Bullous emphysema for VATS lung volume reduction66-year-old man, 62 kg, for elective VATS lung volume reduction of both upper lobes

The patient

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1. Consider

   What are the key issues in this man?

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   • A 66-year-old with severe bullous emphysema and CO2 retention, for elective VATS lung volume reduction. Patient
   • At 66 on home oxygen, his walking distance and baseline cognition set my expectations; delirium risk rises past 60.
   • He suits the operation: upper-lobe, uneven disease, and his FEV1 and DLCO sit above 20%. Disease
   • His CO2 of 54 doesn't exclude him; hypercapnia is not a contraindication here.
   • Positive pressure will swell his bullae, risking rupture, tension pneumothorax and a fistula.
   • Gas trapping means hyperinflation and hypotension once I ventilate him by machine.

2. Prepare

   What do you check and set up before surgery?

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   • His CT shows the target upper-lobe areas and the bullae I must keep away from pressure. Disease
   • Arterial gas done: as a CO2 retainer, his baseline of 54 is my target afterwards.
   • Echo for his right ventricle; up to half of COPD patients have RV dysfunction.
   • Full bronchodilator therapy continued, and any chest infection treated before he comes.
   • Thoracic epidural or paravertebral catheter: strong analgesia keeps him off the ventilator afterwards. Surgery
   • Chest drain kit and lung isolation kit in the room before induction. Airway

3. Plan

   How will you anaesthetise and ventilate him?

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   • Nitrous oxide is avoided; it would enter and enlarge his bullae. Disease
   • Gentle induction; he breathes himself or gets small, low-pressure breaths until the lungs are separated. Airway
   • Left double-lumen tube, checked by bronchoscope after placement and again after turning him.
   • One-lung: small tidal volumes, slow rate, long expiratory time, and no extra PEEP in emphysema. Disease
   • Peak pressure kept under 35, plateau around 25 cmH2O.
   • I accept a high CO2 as long as his pH stays above 7.25.
   • With epidural analgesia and VATS, I plan to extubate him at the end, awake, warm and comfortable. After surgery

4. Crisis

   After twenty minutes of one-lung ventilation, BP is 72/40, HR 118, SpO2 90%, peak pressure 38 cmH2O, and ETCO2 has fallen from 48 to 24 mmHg. What do you do?

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   • Falling ETCO2 with low pressure means low output from hyperinflation: I disconnect him and let gas out. (Crisis)
   • If his pressure comes back within seconds, gas trapping was the cause.
   • Reconnect with a slower rate, smaller breaths and longer expiration, since auto-PEEP tracks all three.
   • No recovery: tension pneumothorax in the ventilated lung, with high pressures and lost breath sounds.
   • Needle in the 2nd intercostal space midclavicular, then a drain in the 5th, anterior to midaxillary.
   • Phenylephrine 50–100 mcg while his circulation recovers; the CO2 I tolerate if pH holds.

5. Crisis

   After resection the lung is re-expanded. Half of each breath now escapes through the drains; SpO2 86%, PaCO2 75 mmHg. What do you do?

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   • A big leak from the staple lines: 100% oxygen and tell the surgeon now. Crisis
   • I size it by the gap between delivered and returned tidal volumes.
   • Back to one-lung ventilation of the side with the smaller leak while the other is repaired.
   • Surgeon reinforces the staple lines; fibrin glue is an option for persistent leaks. Surgery
   • If the leak stays large, high-frequency ventilation gives lower peak pressures and less leak. Crisis
   • Extubate early so positive pressure doesn't strain his staple lines after surgery. After surgery