COPD with CO2 retention for laparoscopic fundoplication74-year-old man, 70 kg, for elective laparoscopic fundoplication of a large hiatus hernia with reflux

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 74-year-old with moderate COPD and CO2 retention, for elective laparoscopic fundoplication. Patient
   • At 74, his age and a hiatal operation both raise his risk of surgical emphysema.
   • His bicarbonate of 32 points to chronic CO2 retention; his gas confirms a PaCO2 of 52. Disease
   • Pneumoperitoneum releases catecholamines and vasopressin, raising his afterload; at 15 mmHg his venous return falls. Surgery
   • The diaphragm rises: his compliance falls, airway pressure rises and his bases collapse.
   • Absorbed CO2 can push his PaCO2 up fast, beyond what extra ventilation can clear. Disease

2. Prepare

   How will you prepare him?

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   • Tiotropium and his inhalers continue on the morning of surgery. Disease
   • Salbutamol 2–4 puffs, 20–30 minutes before I handle his airway.
   • His baseline gas on air tells me which PaCO2 is normal for him.
   • I ask the surgeon for the lowest insufflation pressure that still gives a view. Surgery
   • HDU bed booked, since he may need breathing support afterwards. After surgery

3. Plan

   How will you ventilate him?

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   • 6–8 mL/kg ideal-weight breaths, with PEEP 5–10 cmH2O. Disease
   • Long expiratory time; his compliant emphysematous lungs need longer to empty.
   • Auto-PEEP grows with bigger breaths and shorter expiry, and the ventilator gauge won't show it.
   • I accept a mildly raised CO2 rather than chase it with fast, large breaths.
   • Arterial line for gases, because his end-tidal reads below his true PaCO2.
   • Head-up tilt pools blood in his legs, so I watch his pressure as he tilts. Surgery
   • Insufflation pushes the carina up; I recheck his tube position afterwards. Airway

4. Crisis

   Forty minutes in, end-tidal CO2 climbs from 45 to 68 mmHg and his neck and chest crackle. BP 150/90, HR 104, SpO2 94%. What do you do?

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   • Surgical emphysema: CO2 is tracking outside the peritoneum, as fundoplication invites. Crisis
   • Tell the surgeon, lower the pressure, and mark how far the crackling spreads.
   • More ventilation within his limits; if CO2 keeps rising, the abdomen is deflated.
   • Arterial gas now, since his end-tidal underestimates the real PaCO2.
   • If surgery must go on, reinsufflation at a lower pressure.
   • Neck emphysema: chest X-ray, and his airway checked for obstruction before extubation. After surgery

5. Crisis

   Minutes later, peak airway pressure is 42 cmH2O, SpO2 84%, BP 70/40. What now?

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   • Tension capnothorax until proven otherwise; his hiatus opens into the chest. Crisis
   • Pneumoperitoneum released now, 100% oxygen, and the surgeon told.
   • I listen and watch both sides move, and exclude his tube slipping into a bronchus.
   • Fluids and a vasopressor while it settles; PEEP reduces the abdomen-to-chest gradient.
   • Still unstable after deflation: I decompress with a needle, then a drain goes in.
   • If it recurs on reinsufflation, the case converts to open; ICU afterwards. After surgery