TY  - CHAP
M1  - Book, Section
TI  - Chapter 15. Lung Volume Reduction Surgery
A1  - Nicoara, Alina
A1  - Mathew, Joseph P.
A2  - Barbeito, Atilio
A2  - Shaw, Andrew D.
A2  - Grichnik, Katherine
PY  - 2012
T2  - Thoracic Anesthesia
AB  - For  the  anesthesiologist,  lung  volume  reduction  surgery  is  a  challenging  procedure  and  the  tailoring  of  the  anesthetic  management  requires  profound  knowledge  of  the  pathophysiology  of  COPD,  ventilatory  mechanics  in  awake  and  anesthetized  COPD  patients  and  pain  management  in  thoracic  surgery.  A  variety  of  different  approaches  to  LVRS  have  been  proposed;  these  include  median  sternotomy,  thoracosternotomy,  standard  thoracotomy  and  video-assisted  thoracosopic  surgery  (VATS)  with  both  unilateral  and  bilateral  approaches.Potential  candidates  for  LVRS  undergo  extensive  evaluation  in  order  to  mitigate  perioperative  risks  and  contain  perioperative  complications.  Important  physiologic  variables  when  evaluating  a  patient  are  FEV1  and  DLCO,  the  RV/TLC  ratio,  PCO2  and  oxygen  use.  The  ideal  operative  candidate  should  have  an  FEV1  of  20%  to  35%  predicted  without  very  severe  reductions  in  DLCO  (<20%  predicted),  a  RV/TLV  more  than  0.67,  a  PCO2  less  than  45  mm  Hg,  and  no  or  low  level  supplemental  oxygen  use.Intraoperative  management  is  centered  on  minimizing  further  insult  due  to  induction  of  general  anesthesia  and  institution  of  positive  pressure  ventilation.  Ventilatory  management  during  one-lung  ventilation  (OLV)  aims  to  balance  competitive  priorities:  maintaining  adequate  oxygenation,  minimizing  intrinsic  PEEP,  minimizing  barotrauma  and  maximizing  CO2  elimination.Intraoperative  hypotension  may  be  due  to  sympathetic  blockade  from  local  anesthetics  administered  through  the  thoracic  epidural  catheter,  vasodilatory  effects  of  the  induction  agents,  hypovolemia,  myocardial  ischemia,  dynamic  hyperinflation  or  infrequent  but  possible  catastrophic  causes  such  as  tension  pneumothorax.Tracheal  extubation  immediately  after  surgery  is  an  important  aim  after  LVRS  in  order  to  minimize  the  risk  of  developing  or  exacerbating  an  air  leak  and  avoid  the  deleterious  hemodynamic  effects  of  positive  pressure  ventilation.  Adequate  pain  control  achieved  with  minimal  respiratory  depression  in  LVRS  patients  is  vital  to  the  success  of  the  surgical  procedure.  Inadequate  pain  control  will  result  in  splinting,  poor  respiratory  effort,  and  inability  to  cough  and  clear  secretions  leading  to  airway  closure,  atelectasis,  shunting  and  hypoxemia.  
SN  - 
PB  - The McGraw-Hill Companies
CY  - New York, NY
Y2  - 2024/04/24
UR  - accessanesthesiology.mhmedical.com/content.aspx?aid=56785001
ER  -