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LETTER TO EDITOR
Year : 2015  |  Volume : 9  |  Issue : 4  |  Page : 493-495

Anesthetic consideration in a patient with giant bilateral lung bullae with severe respiratory compromise


Department of Anaesthesia, Pain and Critical Care Medicine, Citizens Hospital, Hyderabad, Telangana, India

Correspondence Address:
Abhijit S Nair
Department of Anesthesia, Pain and Critical Care Medicine, Citizens Hospital, Serilingampally, Hyderabad - 500 019, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.165128

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Date of Web Publication16-Sep-2015
 


How to cite this article:
Sahoo RK, Nair AS, Kulkarni V, Mudunuri R. Anesthetic consideration in a patient with giant bilateral lung bullae with severe respiratory compromise . Saudi J Anaesth 2015;9:493-5

How to cite this URL:
Sahoo RK, Nair AS, Kulkarni V, Mudunuri R. Anesthetic consideration in a patient with giant bilateral lung bullae with severe respiratory compromise . Saudi J Anaesth [serial online] 2015 [cited 2020 Apr 7];9:493-5. Available from: http://www.saudija.org/text.asp?2015/9/4/493/165128

Sir,

A 48-year-old male patient with a 100 pack year smoking history presented with grade 4 dyspnea on Medical Research Council breathlessness scale. [1] On examination, he had absent air entry on the right and left apical area of the chest. Rest of the systems including airway were normal. Chest roentgenogram [Figure 1] and [Figure 2] revealed hyper inflated lungs with multiple large bullae compressing most of the right lung and upper half of the left lung.
Figure 1: Preoperative chest X-ray showing bullae in right upper and lower lobe and giant bullae in left upper lobe

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Figure 2: Chest roentgenogram demonstrating extent of bullous disease

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Computed tomogram of the chest confirmed these findings [Figure 3]. Pulmonary function tests revealed severe restrictive disease with insignificant bronchodilator response. On room air, the partial pressure of oxygen (PaO2) was 50 mm Hg with PaCO 2 of 72 mm hg and SpO 2 of 83%. Transthoracic echocardiogram was normal with no pulmonary hypertension.
Figure 3: Computed tomogram scan demonstrating extent of bullous emphysema

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Median sternotomy was planned due to bilateral disease. Lead II, V5, pulse oximeter, arterial line, central venous pressure via right internal jugular vein was monitored. Thoracic epidural was inserted at T6-7 level. After premedication with 2 mg midazolam and 200 μg fentanyl, anesthesia was induced with 100 mg propofol and 100 mg succinylcholine. Forceful ventilation was avoided till trachea was intubated with 39 Fr.

Mallinckrodt left sided double lumen tube (DLT) and the position was confirmed using fibreoptic bronchoscope. Ventilation was started with low tidal volume keeping peak airway pressure below 15 cm H 2 O. Peak inspiratory pressure (PIP) was titrated to target EtCO 2 of 60 mm Hg and fractional O 2 concentration (FiO 2 ) titrated to maintain SpO 2 of 95-97% with zero positive end-expiratory pressure. Balanced anesthesia was maintained over next 3 h with O 2 , sevoflurane, dexmedetomidine, and atracurium infusion.

By median sternotomy, right sided bullectomy was done first followed by the left [Figure 4].
Figure 4: Intra-operative picture demonstrating bullous disease

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Bilateral chest tubes were inserted and sternal wiring done. Patient received 1.5 L of crystalloid intraoperatively. In surgical Intensive Care Unit, the patient was on pressure support ventilation after changing DLT to 8.0 mm endotracheal tube.

Immediate postoperative chest X-ray showed nicely inflated both lungs with no other abnormality [Figure 5]. The patient was extubated the next day. Bilateral chest drains were taken out in a gradual manner as air leak sealed and the patient was discharged on the 21 st postoperative day. His FEV1 improved to 42% of predicted with PaO 2 65 mm Hg and PaCO 2 47 mmHg on room air. His dyspnea score improved to grade 2.
Figure 5: Postoperative roentgenogram demonstrating expansion of lung

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Bullectomy helps in recruiting alveoli compressed by bullae, improves ventilation-perfusion matching, improved airflow, more efficient chest wall, and diaphragm mechanics. [2]

Rupture of giant bullae during anesthesia induction and positive pressure ventilation can lead to potential life-threatening situations such as pneumothorax, pneumopericardium, hypoxemia, and death in spite of cardiopulmonary bypass. [3] The best ventilation practice in bullectomy includes use of air: Oxygen mixture, avoid nitrous oxide, PIP <20 cm H 2 O, tidal volume of 5-6 ml/kg of ideal body weight, permissive hypercapnea, increase expiratory time to prevent air trapping (I:E ratio 1:4-1:5), early extubation. [4] Patients with long-standing bullous disease might have underlying pulmonary hypertension.

Therefore, a screening echocardiogram is mandatory.

Acknowledgement

  1. Dr. Saikrishna Yendamuri, Chief Thoracic Surgeon, Yashoda Superspeciality Hospital, Secunderabad, India.
  2. Dr. S. V. Praveen Kumar, Chief Pulmonologist, Citizens Hospital, Serilingampally, Hyderabad - 500 019, India.


 
  References Top

1.
Stenton C. The MRC breathlessness scale. Occup Med (Lond) 2008;58:226-7.  Back to cited text no. 1
[PUBMED]    
2.
Benumof JL. Sequential one-lung ventilation for bilateral bullectomy. Anesthesiology 1987;67:268-72.  Back to cited text no. 2
[PUBMED]    
3.
Conacher ID. Anesthesia for the surgery of emphysema. Br J Anesth 1997;79:530-8.  Back to cited text no. 3
    
4.
Myles PS, Moloney J. Anesthetic management of a patient with severe bullous lung disease complicated by air leak. Anaesth Intensive Care 1994;22:201-3.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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