RT Book, Section A1 Nicoara, Alina A1 Mathew, Joseph P. A2 Barbeito, Atilio A2 Shaw, Andrew D. A2 Grichnik, Katherine SR Print(0) ID 56785001 T1 Chapter 15. Lung Volume Reduction Surgery T2 Thoracic Anesthesia YR 2012 FD 2012 PB The McGraw-Hill Companies PP New York, NY SN 978-0-07-162566-1 LK accessanesthesiology.mhmedical.com/content.aspx?aid=56785001 RD 2024/03/29 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.