Principle of thoracic anesthesia

with determinants of operability

for resection,One lung anesthesia
Dr. Rajesh Kumar

University College of Medical Sciences & GTB

Hospital, Delhi

objectives

Preanesthetic assessment

Anesthetic management

Postoperative management

Fundamentals to
anesthetic management
of thoracic procedures
Lung

isolation to facilitate surgical

access
Management of one lung anesthesia

Preoperative evaluation
done in two disjoint phases:

1.
2.

The initial clinical assessment

The final assessment on the day
of admission

Primary function of
PAC
To

identify patients at elevated risk,

To

stratify perioperative
management and focus resources
Feasibility

of lung resection in a
high risk patient

Perioperative complications
(overall mortality 3-4%)
complication

incidence

Respiratory
(atelectasis,
pneumonia,respiratory
failure)

15-20 %

Cardiovascular
(arrhythmia and
ischemia)

10-15%

Assessment of respiratory functions

History

Detailed history regarding the quality of life

preoperatively

Respiratory
mechanics

All patients should have a baseline spirometry:

FEV1, FVC, MVV, RV/TLC
FEV1% ( % of predicted volume corrected for
age,gender and height).
ppo FEV1 % ( predicted post operative FEV1 )
Calculated as ppoFEV1 % = preop FEV1 % (1-%
functional lung tissue removed/100)

ppo FEV1 % > 40%

ppoFEV1 % <40%
ppo FEV1 % <30%

low risk
major complication
high risk

Assessment of respiratory functions

continued
Lung
parenchymal
tests

ABG parameter :

PaO2 < 60mm Hg

PaCO2 >45 mmHg
( warning indicator of increased risk, however
resections are done with these figures
nowadays)
Most useful test : DLCO
ppo DLco can be calculated like ppo FEV1
ppo DLco < 40 % increases respiratory and
cardiac complications
PREOP. FEV1 OR DLco < 20% Is
UNACCEPTABLE and is the absolute MINIMAL
value required. ( national emphysema
treatment trial )

Assessment of respiratory functions

continues
cardiopulmonary interactions
(most important assessment of respiratory
function)
Laboratory
exercise
testing

Gold standard
Vo2 max (maximum oxygen consumption) is the
most useful predictor of post operative
outcome.
Vo2 max < 15 ml/kg/min is unacceptable
Vo2 max >20 ml/kg/min has fewer complication
EXPENSIVE

Stair
climbing
tests

5 flights of stairs ~ V02 max >20 ml/kg/min

2 fight of stairs ~ Vo2 max ~ 12 ml/kg/min -- very
high risk
(climbing should be at patients own pace without
stopping,
1 flight of stairs = 20 steps withs each step of 6
inches )

Assessment of repiratory functions

continues
Six minute
walk
test(6MWT)

< 610 m/ 2000 ft ------ Vo2 max< 15 ml/kg/min

~fall in SpO2 > 4% during
exercise
( increased morbidity and mortality)

ppo V02 max

< 10 ml/kg/min is an absolute contraindication

mortality rate is approximately 100%

V-P
scintigraphy

Should be considerd for any patient of pneumonenctomy

having a preop FEV1 &/or Dlco <80%
performed at rest while FEV1 is a forced maneuver

Assessment of repiratory functions

continued

Split lung function

test

These tests have not shown sufficient

predictive value or validity for universal
adoption and are hence not
recommended any longer
Replaced by spirometry/ DLco/ exercise
tolerance & V/Q scaning.

The three legged stool of pre

thoracotomy respiratory assessment
Respiratory
mechanics

FEV1(ppo>40%)

MVV, RV/TLC, FVC

Cardiopulmonary
reserve

Vo2 max
>15ml/kg/min
Stair climbing>2
flight

6MWT>610m/200
0ft
Exercise SpO2 < 4
%

Dlco (ppo >40%)

PaO2 >60
PaCO2 <45

Lung
parenchymal
function

 Rate of respiratory complication doubles(40%) and cardiac

complications (40%) triples in elderly

Perioperative mortality is 19% in pt. developing deranged KFT

in periop. Period as against 0% in those having normal KFT
Increased risk in pt. having h/o renal impairment

use of diuretic

use of NSAIDS
Hence I/op fluid management and intensive perioperative fluid
management is essential

Ischemia : intermediate risk surgery

5% incidence post thoracotomy

peaks on 2 and 3rd post op day

ACC/AHA guidelines to be followed

Arrhythmias
Right ventricular dysfunction

Age
Renal
dysfunction
cardiovascular

Concomitant medical conditions

Concomitant medical conditions

continues.

