronchiectasis, and TB.

  2. Assess cardiorespiratory reserve and estimate post-resection lung function (see [link]).

  3. Assess airway with respect to placement of DLT.

  4. Plan postoperative analgesia regime.

Perioperative

  1. Select appropriate DLT and check lung isolation carefully after intubation.

  2. Use a left-sided tube unless the surgery involves a proximal left lobectomy or pneumonectomy or abnormal bronchial anatomy is likely to obstruct intubation of the left main bronchus.

  3. IV infusion in non-dependant arm—14–16G cannula.

  4. Radial arterial lines function better in the dependent arm as that wrist is usually extended.

  5. CVP monitoring is unreliable in lateral position with open chest. Central lines are not recommended for routine use but may be indicated for access purposes or postoperative monitoring. Similarly oesophageal Doppler monitoring is unhelpful since lateral position and an open chest prevent a steady signal for analysis.

  6. OLV facilitates surgery and prevents soiling of dependent lung.

  7. Continuous display of the airway pressure/volume loop is a valuable adjunct to monitoring and managing OLV.

  8. Surgical manipulation often causes cardiac and venous compression, which reduces cardiac output/blood pressure and may cause arrhythmias.

  9. Suction the airway to the collapsed lung prior to reinflation.

  10. The bronchial suture line is ‘leak tested’ under saline by manual inflation to 40cmH2O.

  11. Titrate IV fluids to losses and duration of surgery. Avoid excessive fluid replacement especially in pneumonectomy.

  12. Preoperative epidural or paravertebral block with surgically inserted catheter. Epidural can be used preoperatively, but cautious incremental boluses are recommended (3ml of 0.25% bupivacaine ± opioid).

Postoperative

  1. Aim to extubate patient awake and sitting at end of procedure.

  2. Prescribe continuous supplementary oxygen—humidified is preferable, but nasal cannulae are more likely to stay on the patient in the ward.

  3. Ensure good analgesia is achieved.

  4. A CXR is usually required in recovery room.

Special considerations

  1. Occasionally patients with bronchial carcinoma may have ‘non-metastatic’ manifestations (Eaton–Lambert myasthenic syndrome or ectopic hormone production). See [link] and [link] and [link].

  2. Perioperative mortality from pneumonectomy is 5%. Acute lung injury occurs in 2–5% of resections and is three times more common after pneumonectomy when the mortality is 25–50%.1 Additional risk factors include the inflammatory response to surgery, chronic alcohol abuse, genetic predisposition, intraoperative plateau pressures >15cmH2O, and >4000ml of IV fluid in first 24hr.2 Incidence may be reduced by the intraoperative use of lung protective strategies (as established in adult respiratory distress syndrome—management) and goal-directed fluid therapy.

  3. Arrhythmias, especially atrial fibrillation, are quite common after pneumonectomy and many advocate prophylactic digitalisation (digoxin 500µg IV over 30min given during surgery followed by 250µg/d orally for 4–5d).

Thoracoscopy and video-assisted thoracoscopic surgery (VATS) procedures

Procedure

Inspection of thoracic cavity via scope passed through intercostal incision. Used for drainage of effusions, lung and pleural biopsy, pleurectomy/ pleurodesis, pericardial biopsy/window

Time

30–120min

Pain

++/+++

Position

Lateral decubitus with table ‘broken’, elbows flexed to bring forearms parallel to face with upper arm in gutter support

Blood loss

Minimal–200ml, G&S

Practical techniques

IPPV and OLV via left-sided DLT. Percutaneous paravertebral block/catheter or intercostal blocks, ± art line

Preoperative

  1. Assess as for a thoracotomy but this procedure is less invasive, with less postoperative deterioration of lung function.

