This document discusses anesthesia considerations for patients with chronic lung disease undergoing surgery. It covers preoperative assessment of pulmonary function, intraoperative monitoring and lung isolation techniques, positioning, and one lung ventilation. Postoperative management focuses on analgesia and complications related to chronic lung conditions. Preoperative optimization aims to improve patient risk stratification and respiratory status prior to surgery.

1. ANESTHESIA FOR
CHRONIC LUNG DISEASE

2.  Preoperative assessment
 Intraoperative management
 Monitoring
 Lung isolation techniques
 Positioning
 One lung Ventilation
 Postoperative management
 Postoperative analgesia
 Complications

3. Preoperative Assessment
 Aim
 Identify patients at high risk
 Use that risk assessment to stratify
perioperative management and focus
resources on the high-risk patients to
improve their outcome.

4. Assessment of Respiratory
function
 Detailed history
 Baseline Spirometry
 Respiratory Mechanics
 Lung parenchymal function
 Cardiopulmonary interaction

5. Respiratory mechanics
ppoFEV1% = preop FEV1% ×
(1- %Functional lung tissue removed/100)
For example, after a right lower
lobectomy a patient with a preoperative
FEV1 (or DLCO) 70% of normal would be
expected to have a postoperative
FEV1 = 70% × (1 - 29/100) = 50%
Ppo FEV1
>40% -Low risk
30-40%- mod risk
< 30% - high risk
Slinger PD, Johnston MR: Preoperative assessment: an anesthesiologist's perspective. Thorac Surg Clin 15:11, 2005.

6. Cardiopulmonary Interaction
 Maximum oxygen consumption (Vo2max)
 Most useful predictor of post-thoracotomy outcome.
 Morbidity and mortality is unacceptably high- Vo2max <15 mL/kg/min.
 Few patients with a Vo2max >20 mL/kg/min have respiratory
complications
 Stair climbing
 5 flights - Vo2max >20 mL/kg/min
 2 flights - Vo2max of 12 mL/kg/min
 6-minute test (6MWT)
 <2000 ft (610 m) - Vo2max <15 mL/kg/min
 Patients with a decrease of Spo2 greater than 4% during exercise are at
increased risk for morbidity and mortality.

9. Preoperative Optimization
• Stop smoking, avoid industrial • Adjunct medication
pollutants – Antibiotics—if purulent
• Dilate airways sputum/bronchitis
• Loosen secretions – Antacids, H2 blockers, or
PPIs—if symptomatic reflux.
– Airway hydration
(humidifier/nebulizer) • Increased education,
– Systemic hydration motivation, and facilitation of
– Mucolytic and expectorant
postoperative care
drugs – Psychological preparation
• Remove secretions – Preoperative pulmonary care
training
– Postural drainage • Incentive spirometry
– Coughing • Secretion removal maneuvers
– Chest physiotherapy – Preoperative exercise
(percussion and vibration) – Weight loss/gain
– Stabilize other medical
problems

11. Summary of initial preoperative
assessment
 All patients:  Cancer patients:
 Assess exercise tolerance  consider the “4 Ms”:
 mass effects
 estimate predicted
 metabolic effects
postoperative FEV1%
 Metastases
 discuss postoperative  medications
analgesia  COPD patients:
 discontinue smoking  Arterial blood gas analysis
 Patients with predicted  Physiotherapy
postoperative FEV1< 40%:  bronchodilators
 DlCO  Increased renal risk:
 Ventilation perfusion Scan  Measure creatinine and
 VO2 max blood urea nitrogen

12. Intraoperative Monitoring
• Oxygenation
• Capnometry
• Arterial blood pressure
• CVP
• Pulmonary artery pressure
• Fibreoptic bronchoscopy
• Urine output
• Temperature

13. Lung Isolation Techniques
• Double lumen tube
• Bronchial blocker
– Arndt
– Cohen
– Fuji
• Univent tube
• Endobronchial tube
• Endotracheal tube advanced into bronchus

14. Double lumen tube
 Carlens tube
 Robertshaw tube
 Advantages
 Quickest to place successfully  Disadvantages
 Repositioning rarely required  Size selection more difficult
 Bronchoscopy to isolated lung  Difficult to place in patients
 Suction to isolated lung with difficult airways or
abnormal tracheas
 CPAP easily added
 Not optimal for postoperative
 Can alternate OLV to either ventilation
lung easily
 Potential laryngeal trauma
 Placement still possible if
bronchoscopy not available  Potential bronchial trauma

15. Lateral decubitus position for
thoracotomy

16. Positioning
• Position Change
– W/f hypotension
– Secure all lines and monitors
– Make an initial “head-to-toe” survey
– Check oxygenation, ventilation,
hemodynamics, lines, monitors, and potential
nerve injuries.
– Reassess after repositioning
– Recheck Endobronchial tube/blocker position
and the adequacy of ventilation by auscultation
and fiberoptic bronchoscopy after
repositioning.

