Lung Volume Reduction Surgery

Airway: ETT/ lung isolation required.
Access: 1-2× large IV.
Pain: Variable, but excellent analgesia and avoidance of opioids is critical.
Position: Lateral (for VATs or thoracotomy) or supine (for median sternotomy).
Time: 1-2 hours
Blood loss: Minimal
Special:

Palliative surgical technique which aims to improve exercise tolerance and symptoms in patients with severe emphysema in patients refractory to medical therapy. Improvement may occur due to:

Removal of ineffective lung tissue allows compressed, relatively normal lung to expand
Reduces chest hyperinflation, improving work of breathing
Improves cardiac function by reducing dynamic hyperinflation and cardiac and vascular compression
Improved systemic endothelial function

Evidence suggests improved quality of life and some improvement in mortality in highly select patient groups.

Surgical Stages

Approach is variable and may be:

Median sternotomy
Thoracotomy
VATS

Preoperative

Assessment: * Respiratory function
Typically severe emphysema, with: * FEV₁ <50% * Low DLCO * ↑ TLC/RV * Cardiac function
Presence of pulmonary HTN or RHF. * Coronary artery disease
Common in this patient group.

Consultation: Optimisation: * Long acting bronchodilators * Maintain smoking cessation

Premedication: Explain/Consent:

Intraoperative

Preparation: * Arterial line * Consider CVC
Especially if placing epidural, for administration of vasoactives. * Consider regional * Thoracic epidural if bilateral * PVB/ESP if unilateral

Induction: Maintenance: * Ventilation * Lung isolation * Avoid high inflation pressures
* Usually <20cmH₂O to reduce risk of air leak * PCV ideal * Ensure adequate expiratory time; may require tolerating moderate hypercapnoea * Anaesthesia * Propofol TCI
* Offset independent of pulmonary function * May reduce shunt fraction by maintaining pulmonary vasoconstriction * Volatile * Avoid nitrous oxide due to gas trapping

Emergence: * Extubate awake * Avoid precipitants of bronchopleural fistulae: * Positive pressure ventilation * Coughing/straining * Suctioning

Postoperative

Disposition: Referrals/Review: * HDU or ICU post-operatively to reduce risk of post-operative pulmonary complications

Analgesia: * Adequate analgesia critical given high risk population for respiratory complications * Minimisation of opioids is preferable

Fluids: Thromboprophylaxis: Specific:

References

Brister, Neil W., Rodger E. Barnette, Victor Kim, and Michael Keresztury. ‘Anesthetic Considerations in Candidates for Lung Volume Reduction Surgery’. Proceedings of the American Thoracic Society 5, no. 4 (1 May 2008): 432–37. https://doi.org/10.1513/pats.200709-149ET.
Elayaperumal, A.K., and R.E. Jackson. ‘Anaesthesia for Lung Volume Reduction Surgery and Endobronchial Valves’. BJA Education 18, no. 7 (July 2018): 193–98. https://doi.org/10.1016/j.bjae.2018.04.002.