  2. Discuss regional analgesia and where appropriate PCA.

Perioperative

  1. Consider invasive arterial pressure monitoring for high-risk or compromised patients.

  2. IV infusion in upper arm; arterial line in radial artery of dependent arm.

  3. Boluses of fentanyl (50–100µg) for intraoperative analgesia.

  4. Commence OLV (using left-sided DLT) before insertion of trocar.

  5. Good collapse of the lung is required for surgical access.

  6. Intercostal or paravertebral blocks. A paravertebral catheter can be inserted under thoracoscopic guidance for more extensive procedures.

Postoperative

  1. Extubate, sit up, and start supplementary oxygen in theatre before transfer to recovery.

  2. CXR in recovery is required to confirm full lung re-expansion.

  3. Patients need balanced analgesia as for lung resection. PCA morphine may be required for 24–48hr for more painful procedures such as pleurectomy, pleurodesis, and wedge resections.

  4. Encourage early mobilisation.

Special considerations

  1. There is always the possibility of conversion to an open thoracotomy.

  2. Epidural is not usually necessary but worth considering if bilateral.

Lung volume reduction surgery and bullectomy

Procedure

Non-anatomical resection of regions of hyperinflated and poorly functioning pulmonary tissue

Time

2–5hr

Pain

+++/+++++

Position

Median sternotomy (bilateral surgery)—supine with arms to sides. Thoracotomy—lateral decubitus (as for lung resection)

Blood loss

200–800ml, X-match 2U

Practical techniques

Thoracic epidural preinduction. GA with TIVA, relaxant, DLT—extreme care with IPPV and OLV

Lung volume reduction surgery is a surgical treatment for selected patients with severe respiratory failure secondary to emphysema. The aim is to reduce total lung volume to more physiological levels by resecting most diseased areas, thereby improving respiratory function. Most of these patients belong to a group in which general anaesthesia would normally be avoided at any cost. The procedure is also considered for those with bullous disease and recurrent pneumothoraces.

Preoperative

  1. Patients require intensive assessment, careful selection, and optimisation prior to surgery.

  2. Cardiac assessment for lung volume reduction surgery often includes coronary angiography and right heart catheterisation to evaluate IHD, ventricular function, and pulmonary artery pressures.

  3. Patients are often on corticosteroids—perioperative supplementation is required.

  4. A clear understanding of pathophysiology and adequate thoracic experience is essential to safe anaesthetic management.1

Perioperative

  1. Surgery may be performed via sternotomy, thoracotomy, or by video-assisted thoracoscopic surgery.

  2. There is a serious risk of rupturing emphysematous bullae with IPPV, causing leaks and tension pneumothorax.

  3. Nitrous oxide is contraindicated and, since an increased alveolar–arterial gradient may exist for volatile agents, total IV anaesthesia with remifentanil and propofol is recommended.2

  4. Continuous spirometry, and invasive arterial and CVP monitoring are essential.

  5. Clinical assessment of DLT placement is difficult—verify position bronchoscopically.

  6. Limit risk of ‘gas trapping’ and dynamic pulmonary hyperinflation (see [link]) by deliberate hypoventilation and permissive hypercapnia (PaCO2 up to 8.5kPa). Recommend VT 6–7ml/kg, 10–12bpm, I:E ratio 1:4, and peak airway pressure <30cmH2O.

  7. Disconnect from ventilator intermittently to allow lungs to ‘empty’.

  8. Bronchospasm and sputum retention with mucus plugging can be a problem.

  9. Use colloids for fluid replacement to minimise risk of pulmonary oedema.

Postoperative

  1. HDU or ICU care will be required—extubate as soon as possible.

  2. Anticipate and accept raised PaCO2 (7–9kPa) and adjust FiO2 to maintain SaO2 in range 90–92%.

  3. Watch closely for air leaks—use a maximum of 10cmH2O suction on intercostal drains.

  4. Requires excellent pain relief, skilled physiotherapy, and a pulmonary rehabilitation programme.

Special considerations1,2

  1. Commonest complication is prolonged air leak—more than 7 days in 50% of patients.

  2. Mortality from recent series is 5–10%.

  3. The National Emphysema Treatment Trial demonstrated that lung volume reduction surgery benefits patients with predominantly upper lobe disease and a low baseline exercise capacity.

