Pneumonectomy

Reviewed and revised [last-modified]

OVERVIEW

  • Pneumonectomy is the surgical removal of an entire lung, performed via thoracotomy

INDICATIONS

  • usually bronchogenic cancer
  • may be performed for chronic infection such as tuberculosis, bronchiectasis, necrotizing pneumonia or lung abscess

PHYSIOLOGICAL EFFECTS

Respiratory

  • increased negative pleural pressure on the side of the pneumonectomy
  • elevated diaphragm on the side of the pneumonectomy
  • intact lung hyperinflated with decreased compliance
  • decreased diffusion capacity due to reduced alveolar area
  • normal inspired gas distribution (higher at apex) but V-Q distribution more homogeneous
  • increased work of breathing (WOB), O2 consumption (VO2) and ventilatory energy expenditure (due to decreased compliance)
  • increased respiratory rate (RR) and depth of breathing leads to increase lung efficiency
  • normal arterial blood gas (ABG)
  • pneumonectomy space initially filled with air, eventually filled with fluid that leaks from parietal pleura and mediastinum

Cardiovascular

  • pulmonary blood flow to the remaining lung is doubled
  • increased pulmonary artery (PA) and right ventricular (RV) pressures temporarily to compensate for increased blood flow through one remaining lung and reduced gas exchange; however little change in PA pressure in the long term

RADIOLOGY

Radiographic appearance evolves over time

  •  immediately after pneumonectomy:
    •  midline position of the mediastinum and gas in the pneumonectomy space
  • first few days:
    • ipsilateral hemidiaphragm elevates
    • fluid begins to accumulate within the pneumonectomy space as the gas is resorbed
  • first week:
    • 50-70% of the time the hemithorax fills within the first week, sometimes takes weeks-months
    • mediastinum shifts toward the operative side as the remaining lung hyperinflates and herniates across the midline, anterior to the heart
    • the degree of mediastinal displacement depends on the compliance and degree of hyperinflation of the remaining lung
    • Appropriate mediastinal displacement is the most reliable indicator of a normal course after pneumonectomy. Failure of the mediastinum to shift to the operative side indicates an abnormality in the pneumonectomy cavity such as bronchopleural fistula, hemothorax, or empyema.

COMPLICATIONS

Early

  • bleeding
    • may not be initially obvious as ICC is clamped; look for hypotension, increased HR, decreased CVP and mediastinal shift
    • if suspected can release clamp to confirm bleeding
    • can be fatal as unable to tamponade effectively without operative intervention
  • mediastinal shift
    • some is expected
    •  excessive shift away from good lung, e.g. inappropriate use of UWSD, then hemodynamic compromise from kinking of great vessels may occur: need to clamp ICC +/- reintroduce air
  • post-pneumonectomy pulmonary oedema (non-cardiogenic) (4-15%)
    • remaining lung has double usual pulmonary blood flow
    • occurs 12-96h post-operatively
    • worse with fluid overload
    • diagnosis of exclusion
  • arrhythmias (5-40%)
    • atrial fibrillation is common
    • usually day 2-3 (<5 days)
  • respiratory compromise
    • due to decreased lung volume, poor pain control, sputum retention, fluid overload, new pathology (e.g. pneumonia)
  • bronchopleural stump rupture
    • rare — more likely with right pneumonectomy (left-sided stump tends to retract into mediastinum behind aortic arch)
    • causes massive air leak into pneumonectomy space +/- subcutaneous emphysema due bronchopleural fistula
    • respiratory compromise due to mediastinal shift towards good lung, resorption of fluid in pneumonectomy space cause pulmonary oedema and productive cough
    • empyema can also occur due to infective contamination of the pneumonectomy space
  • chylothorax
    • rare
    • difficult to diagnose, as the filling of the pneumonectomy space is expected
    • suspect if the mediastinal shift away from the pneumonectomy side
  • vocal cord dysfunction (recurrent laryngeal nerve injury) with a hoarse voice, poor cough, dysphagia, and aspiration
  • Right to left shunt through a patent foramen ovale (PFO) (due to higher RV filling pressures)
  • cardiac herniation (through incised pericardium; rare)

Late

  • Post-pneumonectomy syndrome
    • an excessive shift of contralateral lung and mediastinum into empty pleural space causing airway obstruction due to mainstem bronchus stretch and gas trapping
    • presents after months to years with dyspnoea, stridor, and recurrent pneumonia
    • more common after right pneumonectomy
    • main require treatment with a silicone space-filling prosthesis

Right pneumonectomy carries the highest mortality, and morbidity, especially bronchopleural fistula (BPF)

POST-OPERATIVE CARE

General

  • high Fowler’s position (sitting upright with a 60-to-90-degree flexion at the hips)
  • do not roll onto the side of the intact lung
  • if right pneumonectomy then NGT on free drainage
  • supportive care and monitoring (e.g. analgesia, physiotherapy)

Intercostal catheter (ICC)

  • Reason for use
    • detect bleeding
    • equalize intrathoracic pressure changes: “when the patient is turned from the decubitus to the supine position after the operation, the mediastinum shifts and air in the post-pneumonectomy space becomes compressed, often resulting in immediate subcutaneous emphysema, sometimes massive.” (Weissber, 2002)
  •  Options
    • May not be inserted if deemed unnecessary by cardiothoracic surgeon
    • Drains are double clamped with no suction, alternatively a balanced chest drain system with no suction may be used
  •  Every hour unclamp the drain for 2 minutes
    • ensures a haemo/pneumothorax is not accumulating
    • do not leave patient unattended
  • ICC usually removed day 1 post-operatively
  • Do NOT connect to underwater seal drain (UWSD)
    • if connected to UWSD then air will not accumulate in pneumonectomy space causing a mediastinal shift towards that side, resulting in hemodynamic compromise
    • this can be corrected by reintroducing air and clamping the tube

Seek and treat complications


References and Links

Journal articles

  • Cerfolio RJ, Bryant AS. The management of chest tubes after pulmonary resection. Thoracic surgery clinics. 2010; 20(3):399-405. [pubmed]
  • Groth SS, Burt BM, Sugarbaker DJ. Management of Complications After Pneumonectomy. Thoracic surgery clinics. 2015; 25(3):335-48. [pubmed]
  • Morcos K, Shaikhrezai K, Kirk AJ. Is it safe not to drain the pneumonectomy space? Interactive cardiovascular and thoracic surgery. 2014; 18(5):671-5. [pubmed]
  • Slinger P. Update on anesthetic management for pneumonectomy. Current opinion in anaesthesiology. 2009; 22(1):31-7. [pubmed]
  • Weissberg D. Post-pneumonectomy chest tubes. Texas Heart Institute Journal. 2002; 29(2):155. [pubmed]

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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.

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