61yo male with an umbilical hernia which is increasing in size and with recurrent incarcerations.
- Severe bullous emphysema
- Distant ex-smoker
- Regular review by respiratory physician
- Distant lung reduction surgery.
- Endobronchial valves on right side inserted ~ 10yrs ago. Designed to reduce distal gas trapping.
- Previous spontaneous Pneumothorax
- Home O2 (concentrator)
- 4 x admissions with exacerbations, last in ’20, nil ICU.
- Formal PFTS: FEV1 1.15 (36%), FVC 3.82 (94%), bronchodilator responsive, TLCO 48%
- Desaturated to 74% with ~50m walk. Declined stairs.
- Clinical Frailty Scale 4
- T2DM – OHA, HbA1c 7.2%
- Chronic back pain, opioid tolerant
Issues and discussion
- Should surgery proceed
- Without elective procedure, the patient will likely present for an emergency procedure, perhaps critically unwell, due to an incarceration or strangulation.
- Severe respiratory disease
- BODE index 80% mortality at 52mths.
- GUPTA postop resp failure 5.45% risk
- Short course of high dose steroids indicated preoperatively? With such critical lung disease any gains welcome. See attached article.
- Anaesthetic technique?
- What is the implication of the endobronchial valves if GA with PPV indicated?
- Procedure under combination of regional anaesthesia (rectus sheath blocks) and top up with LA by surgeon ideal.
- Risk of precipitating respiratory failure (or at least respiratory anxiety!) if intercostal muscles inactivated by high SAB.
- Slowly titrated EDB an option.
- Regional/neuraxial ideal for post-op analgesia.
- GA an option – Lung volumes and TLCO reassuring, however risk of bullae rupture.
Plan and Requested Actions:
- Respiratory physician discussion. Update:
- Physician felt that this patient has been stable for several years
- Recent review suggested no targets for optimisation
- Preoperative prednisone won’t cause harm but unlikely improvement due to the bullous nature of this patient’s emphysema.
- Intraoperative implications of the endobronchial valves. Update:
- Spoke to Cardiothoracic team – no local experience.
- Spoke to resp team (who insert and manage these valves) – no implications for PPV.
- If GA required; low pressures, spontaneous ventilation where possible, and cognisant of risk of bullae rupture.
- ICU level 3