Problems in a COPD
patient
Respiratory drive,
CO2 retainers,
Increased role of HPV

Right ventricular dysfunction

Bullae
Flow limitation :
Nocturnal hpoxemia because
stage I :FEV!>50% no
of rapid shallow breathing in
significant
dyspnoea
a REM sleep
,hypoxemia or hypercapnia
Stage III :FEV1 <35% --life
expectancy <3 years post
thoracotomy

Beneficial effects of smoking

cessation and time course
Time Course

Beneficial Effects

1224 hr

Decreased CO and nicotine levels

4872 hr

COHb levels normalized, ciliary

function improves

12 wk

Decreased sputum production

46 wk

PFTs improve

68 wk

Immune function and metabolism

normalizes

812 wk

Decreased overall postoperative

morbidity and mortality

Anesthetic considerations in lung

cancer patients (the 4 Ms )
Mass effects

Obstructive pneumonia,lung abscess, superior

vena cava syndrome, tracheobronchial
distortion , pancoast syndrome, recurrent
laryngeal nerve or phrenic nerve palsy, chest
wall or mediastinal extension

Metabolic
effect

Lambert Eaton syndrome, hypercalcemia,

hyponatremia, cushing syndrome

Metastases

Particularly to brain, bone , liver and adrenal

Medications

Chemotherapy agents , pulmonary toxicity

( bleomycin,mitomycin C), cardiac
toxicity(doxorubicin), renal toxicity ( cisplatin )

Preoperative therapy for

COPD

To discuss post op analgesia

the
the risks
risks and
and
benefits
of
benefits of the
the
various
various forms
forms
of
of postpostthoracotomy
thoracotomy
analgesia
analgesia
should
should be
be
explained
explained to
to
the
the patient
patient

Potential
Potential
contraindicatio
contraindicatio
ns
ns such
such as
as
coagulation
coagulation
problems,
problems,
sepsis,
sepsis, or
or
neurologic
neurologic
disorders
disorders
should
should be
be
determined
determined

American
American
Society
Society of
of
Regional
Regional
Anesthesia
Anesthesia
(ASRA)
(ASRA)

an
interval of
an interval
of 2
2
to
4
hours
to 4 hours
before
before or
or 1
1
hour
after
hour after
catheter
catheter
placement
placement for
for
prophylactic
prophylactic
heparin
heparin
administration.
administration.

an
an interval
interval of
of
12
to
12 to 24
24 hours
hours
before
before and
and 24
24
hours
after
hours after
catheter
catheter
placement
placement is
is
recommended
recommended
for
for LMWH
LMWH

 Staged weaning
Consider extubation if >20% + thoracic epidural
analgesia

Extubation on the basis of

Exercise tolerance,Dlco,V/Q scan, associated diseases

Extubate in the OR
Patient AWaC (alert ,warm and comfortable)

<30%

30-40%

>40%

Think about post thoracotomy

anesthetic management
(based on ppo FEV1%)

Increased risk of hypoxemia

High percentage of ventilation or
perfusion to the operative lung
preoperatively
Poor PaO2 during two-lung ventilation
particularly in the lateral position
intraoperatively

Right sided thoracotomy

Normal preoperative spirometry or

restrictive lung disease

Supine position during OLV

Premedication

avoid inadvertent withdrawal of those drugs that are taken for

concurrent medical conditions

For surgeries like oesophageal reflux surgeries aspiration

prophylaxis are routinely ordered preoperatively

do not routinely order preoperative sedation or analgesia for

pulmonary resection patients

Mild sedation short-acting benzodiazepine is often given

immediately before placement of invasive monitoring lines and
catheters.