  4. Patients with an isolated congenital bulla or ‘lung cyst’ require same careful intraoperative anaesthetic management but are usually much fitter and do not normally require invasive cardiological assessment.

Drainage of empyema and decortication

Procedure

Surgical removal of pus (empyema) and organised thick fibrinous pleural membrane (decortication)

Time

Drainage 20–40min; decortication 2–3hr

Pain

+++/+++++

Position

Lateral decubitus for thoracotomy

Blood loss

Simple drainage: minimal Decortication: 500–2000ml, X-match 2U

Practical techniques

GA with IV induction, relaxant, intubation, IPPV DLT advised for decortication (risk of air leaks); single lumen tube adequate for drainage procedures; art line/CVP

Preoperative

  1. Intrapleural infection usually secondary to pneumonia, intercostal drains, and chest surgery.

  2. Patients are often debilitated by infection and may be frankly septic.

  3. Respiratory function often already compromised by pneumonia or prior lung resection.

  4. Check for bronchopleural fistula created by erosion into the lung.

Perioperative

  1. Empyema usually drained by rib resection and insertion of a large-bore intercostal drain.

  2. Thoracoscopy may be used to break down a loculated effusion or empyema and free pleural adhesions.

  3. Decortication requires ‘thoracotomy’ anaesthetic with epidural analgesia since paravertebral catheter usually not possible due to loss of pleura.

  4. Decortication frequently causes significant haemorrhage.

  5. Arterial line/CVP monitoring are advisable for all but the fittest of patients.

Postoperative

  1. Balanced analgesia with regular paracetamol, NSAID, regional block (intercostal blocks useful for drainage procedures), and opioids.

  2. High-dependency care is recommended for debilitated patients undergoing decortication.

Special considerations

  1. The surgical principle is to remove infected tissue including pleural ‘peel’, fully re-expand the lung, and obliterate the infected pleural space.

  2. Air leaks are common following decortication of the visceral pleura and lobectomy is occasionally required if a massive air leak or severe parenchymal lung damage occurs.

  3. Decortication is a major procedure which requires careful evaluation of risks and benefits in elderly, frail, and sick patients.

Repair of bronchopleural fistula

Procedure

Closure of communication between pleural cavity and trachea or bronchi

Time

2–3hr (for thoracotomy approach)

Pain

++++/+++++

Position

Keep sitting upright with affected side tilted down until good lung isolated, then lateral decubitus for thoracotomy

Blood loss

300–800ml, G&S, X-match 2U if anaemic

Practical techniques

IV induction and fibreoptic guided endobronchial intubation with DLT. Awake fibreoptic guided intubation with DLT. Intubation with DLT under deep inhalation anaesthesia with spontaneous ventilation

Preoperative

  1. Features are productive cough, haemoptysis, fever, dyspnoea, SC emphysema, and falling fluid level in post-pneumonectomy space on the chest radiograph.

  2. The severity of symptoms is proportional to the size of the fistula—big fistulae with large air leaks cause severe dyspnoea and may necessitate urgent respiratory support.

  3. Patients are often debilitated with respiratory function compromised by infection and prior lung resection.

  4. Check previous anaesthetic charts for ease of intubation and type of DLT used.

  5. Check the anatomy of the lower airway carefully on chest radiograph—it is often distorted by previous surgery.

  6. Patients require supplementary oxygen, a functioning chest drain, IV antibiotics, and fluids.

Perioperative

  1. Key principles are to protect the ‘good’ lung from contamination and to control the distribution of ventilation. Failure to adequately isolate lungs after induction will put the patient at grave risk.

