Preoperative Evaluation and Questions: Extent of resection? Wedge, Segment, Lobe, or Pneumonectomy? Thoracoscopic? What is the surgeon’s estimated likelihood to convert from Thoracoscopy to Open Thoracotomy?
PFT’s Should have FEV1 and DLCO > 60% predicted to have enough reserve function post-op.
Risk: Mortality: <1%, 5% for pneumonectomy
Morbidity: arrhythmia 10-30%, DVT 5-20%
[Jaffe RA: Anesthesiologist’s Manual of Surgical Procedures, 4th ed. LWW: Baltimore, 2009]
Induction/Airway: Standard induction. Depending on surgeon preference may start with Single lumen tube for flexible bronchoscopy then convert to Double Lumen Tube. Use patient’s height to estimate DLT size; 5’5″-5’10 use 37-39fr, >5’11 use 39-41. smaller for women.
Lines and Monitors: Standard ASA, A-line, Bronchoscope. If Thorocotomy then place thoracic epidural pre-op. If thoracoscopic but conversion to open is likely consider placing epidural pre-op or at least consenting the patient for possible post-op epidural if needed.
Mode of anesthesia: General Anesthesia.
Surgical Course: Induction, Single or Large DLT to facilitate Bronchoscopy by surgeon. Lateral position. Initiate one lung ventilation as soon as possible to assess patient tolerance and adequacy of lung isolation.
Intraoperative Goals and Events: Double Lumen Tube placement, verify positioning with bronchoscope before and after position patient lateral.
Maneuvers to improve oxygenation during one-lung ventilation: PEEP to the non-operative lung, CPAP to the operative lung, Intermittent two-lung ventilation, Occlusion of Pulmonary Artery on operative side.
Tolerate Hypercapnea up to 50-60mmHg.
Post-Operative Concerns, Transport, Disposition: PACU, then to Intermediate Care Unit. Epidural for pain control. Shoulder pain from positioning (Contralateral side) is very common.
Evidence-Based Medicine: [Shapira BA, Clinical Application of Respiratory Care. 3rd edition. Year Book Medical Publishers, Chicago: 1985]