17. “Head-to-Toe” Survey
• Dependent eye
• Dependent ear pinna
• Cervical spine in line with thoracic spine
• Dependent arm:
– Brachial plexus
– Circulation
• Nondependent arm:
– Brachial plexus
– Circulation
• Dependent and nondependent suprascapular nerves
• Nondependent leg: sciatic nerve
• Dependent leg:
– Peroneal nerve
– Circulation

18. Treatment of Hypoxemia
• Severe or precipitous desaturation:
– Resume two-lung ventilation (if possible).
• Gradual desaturation:
– Ensure that delivered FIO2 is 1.0
– Check position of DLT or blocker with fiberoptic bronchoscopy
– Ensure cardiac output is optimal; decrease volatile anesthetics to < 1
MAC
– Apply a recruitment maneuver to the ventilated lung
– Apply PEEP 5 cm H2O to the ventilated lung
– Apply CPAP 1-2 cm H2O to the nonventilated lung (apply a
– recruitment maneuver to this lung immediately before CPAP)
– Intermittent reinflation of the nonventilated lung
– Partial ventilation techniques of the nonventilated lung:
• Oxygen insufflation
• High-frequency ventilation
• Lobar collapse (using a bronchial blocker)
– Mechanical restriction of the blood flow to the nonventilated lung

19. Ventilation Strategies
Parameter Suggested Guidelines/ Exceptions
Maintain:
Tidal volume 5-6 mL/kg
Peak airway pressure <
35 cm H2O
Plateau airway pressure <
25 cm H2O
Positive end-expiratory Patients with COPD: no
5 cm H2O
pressure added PEEP
Maintain normal PaCO2;
Pa-ETCO2 will usually
Respiratory rate 12 breaths/min
increase 1-3 mm Hg during
OLV
Pressure control for
patients at risk of lung
Volume or pressure
Mode injury (e.g., bullae,
controlled
pneumonectomy, post lung
transplantation)

20. Postoperative mangement-
Analgesia
• Systemic Analgesia
– Opioids
– Nonsteroidal Anti-inflammatory Drugs
– Ketamine
– Dexmedetomidine
• Local Anesthetics/Nerve Blocks
– Intercostal Nerve Blocks
– Intrapleural Analgesia
– Epidural Analgesia
– Paravertebral Block

21. Thoracic Epidural Analgesia
• Better preservation of the functional
residual volume
• Efficient mucociliary clearance
• Alleviation of the inhibiting reflexes acting
on the diaphragm
• prevention of atelectasis and secondary
infections

22. Postoperative Complications
• Early Major Complications
– Torsion of a remaining lobe after lobectomy
– Dehiscence of a bronchial stump
– Hemorrhage from a major vessel
– Respiratory Failure
– Cardiac Herniation

23. Anaesthetic management of bronchopleural fistula
Bronchopleural fistula
Communication from major bronchus to pleural space
Commonly associated with pneumonectomy, trauma,
abscess or empyema
Relevant complications
Pus may contaminate other lung-associated injuries with trauma
Surgery
Usually semi-elective
Resuturing of bronchial stump, muscle flap to stump,
drainage of abscess
High risk surgery requiring GA and one-lung ventilation
If incidental surgery, GA may be avoided, regional preferred
Positioning still important to avoid soiling

24.  Patient
 Commonly debilitated, may have coexistent medical
problems
 Respiratory function assessed
 Clinical, spirometry, ABGs
 Routine assessment for thoracic surgery
 Consideration of epidural
 Decision to proceed
 Respiratory function optimized
 Chest drain inserted to avoid tension pneumothorax and
drain pleural collection

25.  Induction
 Objectives
 Maintain oxygenation and ventilation, avoid tension pneumothorax
 Avoid soiling good lung
 Protection of lung requires DLT, bronchial lumen to good side
 Small leak without infection may be manageable with single-lumen
ETT
 Paediatric patients are typically too small for DLT or FOB -->
blocker or endobronchial intubation
 Fistula reduces effectiveness of mask IPPV, so spontaneous
ventilation
 Ideally awake DLT intubation
 Topical local anaesthetic to airway
 Position head-up and bad side down
 Sedation for intubation
 Alternatively spontaneously ventilating GA with DLT insertion
when deep
 Verification of DLT position with differential ventilation or FOB

26.  Maintenance
 IPPV to healthy lung
 Lung with fistula may benefit from small VT ventilation
or CPAP below critical pressure for fistula or HFJV
 Emergence
 Avoid high airway pressures if fistula has been repaired
 Hand ventilation or SIMV
 Postoperative
 Epidural analgesia
 HDU monitoring post-op
 High incidence of arrhythmia post-thoracotomy