• Pneumonectomy describes the complete removal of the lung and can be performed for ipsilateral lymph node metastasis or when a lobectomy and its modifications are not sufficient to remove diseased tissue.
• for open procedures (thoracotomy), exposure and dissection involves either rib spreading or removal of a portion of the rib. The pulmonary artery and veins are identified and stapled first, followed by the main bronchus; removal of the lung from the chest cavity occurs subsequently. An extrapleural pneumonectomy requires a more extensive resection of lymph nodes, pericardium, diaphragm, parietal pleura, and the chest wall.
• The procedure may also be performed thoracoscopically (VATS). The smaller incision and reduced surgical stress (inflammatory mediators) may decrease postoperative pain and pulmonary dysfunction.

• Lateral decubitus with the operative side up.
• A bean bag and axillary roll are often utilized.

• Posterior-lateral incision usually at the fifth or sixth intercostal space.
• Median sternotomy approach has been described but is rarely performed today.

~2–3 hours

<500 mL; re-do or extrapleural pneumonectomies can be significantly higher

An average of 5–12 days

Arm boards and arm rest for lateral positioning

Incidence

Most commonly performed for lung carcinoma

Prevalence

The prevalence of lung cancer is second to that of prostate cancer in men and breast cancer in women.

• Postoperative pulmonary complications range from 11 to 49% (1) [B].
• Right pneumonectomy is associated with cardiac herniation.
• Age > 65 years, right-sided procedures, and dysrhythmias were associated with an increased risk of a major complication (p < 0.05) (2) [B].
• Dysrhythmias increased the median length of stay from 8 to 11 days (p < 0.05). Age > 65 years, intrapericardial or extrapleural pneumonectomy, right-sided procedure, and any major complication are factors associated with an increased risk of dysrhythmias (p < 0.05) (2) [B].
• Others: Pulmonary embolism, myocardial infarction (MI), bronchopleural fistulas, chylothorax, subcutaneous emphysema, phrenic and recurrent laryngeal nerve injury.

• Overall 30-day mortality ranges from 5–13% (5) [B].
• Increased with low predicted postoperative FEV₁ (ppo-FEV₁), high perfusion fraction of the resected lung (3) [B], and postoperative acute lung injury (30–50%) (4) [B].

History

• Extensive evaluation of pulmonary disease and cardiac status; exercise tolerance, cigarette smoking
• Myasthenic syndrome (Eaton–Lambert)

Signs/Physical Exam

• Cyanosis, clubbing
• Auscultation: Crackles, wheezes, distant sounds.
• Pulmonary hypertension: Split or increased second sound
• Heart failure: Peripheral edema, jugular venous distention, hepatomegaly

Labs/Studies

• EKG
  • COPD: Right atrial and ventricular hypertrophy, low voltage QRS, and poor R wave progression across the precordial leads
  • Cor pulmonale: Enlarged P waves in lead II.
• Arterial blood gas: Baseline hypoxia or CO₂ retention
• Imaging: Chest x-ray (CXR), CT scan, MRI to identify airway anatomy, masses, obstruction to flow and narrowing of airway, lung lesions/disease, lung hyperinflation, effusions, abscesses and hematomas
• Pulmonary function tests: Performed to establish a baseline, to determine the ability to tolerate lung resection, and to risk stratify.
• Split-lung function tests: Predicts the function of the lung tissue that will remain after resection

• Minimize use of benzodiazepines and narcotics (may worsen hypercarbia). Benzodiazepines may contribute to postoperative delirium, especially in elderly patients.
• Nebulizers: Beta agonists and anticholinergics.

• Possibility of prolonged postoperative intubation and mechanical ventilation
• Blood and blood product transfusion
• Invasive monitoring: Central line, arterial line, transesophageal echocardiography (TEE)
• Regional anesthesia: Epidural, paravertebral blocks(6) [B]

Third generation cephalosporin for skin organisms

General anesthesia with thoracic epidural placement or ipsilateral paravertebral blocks with catheter placement for continuous infusion (6,7) [B]

• Standard ASA monitors
• Arterial line
• Central line for CVP tracing and SvO₂ monitoring
• TEE

• Induction agent (often based on cardiac status) along with IV lidocaine, narcotics, and muscle relaxation are most commonly used. Introduction of volatile agent during bag mask ventilation will bronchodilate prior to laryngoscopy and intubation.
• Double lumen tube (DLT), bronchial blocker, or main-stemmed single lumen tube. A fiberoptic scope is used to confirm proper placement.

• Ventilation
  • During OLV, implement an FiO₂ of 1.0, low tidal volumes 5–6 mL/kg, and limit peak and plateau pressures to <35 and 25 cm H₂O, respectively (8) [A].
  • In the event of hypoxia, reassess tube position with FOB, if surgically possible proceed with brief manual bilateral lung ventilation, if not possible implement CPAP to the nondependent lung, followed by PEEP to the dependent lung, and consider pulmonary artery clamping.
  • ABGs should be performed intermittently or for intraoperative events to assess PaO₂, PaCO₂
• Fluids: A fluid restrictive technique has been shown to decrease the risk of ALI; however, it must be balanced with preserving renal funciton. It may be necessary to implement inotropes and vasoactive drugs to maintain adequate perfusion pressure and hemodynamic stability. Blood products should be administered in accordance with blood loss.
• Renal: Maintain adequate perfusion pressures and a urine output of 0.5 mL/kg/hr.
• Hemodynamics: Monitor cardiac function through TEE, CVP for right ventricle straining and failure, especially after pulmonary artery occlusion.
• Analgesia: IV narcotics should be limited if a regional epidural catheter has been placed. Medication administration through the epidural catheter is usually initiated toward the end of the procedure once the chance of acute blood loss and unexpected hypotension is low.

• Following repositioning, the heart can herniate into the empty right chest causing severe hemodynamic changes. The patient should be immediately repositioned in the left lateral decubitus and the surgeon should evaluate. A CXR can reveal if there is rapid filling of the empty chest and if drainage is necessary to balance the mediastinum.
• If the patient is left intubated, the DLT needs to be exchanged for a single lumen. Sedation with propofol, dexmedetomidine, midazolam, or fentanyl should be started for transport to the ICU.