Question 12

College Answer

Although  not  stated  in  the  question,  it  was  expected  that  the  plan  would  only  cover  the immediate  postoperative  period. Success  of  the operation  is dependent  on  patient  selection, preparation surgical skill and ICU care.

It should include: 
(a) Airway/Breathing- the patient should be extubated as soon as possible to avoid the risks of barotrauma and nosocomial pneumonia.This is facilitated by a light general anaesthetic and thoracic epidural analgesia.                                    · 
(b) Circulation·arterial line for BP monitoring  and sampling. BP should be maintained with blood  transfusion  and  low  dose  vasoconstrictor.  Excessive  amounts  of  crystalloid  are avoided.  Maintenance fluids (eg. lml/kglhour of 5% D +KCL +MgS04).                                                                                       · 
. (c) Analgesia- thoracic epidural. If ineffective PCA & regular paracetamol. (d) Drains underwater usually no suction. 
{e) Early mobilisation into chair. 
(f)  Antibiotics as per preop sputum culture or 24 hours IV cephalothin.

(g) Bronchodilators as indicated. 
(b) Investigations- CXR to check lung expansion. 
(i)  ABG to check for hypercarbia.

Discussion

This question is really about managing an intubated patient with severe COPD, who happens to have recently had major thoracic surgery.

One can approach this systematically

• Airway
  • extubate onto NIV as soon as permitted by gas exchange and comfort.
  • Ideally, these people should be extubated in the operating theatre immediately following surgery
• Breathing/ventilation
  • monitor ABGs for hypercapnea
  • Aim for SpO2 88-90% if the patient is a CO₂ retainer
  • Avoid narcotics as they depress respiratory drive; use epidural anaesthesia if possible
  • ventilated with an I:E ratio with a long E phase, to permit CO₂ clearance
  • Minimise PEEP and peak airway pressures to avoid barotrauma (lung capacity has been reduced by lung reduction surgery; tidal volumes should be kept low)
  • Observe chest drains for air leak
• Circulation
  • Maintain normovolaemia, but avoid large volumes of fluid, as this may result in pulmonary oedema and force you to ventilate the patient at undesirably high pressures
• Progress to sitting in a chair as soon as practical
• Mobilise early, and encourage vigorous physiotherapy (chest physiotherapy can begin as soon as 1 hour post operatively)
• Adequate analgesia is the key to success

Care for the patient recovering from lung reduction surgery is discussed with more detail in the "Required Reading" section.

This procedure is not frequently seen these days; to learn more about it I recommend a good review article from the ERJ:

Russi, E. W., U. Stammberger, and W. Weder. "Lung volume reduction surgery for emphysema." European Respiratory Journal 10.1 (1997): 208-218.

The anaesthetic perioperative management of these patients is deteailed here:

Hillier, J., and C. Gillbe. "Anaesthesia for lung volume reduction surgery."Anaesthesia 58.12 (2003): 1210-1219.