Question 12 from the first paper of 2000 asks: "Outline your postoperative management plan for a patient  who has just -returned from the operating theatre after undergoing bilateral thoracoscopic lung reduction for emphysema".

This question can be generalised to any patient with a bilateral thoracoscopic lung resection.

(of course, the bilateral open lung resection is an entirely different animal - apparently the approach is usually through a sternotomy, at least in the former Soviet Union).

A great LITFL article on the topic of lung reduction surgery presents up to date information regarding the patient selection process and appropriate work-up.

A generic-looking systematic approach to the post-operative management of the bilateral lung reduction surgery patient can be found in the discussion of Question 12. The core of this brief summary will focus on idiosyncratic features of this procedure, rather than the bog-standard ICU supportive care. Yes, they will get some TEDs and ulcer prophylaxis, but that is not exciting or special. Yes, vigorous physiotherapy and early mobilisation is recommended, but ... when is it not recommended?

Key issues in the care of the patient recovering from lung reduction surgery

Early extubation

  • These people should progress to spontaneous breathing as soon as possible.
  • A major reason why early post-op extubation might be impossible is post-operative hypothermia and shivering: the increased CO2 production may result in a prohibitively high ventilatory demand.

Patient position

  • As close as possible to upright positioning is ideal
  • This is purely to improve lung mechanics

Analgesia

  • A thoracic epidural would be ideal
  • PCA is a poor second

Chest drain management

  • There will inevitably be some pneumothorax post-op, and there will inevitably be chest drains. There will also be an air leak in something like 90% of patients.
  • These should be set to underwater seal only, rather than suction.
  • Suction should be avoided unless the pneumothorax is truly massive.
  • Avoidance of suction promotes decreased rates of bronchopleural fistula.

Neutral fluid balance

  • These people are for a number of reasons at a greater risk of ALI.
  • A recent review of the evidence recommends a perioperative positive fluid balance of no greater than 1.5L

References

This procedure is not frequently seen these days, as it has to some extent been superceded by the endobronchial valve. Why? To quote the NEJM authors, "concern regarding the risk of perioperative death and complications contributes to underutilization".

LITFL have an excellent article on this topic. It also details the stages of the selection process, and the appropriate preoperative investigations; it was written by Dr Jeremy Fernando, who has dual Fellowships in Anaesthetics and ICU, so one gets the impression that he has actually been involved with the patient selection and preoperative work-up of these sorts of patients.

J.Fernando's article from LITFL quotes Sharafkhaneh, Amir, et al. "Overview of the perioperative management of lung volume reduction surgery patients." Proceedings of the American Thoracic Society 5.4 (2008): 438-441.

Another good review article comes 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.

Ots, O. N. "[Bilateral lung resections]." Grudnaia i serdechno-sosudistaia khirurgiia/Ministerstvo zdravookhraneniia SSSR [i] Vsesoiuznoe nauchnoe obshchestvo khirurgov 11 (1991): 35-38.

Cooper, Joel D., et al. "Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema." The Journal of thoracic and cardiovascular surgery 112.5 (1996): 1319-1330.

Sciurba, Frank C., et al. "A randomized study of endobronchial valves for advanced emphysema." New England Journal of Medicine 363.13 (2010): 1233-1244.

Evans, Robert G., and Babu Naidu. "Does a conservative fluid management strategy in the perioperative management of lung resection patients reduce the risk of acute lung injury?." Interactive cardiovascular and thoracic surgery(2012): ivs175.