  2. Small or moderate fistulae are usually assessed by bronchoscopy and may be amenable to sealing with tissue glue.

  3. Commence invasive arterial pressure monitoring before induction.

  4. Traditionally, awake intubation under local anaesthesia has been recommended as the safest option, but ultimately the technique should be selected to give the best balance of risks and benefits for each patient. Many thoracic anaesthetists use a modified rapid sequence induction and advance the DLT under direct vision with a fibreoptic bronchoscope to ensure correct placement in the bronchus contralateral to fistula. The potential exists to enlarge the fistula by inappropriate placement of the DLT.

  5. IPPV increases gas leakage, causing loss of tidal volume and the risk of tension pneumothorax.

  6. TIVA is recommended—delivery of volatile agents may be unreliable with large gas leaks. Ketamine may be useful in high-risk patients.

Postoperative

  1. Plan HDU/ICU care for all but the most straightforward cases.

  2. Minimise airway pressures during ventilation and extubate as soon as possible.

  3. Use standard post-thoracotomy analgesic regimen, but watch renal function with NSAIDs.

Special considerations

  1. Most fistulae are postoperative complications of pneumonectomy or lobectomy, but some are secondary to pneumonia, lung abscesses, and empyema.

  2. Anaesthesia for repair of bronchopleural fistula is challenging and not recommended for an ‘occasional’ thoracic anaesthetist!

Tips for controlling a massive air leak (i.e. unable to ventilate effectively)

If a DLT cannot be positioned satisfactorily these are worth attempting:

  1. Intubate with an uncut cuffed 6mm-diameter single lumen tube—pass fibreoptic bronchoscope through tube into intact main bronchus and ‘railroad’ the tube into the bronchus to isolate and ventilate the good lung.

  2. Ask the surgeon to pass a rigid bronchoscope into the intact main bronchus and slide a long flexible bougie or Cook airway exchange catheter (which allows jet ventilation) into bronchus—remove bronchoscope and railroad single lumen tube.

  3. If all else fails an Arndt endobronchial blocker or a large Fogarty embolectomy catheter passed into the fistula via a rigid bronchoscope may control the leak temporarily.

Pleurectomy/pleurodesis

Procedure

Stripping of parietal pleura from inside of chest wall (pleurectomy). Production of adhesions between parietal and visceral pleura either chemically (talc, tetracycline) or by physical abrasion (pleurodesis)

Time

Pleurectomy 1–2hr; pleurodesis 20–40min

Pain

+++/++++

Position

Lateral decubitus for open thoracotomy or VATS. May be supine for pleurodesis

Blood loss

Minimal if thoracoscopic; up to 500ml for thoracotomy, G&S

Practical techniques

IPPV, DLT, and OLV advised for open/VATS procedures. A single lumen tube is usually adequate for talc pleurodesis

Preoperative

  1. Patients fall into two groups: the relatively young and fit with recurrent pneumothoraces (check for asthma) and older patients compromised by COPD or recurrent pleural effusions (check respiratory reserve).

  2. Even very large unilateral effusions rarely cause orthopnoea in previously healthy patients. Symptomatic orthopnoea should alert the anaesthetist to possible additional pathology such as heart failure.

  3. Check a recent CXR for pneumothorax and/or effusion.

  4. A preoperative intercostal drain is advised if pneumothorax present.

  5. Check the planned surgical approach.

  6. Discuss postoperative analgesia and regional technique.

Perioperative

  1. Keep airway pressures as low as possible in patients with history of pneumothorax.

  2. Be alert for pneumothoraces as they can tension rapidly on IPPV even with drain in situ and can be on the ‘healthy’ side.

  3. Avoid nitrous oxide.

  4. Collapse the lung during instillation of irritant to facilitate pleural coating. If using a single lumen tube preoxygenate and then briefly disconnect lungs from ventilator.