an antisialagogue (e.g., glycopyrrolate) is useful to facilitate

fiberoptic bronchoscopy

It is a common practice to use short-term intravenous

antibacterial prophylaxis

Intraoperative monitoring
Oxygenation :
significant desaturation( SpO2<90%) occurs in 1-10% of
patients inspite of high FiO2 (1.0).
PaO2 offers a better margin of safety then SpO2
Decreased initial PaO2 and rapid fall in PaO2 after initiation
of OLV is a good indicator of subsequent desaturation.
Useful to measure PaO2 before and 20 minutes after OLV
Capnometry
Less reliable then PaCO2
PaCO2-EtCO2 gradient increased
Other components of minimum mandatory monitoring :
BP,ECG,temperature

Transesophageal
echocardiography
:continuous real time
monitoring ofmyocardial
function and preload
Potential indication:
hemodynamic
instability,pericardial
effusion,cardiac
involvement by tumour,air
emboli,pulmonary
thromboendarterectomy,
thoracic trauma,lung
transplantation.
Difcult in pt. having
esophageal pathology,

Continuous spirometry
monitoring of inspired and
expired volume auto-PEEP
aids in assessing and
managing pulmonary air
leak during pulmonary
resection

Arterial line:Surgical
compression of heart &
great vessels l/t hypotension
CVP : non reliable ,
useful
postoperatively
Pulmonary artery
catheters: less reliable for
OLV

unsurety about the

location of the tip

signficant u/l
differences in lung
perfusion.
complications

Invasive monitoring

Positioning

The majority of thoracic procedures are performed with the

patient in the lateral position

monitors will be placed and anesthesia will usually be induced

with the patient in the supine position
hypotension on turning the patient to or from the lateral position
All lines and monitors will have to be secured during position change and
their function reassessed after repositioning
anesthesiologist should take responsibility for the head, neck, and airway
during position change
Endobronchial tube/blocker position and the adequacy of ventilation must
be rechecked by auscultation and fiberoptic bronchoscopy after patient
repositioning.

Head-to-toe survey for neurovascular

injury after position change
1.
2.
3.
4.

Dependent eye
Dependent ear pinna
Cervical spine in line with thoracic spine
Dependent arm:
a. Brachial plexus
b. Circulation
5. Nondependent arm :

a. Brachial plexus
b. Circulation

Anesthetic management
Fluid Management for Pulmonary Resection Surgery
1. Total positive fluid balance in the first 24-hour
perioperative period should not exceed 20mL/kg.
2. For an average adult patient, crystalloid administration
should be limited to < 3L in the first 24 hours.
3. There should be no fluid administration for third space
fluid losses during pulmonary resection.
4. Urine output > 0.5mL/kg/hr is unnecessary.
5. If increased tissue perfusion is needed postoperatively,
it is preferable to use invasive monitoring and inotropes
rather than to cause fluid overload.

Use of nitrous
oxide
use of N2O/O2 mixtures is associated with a higher incidence of postthoracotomy radiographic atelectasis (51%) in the dependent lung than when
air/oxygen mixtures are used (24%).
also tends to increase pulmonary artery pressures in patients who have
pulmonary hypertension

N2O inhibits HPV

N2O is contraindicated in patients with blebs or bullae

N2O is usually avoided during thoracic anesthesia

Cardiovascular and Respiratory

goals

anesthetic technique should optimize the myocardial

oxygen supply/demand
Thoracic epidural anesthesia/analgesia is recommended
high incidence of coexisting reactive airway disease,
added airway manipulation by the DLT or bronchial
blocker
Thus, need anesthetic technique that decreases bronchial
irritability, causes bronchodilation, and avoids release of
histamine
For intravenous induction of anesthesia either propofol or
ketamine, & for maintenance of anesthesia, propofol
and/or any of the volatile anesthetics are recommended

