Pneumonectomy 

 

 

Considerations

 

  • Determine physiological suitability for procedure by assessing predicted postpneumonectomy pulmonary function:

    • ppoFEV1 > 40%

    • ppoDLCO > 40%

    • VO2 max > 15 mL/kg/min (> 4 METS)

    • Consider V/Q scanning for all pneumonectomies &/or if ppoFEV1 < 40%

  • Assess & optimize cardiorespiratory comorbidities:

    • Coronary artery disease & arrhythmias (atrial fibrillation)

    • Smoking, chronic obstructive lung disease

    • Pulmonary hypertension

    • 4M’s of lung malignancies (mass effects, metastases, medications, metabolic abnormalities)

  • Method of lung isolation as determined by:

    • Type of resection: right vs left, sleeve

    • Patient factors: difficult airway, anatomical distortion

  • Management of hypoxemia during one lung ventilation

  • Perioperative management to avoid acute lung injury:

    • Fluid restriction (< 20cc/kg first 24 hours) 

    • Lung protective ventilation with open lung techniques (tidal volume 4-6cc/kg, peak pressure < 40 cmH2O, plateau pressure < 30 cmH2O, PEEP/FiO2 for oxygen saturation > 90%) 

  • Postoperative pain management strategies: thoracic epidural, paravertebral block

  • Postoperative complications: 

    • Acute lung injury/respiratory failure (aka post-pneumonectomy pulmonary edema) 

    • Cardiac herniation (see below) 

    • Arrhythmias, especially atrial fibrillation

    • Myocardial ischemia

    • Bronchopleural fistula

      • Signs & symptoms: fever, productive cough, hemoptysis, subcutaneous emphysema, & persistent air leak from a chest tube

    • Hemorrhage 

    • Pulmonary embolism 

    • Myocardial infarction 

 

 

Goals 

 

  • Determine suitability for resection with “3-legged stool” approach:

    • ​Respiratory mechanics, gas exchange, cardio-respiratory interaction

  • Preoperative optimization: smoking cessation, pulmonary rehabilitation, treatment of lung infections & bronchospasm

  • Pristine intraoperative management: thoracic epidural, fluid restriction, lung protective ventilation, avoidance of hypothermia

 

 

Conflicts

 

  • Requirement for curative treatment vs predicted inability to tolerate lung resection

  • Lung protective ventilation vs contraindication to hypercarbia (pulmonary hypertension, intracranial hypertension, cardiac ischemia)

  • Fluid restriction vs chronic kidney disease

  • Need for thoracic epidural but requirement for full anticoagulation (mechanical heart valve, severe CHADS2, DVT/PE) 

 

 

Cardiac Herniation

 

  • Emergent OR required

  • Occurs after chest closure due to pressure difference between the two hemithoraces; if a pericardial defect is present, this pressure difference may result in the heart being extruded through the defect 

  • The patient should NOT be placed on the operative side in the dependent position after a pneumonectomy because of the risk of cardiac herniation 

  • Mortality > 50%

  • Pathophysiology: 

    • Right pneumonectomy: impaired venous return (obstructive shock) → tachycardia, ↑ CVP, hypotension, shock, acute SVC syndrome 

    • Left pneumonectomy: myocardial compression → MI, arrhythmias, LVOT obstruction 

  • Differential diagnosis:

    • Massive intrathoracic hemorrhage, pulmonary embolism, mediastinal shift

  • Management principles:

    • Definitive management is operative repair  notify surgeon immediately & prepare OR 

    • 100% O2 

    • Support with vasopressors & inotropes 

    • Check chest tube & ensure not on suction (as this would suck the heart further into the empty hemithorax) 

    • Inject air into chest tube to reduce herniation 

    • Position with the operative side up to minimize cardiac compression