  5. Aim for full expansion of lung at end of procedure to appose parietal and visceral pleura.

Postoperative

  1. Extubate and sit the patient upright before transfer to recovery room.

  2. A CXR is needed to check full lung expansion. Suction on intercostal drains is often prescribed to assist expansion.

  3. Pleural inflammation usually causes severe pain, particularly when abrasion of the pleura is performed.

  4. Use regular paracetamol, but avoid NSAIDs which may make pleurodesis less effective.

  5. Thoracic epidural is recommended for pleurectomy, especially bilateral procedures, and is sited and used as for a thoracotomy. A combination of morphine PCA with intercostal blocks is an alternative. Paravertebral blocks are usually unsuitable due to damage to the pleura.

Special considerations

  1. Pleurectomy is usually performed for recurrent pneumothorax combined with stapling of lung tissue responsible for recurrent air leaks (usually apical ‘blebs’ or small bullae).

  2. Pleurodesis is often used to manage malignant pleural effusions (mesothelioma, metastatic carcinoma)—there may be large volumes of fluid causing significant respiratory compromise.

  3. Patients with massive pleural effusions (more than two-thirds of the hemithorax on chest radiograph or >2000ml) should have these ‘tapped’ and partially drained at least 12hr before surgery because rapid intraoperative reinflation of the collapsed lung can precipitate unilateral postoperative ‘re-expansion’ pulmonary oedema.

  4. Patients with extensive effusions are also at risk of circulatory collapse when turned ‘effusion side up’ for surgery. The mechanism is probably a combination of mediastinal shift and high intrathoracic pressure on IPPV reducing venous return and cardiac output. If this occurs return the patient to the supine position and drain the effusion before proceeding.

Oesophagectomy

Procedure

Total or partial excision of oesophagus with mobilisation of stomach (occasionally colon) into chest

Time

3–6hr

Pain

+++++

Position

Supine with arms by sides and/or lateral decubitus for thoracotomy

Blood loss

500–1500ml; X-match 2U

Practical techniques

IPPV, DLT useful if thoracotomy. Art/CVP lines, urinary catheter, thoracic epidural, or paravertebral catheter for thoracoabdominal incision

Preoperative

  1. Establish indication for surgery—usually oesophageal cancer but occasionally for non-malignant disease (benign stricture, achalasia).

  2. The anaesthetic plan requires understanding of surgical approach:

    1. Transhiatal: laparotomy and cervical anastomosis

    2. Ivor–Lewis: laparotomy and right thoracotomy

    3. Thoracoabdominal: left thoracotomy crossing costal margin and diaphragm

    4. McKeown 3 stage: laparotomy, right thoracotomy, and cervical anastomosis

    5. Minimally invasive: thoracoscopic oesophageal mobilisation, laparoscopic gastric mobilisation, and cervical anastomosis

  3. Preoperative malnutrition or cachexia is common and associated with higher risk of postoperative morbidity and mortality. Requires careful cardiorespiratory assessment.

  4. Plan for duration of surgery and need to reposition patient during procedure.

  5. Preoperative adjuvant chemotherapy may leave residual immunosuppression but can dramatically improve dysphagia.

  6. Reflux is a risk. Give preoperative ranitidine or omeprazole if patient can swallow.

  7. Book HDU or ICU according to patient's fitness and local protocols.

Perioperative

  1. Consider all patients with oesophageal disease to be at risk of regurgitation, so rapid sequence induction with cricoid pressure advised.

  2. If thoracotomy is planned use a DLT and OLV to facilitate surgical access and reduce trauma to the lung.

  3. Plan regional anaesthesia according to surgical approach. Paravertebral LA infusion with morphine PCA for thoracoabdominal approach. For laparotomy/thoracotomy a mid-thoracic epidural (using 3ml boluses of 0.25% bupivacaine perioperatively and postoperative infusion).

  4. A nasogastric tube will be required initially. It is removed for resection and reinserted under surgical guidance following anastomosis.

  5. Do not put internal jugular line on side required for cervical anastomosis.

  6. Monitor core temperature and be obsessional about keeping patient warm (efficient fluid warmer and forced-air warming blanket).

