Lung Volume Reduction Surgery

Reviewed and revised 10 March 2014; Cowritten by Chris Poynter and Jeremy Fernando

OVERVIEW

  • Lung volume reduction surgery is performed on a high risk population with an associated mortality of 5-10%
  • The goal of the operation is to eliminate the most diseased areas of lung to reduce overall lung volume and improve respiratory mechanics
  • Admission to ICU postoperatively is for initial stabilization, close monitoring and respiratory support
  • Success of the operation is dependent on patient selection, preparation, surgical skill and ICU care

Types of operations

  • wedge resection
  • lobectomy
  • pneumonectomy

Usual indications

  • Cancer (20% of bronchogenic carcinomas have resectable disease and even in this group mortality is high; if incidental finding -> do well, symptoms from cancer -> do poorly)
  • Tb
  • COPD (less commonly performed as often do poorly)

HISTORY

From anaesthetist:

  • Indication
  • Pre-op work up – ie. Functional status, relevant tests (e.g. spirometry, DLCO, Echo, ABGs)
  • Comorbidities (e.g. cancer syndromes (e.g. Eaton-Lambert, carcinoid, ACTH secretion), OSA, empyema, esophageal or airway obstruction)
  •  usual meds/allergies
  • Pre-operative discussion with patient and family re:expectations
  • Intraoperative events of note
  • Current status eg. Sedatives on board, ABCs etc., fluid status
  • Analgesia – local/regional techniques used, systemic analgesics, analgesic plan
  • Any specific instructions? Concerns?

From surgeon:

  • Specifics of operation including complications, drains, bleeding, lung state
  • Specific instructions eg. Antibiotics, drains and suction

EXAMINATION

  • AIRWAY – standard assessment + signs of SVC obstruction (Pembertons sign, face and arm venous congestion, JVP)
  • BREATHING – unilateral chest signs (consolidation, effusion, pneumothorax), RR, position of trachea, sputum quality, SpO2 on RA
  • CIRCULATION – signs of right heart failure (pulmonary hypertension) – elevated JVP, RV thrill, oedema, murmurs signs of left heart failure, murmur (TR ?carcinoid), liver enlargement.
  • Walk patient up 2 flights of stairs if possible (50 stairs)

INVESTIGATIONS

STAGE 1

1. Spirometry

  • Surgery Minimum Preoperative % of predicted FEV1

Pneumonectomy >60%
Lobectomy >40%
Wedge Resection >30%

  • Predicted post-operative PFTs = Preop Value (5 – number of lobes resected)/5
  • Goal = preoperative FEV1 >2L and >60% and postoperative FEV1 > 800mL

2. ABG

  • hypoxia or hypercarbia on RA bad prognostic sign

3. DLCO

  • diffusion capacity of lungs
  • Goal = postoperative DLCO >40% of predicted normal

STAGE 2

4. Xe or Technetium V/Q scan

  • works out regional blood flow to both lungs -> and then we can calculate a more accurate FEV1 and DLCO

STAGE 3

5. CPX Testing

  • VO2 max >20mL/kg/min -> they will usually tolerate lung reduction surgery well

OTHER TESTS

  • FBC – polycythaemia from chronic hypoxia, WCC for infection
  • CXR – sizing of DLT, gross pathology
  • CT – assessment of airway and degree of pathology
  • unilateral pulmonary artery occlusion test; blocking off of one pulmonary artery and pressure measured in PA (if PAP >35mmHg or PaO2 < 45mmHg -> cancel surgery)

MANAGEMENT

PRE-OPERATIVE

  • stop smoking 4 weeks prior
  • preoperative physio and incentive spirometry
  • bronchodilators and anti-cholinergics
  • may need post operative ventilation if:
    1. DLCO <40% predicted normal
    2. estimated postop FEV1 <800mL
    3. estimated post op FVC <15mLkg

INTRA-OPERATIVE

  • ateral position with broken table
  • lung protective ventilation (PAP < 30cmH2O, prolonged expiratory phase = short I:E ratio) – aim for extubation post op as mechanical ventilation -> stress stitches and increases risk of infection
  • art line in dependent arm
  • blood loss 200-800mL
  • CVL generally not used and are unrealiable
  • OLV cares

POST-OPERATIVE

Priorities

  • early extubation and rapid commencement of post operative rehabilitation
  • this can usually be achieved with initial stabilization and monitoring and attention to adequate analgesia and careful fluid balance

Immediate assessment and stabilization

  • As patient returns from theatre, they should be met and immediately assessed for stability
  • Airway – are they extubated? If not, why not?
  • Breathing – O2 requirements, how is their ventilation? SpO2? What are the ventilator settings if intubated? What are the pressures?
  • Circulation – What is the pulse rate and BP? What lines and monitoring do they have?
  • Disability – Are they awake? What sedation have they had?

Monitoring

  • ECG, Arterial BP, CVP, SpO2, Consider PiCCO for fluid balance

Specific therapy and supportive care

  • extubate as soon as possible
  • minimize fluid intake
  • set reasonable targets for pO2 and pCO2 (look at old ABGs)
  • watch for gas trapping and/or tension pneumo esp. with PPV
  • humidified O2
  • early Physio and mobilization
  • watch for blood loss
  • careful fluid balance – ensure perfusion of organs but don’t overhydrate as high risk for pulm. Oedema
  • Analgesia – ensure able to breath, cough and mobilize. Careful balance as respiratory depression with systemic analgesia. Local anaesthetic techniques are useful, ideally thoracic epidural. Ensure pain team involvement and follow-up.
  • Pulmonary rehabilitation – involve physiotherapists and rehab team early
  • perioperative antibiotic prophylaxis as per protocol
  • Drains underwater usually no suction

Seek and treat complications

  • Complicated recovery – with prolonged intubation or post-op repiratory failure/weaning difficulty, may need to discuss with patient, family and surgeon re: treatment goals and limits

References and Links

Journal articles

  • Benzo R. Lung volume reduction surgery: nonpharmacological approach. Curr Opin Anaesthesiol. 2011 Feb;24(1):44-8. PMC3390016.
  • Sharafkhaneh A, Falk JA, Minai OA, Lipson DA. Overview of the perioperative management of lung volume reduction surgery patients. Proc Am Thorac Soc. 2008 May 1;5(4):438-41. PMC2645316.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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