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

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 [Figures 1 and 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

Figure 2.

Chest roentgenogram demonstrating extent of bullous disease

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 PaCO₂ of 72 mm hg and SpO₂ of 83%. Transthoracic echocardiogram was normal with no pulmonary hypertension.

Figure 3.

Computed tomogram scan demonstrating extent of bullous emphysema

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 H₂O. Peak inspiratory pressure (PIP) was titrated to target EtCO₂ of 60 mm Hg and fractional O₂ concentration (FiO₂) titrated to maintain SpO₂ of 95–97% with zero positive end-expiratory pressure. Balanced anesthesia was maintained over next 3 h with O₂, 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

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 PaO₂ 65 mm Hg and PaCO₂ 47 mmHg on room air. His dyspnea score improved to grade 2.

Figure 5.

Postoperative roentgenogram demonstrating expansion of lung

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 H₂O, 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.