  7. Stay ahead with fluid replacement—for open procedures aim for 10ml/kg/hr of crystalloid plus colloid or red cells to replace blood loss.

  8. Check Hb (HemoCue® ideal) and blood gases intraoperatively—watch for metabolic acidosis suggesting inadequate tissue perfusion.

  9. Arrhythmias and reduced cardiac output causing hypotension may occur during intrathoracic oesophageal mobilisation.

  10. Change DLT to a single lumen tube to improve surgical access prior to cervical anastomosis (if performed).

Postoperative

  1. Patients require intensive and experienced postoperative nursing care in a specialist ward, HDU, or ICU.

  2. If cold (<35.5°C) or haemodynamically unstable ventilate until condition improves.

  3. Aim for minimum urine output of 1ml/kg/hr.

  4. Use a jejunostomy or nasoduodenal tube for early enteral feeding.

Special considerations

  1. Oesophagectomy has one of the highest perioperative mortality rates of all elective procedures (up to 5% even in specialist centres).

  2. 66% of deaths are from systemic sepsis secondary to respiratory complications or anastomotic breakdown.

  3. Over 30% of patients suffer a major complication.

  4. In some centres minimally invasive (endoscopic) oesophagectomy is replacing the traditional open approaches. Beware ‘tension capnothorax’ if pleura is breached during laparoscopic hiatal dissection.

  5. Occasional practice in anaesthesia (or surgery) for oesophagectomy is not recommended.

Chest injury

The emergency diagnosis and initial treatment of major thoracic trauma is described on pp. [link][link]. This section deals with the anaesthetic management for definitive repair of ruptures of the diaphragm, oesophagus, and tracheobronchial tree.

General considerations

  1. Serious chest injuries are frequently associated with major head, abdominal, and skeletal injuries and appropriate attention and priority must be given to their management (cervical spine immobilisation, laparotomy to arrest bleeding, splintage of limb fractures).

  2. Fewer than 30% of patients with thoracic trauma require a thoracotomy, but persistent bleeding from intercostal drains exceeding 200ml/hr is an indication for urgent surgery.

  3. Most deaths from thoracic trauma are due to exsanguination. Good IV access with two large-bore cannulae will allow rapid infusion.

  4. Emergency thoracotomy in the resuscitation room is seldom indicated and rarely associated with a favourable outcome.

  5. Standard principles of emergency anaesthesia should be applied.

  6. Maintain a high index of suspicion for tension pneumothorax during IPPV as an intercostal drain does not guarantee protection.

  7. Massive air leaks usually indicate significant tracheobronchial injury (see below).

  8. Patients with major thoracic trauma are at high risk of multiple organ failure and require postoperative management in an ICU.

Repair of ruptured diaphragm

  1. Clinical features and diagnosis are described on [link].

  2. May present as a chronic condition or as intestinal obstruction of a herniated bowel, so check preoperative fluid and electrolyte status.

  3. Defect should be closed promptly but this seldom needs to be done as an emergency.

  4. The surgical approach is via standard lateral thoracotomy or thoracoabdominal incision.

  5. Intraoperative management is as for a fundoplication ([link]).

  6. Avoid nitrous oxide as it distends the bowel and may make reduction of the hernia more difficult.

  7. DLT and OLV facilitate surgical access for repair.

  8. A nasogastric tube should be used to decompress the stomach.

Repair of ruptured oesophagus

  1. Clinical features and diagnosis are described on [link]—surgical emphysema and pleural effusions are frequently present.

  2. Other causes of oesophageal rupture include excessive abdominal straining and unco-ordinated vomiting (Boerhaave's syndrome). Oesophageal perforation can be caused by foreign bodies but is often iatrogenic (during endoscopic procedures).

  3. Mediastinitis is followed rapidly by sepsis and a systemic inflammatory response syndrome with associated problems of circulatory shock, renal failure, and ARDS.