Choice of Anesthetic

All of the volatile anesthetics inhibit HPV in a dose-dependent

fashion :
halothane > enflurane > isoflurane

In doses less than or equal to 1 MAC, the modern volatile

anesthetics depress HPV minimally

Hence TIVA has no proven benefit against 1 MAC inhalational

anesthesia

Suggested ventilatory parameters for OLV

Parameter

Suggested

Tidal volume

5-6mL/kg

Guidelines/ Exceptions
Maintain:

Peak airway pressure <

35cm H2O

Plateau airway pressure <

25cm H2O

Positive end-expiratory
pressure
Respiratory rate

Mode

5cm H2O

Patients with COPD: no

added PEEP

12 breaths/min

Maintain normal Paco2;

Pa-ETco2 will usually
increase 1-3mmHg
during OLV

Volume or pressure
controlled

Pressure control for

patients at risk of lung
injury (e.g., bullae,
pneumonectomy, post
lung transplantation)

Therapies for Desaturation during One-Lung Ventilation

Severe or precipitous desaturation:

Gradual desaturation:

Resume two-lung ventilation (if possible).

1. Ensure that delivered Fio 2 is 1.0.

2. Check position of double-lumen tube or blocker with fiberoptic bronchoscopy.
3. Ensure that cardiac output is optimal; decrease volatile anesthetics to < 1 MAC.
4. Apply a recruitment maneuver to the ventilated lung (this will transiently make the
hypoxemia worse).
5. Apply PEEP 5cm H2O to the ventilated lung (except in patients with emphysema).
6. Apply CPAP 1-2cm H 2O to the nonventilated lung (apply a recruitment maneuver to this
lung immediately before CPAP).
7. Intermittent reinflation of the nonventilated lung
8. Partial ventilation techniques of the nonventilated lung:
a. Oxygen insufflation

b. High-frequency ventilation

c. Lobar collapse (using a bronchial blocker)

9. Mechanical restriction of the blood flow to the nonventilated lung

Post operative complications

Early major

Respiratory failure
cardiac herniation
torsion of a remaining lobe
after lobectomy
dehiscence of a bronchial
stump
hemorrhage from a major
vessel

Post operative respiratory

failure

leading cause of postoperative morbidity and mortality

Acute respiratory failure after lung resection is defined as:

acute onset of hypoxemia (PaO2 < 60mmHg) or hypercapnia
(PaCO2 > 45mmHg
use of postoperative mechanical ventilation for more than 24
hours
reintubation for controlled ventilation after extubation
incidence of respiratory failure after lung resection is between
2% and 18%

thoracic epidural
analgesia :

To minimise pulmonary complication

postoperatively

prevention of
atelectasis and
secondary
infections
better
preservation of
the functional
residual
volume

efficient
mucociliary
clearance

alleviation of
the inhibiting
reflexes acting
on the
diaphragm

Chest
physiotherapy,
incentive
spirometry, and
early
ambulation are
crucial

provide better
oxygenation, treat
infection, and
provide vital organ
support without
further damaging
the lungs.

Post operative analgesia

Hence there is no one

analgesic technique that
can block all these various
pain afferents, so analgesia
should be multimodal.

The ideal post-thoracotomy

analgesic technique will
include three classes of
drugs: opioids, antiinflammatory agents, and
local anesthetics.

incision (intercostal nerves T4-T6),

chest drains (intercostal nerves T7-T8),
mediastinal pleura (vagus nerve, CN X),
central diaphragmatic pleura (phrenic nerve,
C3-C5),
ipsilateral shoulder (brachial plexus).

multiple sensory afferents :

 Intercostal nerve blocks

Interpleural blocks
Epidural analgesia

Local
Anesthetics/Ner
ve Blocks:

Opioids:effective in controlling background pain

but the acute pain component associated with
cough or movement requires plasma levels that
produce sedation and hypoventilation
NSAIDS :reduce opioid consumption more than
30%.particularly useful treating the ipsilateral
shoulder pain

Systemic
Analgesia:

Ketamine: less respiratory deppression

Dexmedetomidine: described as an useful
adjunct

Post op analgesia continues

Thank you