Lung cancer for pneumonectomy: one-lung hypoxaemia and AF69-year-old man, 74 kg, for elective left pneumonectomy by thoracotomy for central lung cancer

The patient

The examiner asks

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1. Consider

   What are your main concerns?

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   • A 69-year-old with COPD and paroxysmal AF, for elective left pneumonectomy for central lung cancer. Patient
   • At 69 and about to lose a lung, I record his stair climbing and cognition; delirium risk rises after 60.
   • Pneumonectomy brings AF in about 60%, and he already has it. Disease
   • Losing a lung raises his RV afterload; the right ventricle may dilate afterwards.
   • Post-pneumonectomy pulmonary oedema is rare but kills 30–50%. Surgery

2. Prepare

   Is he fit for pneumonectomy?

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   • I assess three legs: mechanics, lung tissue function, and heart-lung reserve on exercise. (Disease)
   • His V/Q scan was right: pneumonectomy with FEV1 and DLCO under 80%.
   • ppoFEV1 is 62 times 0.55, about 34%; ppoDLCO about 32%.
   • Both sit in the 30–40% band, which means increased risk.
   • VO2max 16 clears the high-risk cut-off of 15 mL/kg/min, so he can proceed.
   • Apixaban off 3 days, so a thoracic epidural is acceptable.
   • Bisoprolol continues to the morning of surgery to protect against AF.

3. Plan

   How will you manage the anaesthetic?

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   • Arterial line, central line and large-bore access for this high-risk resection. Surgery
   • Right-sided double-lumen tube, or a left one pulled back before the bronchus is stapled. Airway
   • Bronchoscope checks the tube after intubation and again after turning.
   • One-lung: 5–6 mL/kg ideal weight, peak under 35, plateau under 25 cmH2O. Disease
   • Restrictive fluids; vasopressors rather than litres of fluid to hold his pressure.
   • Thoracic epidural for analgesia, aiming to extubate him in theatre. After surgery
   • Chest X-ray in recovery to check his mediastinum is central.

4. Crisis

   Twenty-five minutes into one-lung ventilation, SpO2 drifts down to 86% on FiO2 0.6. BP 118/70. What do you do?

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   • Gradual desaturation: FiO2 up to 1.0 first. Crisis
   • Bronchoscope down the tube to recheck position and clear the right lung.
   • Check his output; the surgeon may be pressing on the IVC.
   • Recruit the right lung, then PEEP titrated between 5 and 10 cmH2O.
   • Left lung given CPAP of 1–2 cmH2O, after a recruitment breath.
   • If it falls fast, back to two-lung ventilation until he recovers.
   • Early clamping of the left pulmonary artery ends the shunt for good. Surgery

5. Crisis

   On day 2 he develops AF at 158/min, BP 78/46, and is clammy and confused. What do you do?

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   • Tachycardia algorithm: irregular narrow-complex tachycardia at 158, unstable with hypotension and confusion. Crisis
   • Unstable branch: synchronised cardioversion now, at least 200 J, with sedation.
   • If AF returns, amiodarone 300 mg IV over 1 hour.
   • No diltiazem while he's hypotensive.
   • Correct potassium; magnesium 1–2 g over 15 minutes if low.
   • Find the trigger: hypoxia, RV strain, fluid status; echo now.
   • Anticoagulation restarts with cardiology once surgical bleeding allows. After surgery