  4. The principles of surgical management are initially drainage and prevention of further contamination.

  5. Careful endoscopic assessment will determine extent of oesophageal disruption.

  6. Small tears in unfit frail patients may be managed conservatively with chest drainage and nasogastric suction, but normally urgent surgery is required.

  7. Patients should be stabilised preoperatively in ICU with chest drainage, IV fluid replacement, analgesia, invasive monitoring, and inotropic support.

  8. Intraoperative management is as for oesophagectomy (see [link]).

  9. Upper and lower oesophageal injuries require right and left thoracotomy, respectively.

  10. Primary closure may be possible if the oesophagus is healthy; if not oesophagectomy will be required.

  11. Arrhythmias are common, particularly atrial fibrillation, due to mediastinitis.

  12. Change the DLT for a single lumen tube before transfer to intensive care for postoperative ventilation.

  13. Even patients who are stable at the end of the repair procedure remain at high risk of major complications for several days.

  14. Early postoperative feeding—feeding jejunostomy or parenterally.

  15. There is a significant incidence of dehiscence resulting in oesophagopleurocutaneous fistula with high mortality.

Repair of tracheobronchial injury

  1. Most patients with significant tracheal/bronchial disruption do not reach hospital alive.

  2. Clinical features of laryngeal and tracheobronchial injuries are described on [link].

  3. The priority is 100% oxygen and relief of tension pneumothorax, which may require two large-bore intercostal drains with independent underwater seals.

  4. If ventilation and oxygenation are acceptable call for thoracic surgical assistance and try to assess and identify site of airway injury by fibreoptic bronchoscopy before intubation.

  5. Airway management and anaesthetic principles apply as for a large bronchopleural fistula ([link]).

  6. Adequate positive pressure ventilation may be impossible with single lumen tube.

  7. A torn bronchus can be isolated by fibreoptic guided intubation of the contralateral intact main bronchus with an appropriate DLT.

  8. An uncut single lumen tube can be guided past an upper tracheal tear with a bronchoscope so its cuff lies distal to the injury.

  9. Once the airway is secure and ventilation is stabilised proceed to urgent thoracotomy for repair.

  10. Carinal disruption may require cardiopulmonary bypass to maintain oxygenation during repair.

  11. Inappropriate management can lead to later stenosis and long-term airway problems.

Further reading

Ghosh S, Latimer RD (1999). Thoracic Anaesthesia Principles and Practice. London: Butterworth-Heinemann.

Wilson WC, Benumof JL (2005). Anesthesia for thoracic surgery. In: Miller RD, ed. Miller's Anesthesia, 6th edn, Chapter 49. Philadelphia: Elsevier Churchill Livingstone.

Operation

Description

Time

Pain

Position/approach

Blood loss/ X-match

Notes

Fibreoptic bronchoscopy

Visual inspection of tracheo-bronchial tree ± biopsy and bronchial brushings/lavage

5–10min

+

Supine

None

GA rarely used. Single lumen tube (SLT) (8–9mm) with bronchoscopy diaphragm on angle piece. IPPV with relaxant appropriate to duration. Expect high airway pressures while scope in ETT. Suction can empty breathing system

Lung biopsy

Diagnostic sampling of lung tissue for localised or diffuse abnormality

30–60min

+++/++++

Lateral/VATS or minithoracotomy

Minor/G&S: X-match if anaemic

DLT and OLV facilitate VATS procedures. Patients with diffuse disease can have very poor lung function—risk of ventilator dependence and significant mortality

Oesophagoscopy and dilatation (O&D)

Visual inspection of oesophagus via rigid or fibreoptic scope ± dilatation of stricture with flexible bougies or balloon

5–20min

–/+

Supine

None

Regurgitation risk so rapid sequence induction advised. SLT on left side of mouth—watch for airway obstruction and ETT displacement during procedure. Flexible oesophagoscopy often done under IV sedation

Oesophageal stent insertion

Endoscopic placement of tubular stent through oesophageal stricture

10–30min

+/++

Supine

None

Often emaciated, may be anaemic. Preop IV fluids to correct dehydration. Rapid sequence induction, SLT, and awake extubation in lateral position. Small risk of oesophageal rupture

Fundoplication/hiatus hernia repair

‘Antireflux’ procedure—fundus of stomach wrapped round lower oesophagus, may require a gastroplasty to lengthen oesophagus

2–3min

++++/+++++

Supine/laparotomy. Lateral/left thoracotomy. Now often done laparoscopically

Moderate/G&S: if Hb <12 X-match 2U

Often obese—check respiratory function. Rapid sequence induction or awake fibreoptic intubation mandatory. Nasogastric tube required. DLT helpful for thoracic approach. Epidural or paravertebral catheter and PCA recommended

Pectus excavatum/carinatum repair

Correction of ‘funnel chest’/'pigeon chest’ deformity of sternum

3–5hr

+++/++++

Supine—arms to sides/midline sternal incision

Moderate to severe/X-match 2U

Primarily cosmetic unless deformity severe. Usually young fit adults. GA, IPPV via SLT, and mid-thoracic epidural recommended. Risk of pneumothoraces. Minimally invasive technique for pectus excavatum repair is becoming increasingly popular—epidural still recommended

Thymectomy

Excision of residual thymic tissue and/or thymoma from superior and anterior mediastinum

2–3hr

++/+++

Supine—arms to sides/median sternotomy

Moderate/X-match 2U

Usually for myasthenia gravis. Check for airway compression, other autoimmune diseases, thyroid function, and steroid, immunosuppressive, and anticholinesterase therapy (see [link]). GA, IPPV via SLT, intravenous anaesthesia, minimal or no relaxant, and monitoring of neuromuscular transmission. May need postop ventilatory support

Notes:

1 British Thoracic Society and Society of Cardiothoracic Surgeons Working Party (2001). Guidelines on the selection of patients with lung cancer for surgery. Thorax, 56, 89–108.

2 Burke JR, Duarte IG, Thourani VH, Miller JI (2003). Preoperative risk assessment for marginal patients requiring pulmonary resection. Annals of Thoracic Surgery, 76, 1767–1773.

3 Conacher I (1998). Dynamic hyperinflation—the anaesthetist applying a tourniquet to the right heart. British Journal of Anaesthesia, 81, 116–117.

1 Wildgaard K, Ravn J, Kehlet H (2009). Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. European Journal of Cardio-Thoracic Surgery, 36, 170–180.

2 Gulbahar G, Kocer B, Muratli SN, et al. (2010). A comparison of epidural and paravertebral catheterization techniques in post-thoracotomy pain management. European Journal of Cardio-Thoracic Surgery, 37, 467–472.

2 Campos JH (2003). Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. Current Opinion in Anaesthesiology, 20, 27–31.

1 Brodsky JB, Benumof JL, Ehrenwerth J, Ozaki GT (1991). Depth of placement of left double-lumen endobronchial tubes. Anesthesia and Analgesia, 73, 570–572.

1 Licker M, de Perrot M, Spiliopoulos A, Robert J, Diaper J, Chevalley C, Tschopp JM (2003). Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesthesia and Analgesia, 97, 1558–1565.

2 Slinger PD (2006). Postpneumonectomy pulmonary edema: good news, bad news. Anesthesiology, 105(1), 2–5.

1 Hillier J, Gillbe C (2003). Anaesthesia for lung volume reduction surgery. Anaesthesia, 58, 1210–1219.

1 Wilson WC, Benumof JL (2005). Physiology of one lung ventilation. In: Miller RD, ed. Miller's Anesthesia, 6th edn, Chapter 49, 1890–1894. Philadelphia: Elsevier, Churchill Livingstone.

2 Purugganan RV (2008). Intravenous anesthesia for thoracic procedures. Current Opinion in Anesthesiology, 21, 1–7.