Review Article

Page 1 of 11

Anesthetic considerations for lung resection: preoperative

assessment, intraoperative challenges and postoperative
analgesia
Debra Lederman1, Jasmeet Easwar2, Joshua Feldman2, Victoria Shapiro1
1
New York Medical College, Westchester Medical Center, Valhalla, New York, USA; 2Department of Anesthesiology, New York Medical College,
Westchester Medical Center, Valhalla, New York, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Debra Lederman, DO. Assistant Professor, New York Medical College, Westchester Medical Center, 100 Woods Rd., Valhalla,
New York 10595, USA. Email: [email protected].

Abstract: This article is intended to provide a general overview of the anesthetic management for lung
resection surgery including the preoperative evaluation of the patient, factors influencing the intraoperative
anesthetic management and options for postoperative analgesia. Lung cancer is the leading cause of death
among cancer patients in the United States. In patients undergoing lung resection, perioperative pulmonary
complications are the major etiology of morbidity and mortality. Risk stratification of patients should be part
of the preoperative assessment to predict their risk of short-term vs. long-term pulmonary complications.
Improvements in surgical technique and equipment have made video assisted thoracoscopy and robotically
assisted thoracoscopy the procedures of choice for thoracic surgeries. General anesthesia including lung
isolation has become essential for optimizing visualization of the operative lung but may itself contribute to
pulmonary complications. Protective lung ventilation strategies may not prevent acute lung injury from one-
lung ventilation, but it may decrease the amount of overall lung injury by using small tidal volumes, positive
end expiratory pressure, low peak and plateau airway pressures and low inspired oxygen fraction, as well as
by keeping surgical time as short as possible. Because of the high incidence of chronic post-thoracotomy
pain syndrome following thoracic surgery, which can impact a patient’s normal daily activities for months to
years after surgery, postoperative analgesia is a necessary part of the anesthetic plan. Multiple options such
as thoracic epidural analgesia, intravenous narcotics and several nerve blocks can be considered in order to
prevent or attenuate chronic pain syndromes. Enhanced recovery after thoracic surgery is a relatively new
topic with many elements taken from the experience with colorectal surgery. The goal of enhanced recovery
is to improve patient outcome by improving organ function and decreasing postoperative complications, and
therefore decreasing length of hospital stay.

Keywords: Acute lung injury; one-lung ventilation (OLV); chronic obstructive pulmonary disease (COPD); video-
assisted thoracic surgery (VATS); ventilator induced lung injury

Submitted Feb 01, 2019. Accepted for publication Mar 25, 2019.
doi: 10.21037/atm.2019.03.67
View this article at: http://dx.doi.org/10.21037/atm.2019.03.67

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Page 2 of 11 Lederman et al. Anesthesia for lung resection

Introduction permeability, impaired alveolar macrophage function, and

slow mucociliary clearance, leading to an alteration in gas
Lung cancer is the leading cause of death among cancer
exchange. Positioning and mechanical ventilation cause
patients in the United States with surgical resection being
postoperative atelectasis in up to 90% of patients. The
the only potential cure. These patients have an increased
result of this atelectasis is ventilation-perfusion (V/Q)
risk of perioperative pulmonary complications (PPCs) and
mismatch, a decrease in compliance and hypoxemia (10).
long-term respiratory impairment following lung resection.
Since 1933, when Graham and Singer reported the first
successful pneumonectomy for lung cancer, there have been Pre-operative evaluation
attempts to define a comprehensive preoperative assessment
In patients being evaluated for surgical resection of their
that would identify patients at high risk for PPC (1). A
lung cancer, there is a direct correlation between the extent
PPC is defined as any pulmonary complication occurring
of pulmonary resection and the potential perioperative
during the post-operative period and resulting in significant
morbidity and mortality. After pneumonectomy, the
dysfunction (2). After lung cancer surgery, PPC’s develop mortality is up to two times higher than after lobectomy
in 3.9% to 32.5% of patients, even with the improvements and the mortality rate of segmentectomy is lower than that
in anesthetic and surgical management (3,4). PPCs are a after lobectomy (11). Limited pulmonary resection provides
major cause of morbidity, mortality, lengthy hospital stay, the ability to reduce the risk of physiological impairment
and increased medical costs (4). Several examples of PCCs by preserving a greater amount of lung parenchyma.
include postoperative respiratory failure, pneumonia, Identifying an individual’s acceptable risk for postoperative
atelectasis, bronchospasm, and pulmonary edema. complications is an impetus to pursue efforts to define
Independent risk factors for PPC are Anesthesia Physical the best predictive tests necessary in order to minimize
Status Classification of 3 or more, age ≥75 years, smoking surgical risk. Consequently, when considering whether a
history, body mass index ≥30 kg/m2 and chronic obstructive patient should undergo surgical resection of a lung cancer,
pulmonary disease (COPD) (5). Approximately 73% of the short-term risk from cardiopulmonary disease and the
men and 53% of women are diagnosed with both COPD risk of chronic pulmonary impairment must be considered
and lung cancer (6). Patients with COPD, controlled in comparison to the risk of decreased length of survival if
or uncontrolled, are at a substantially increased risk of surgery is not a viable option.
pulmonary complications after surgery. Risks of bronchial The function of the preoperative evaluation is to
inflammation, airway hyperreactivity and bronchospasm identify patients at an increased risk of perioperative
are consequences of airway manipulation in patients with complications and long-term disabling consequences from
COPD. The effects of smoking in the intraoperative surgical resection of lung cancer. Preoperative evaluation
and postoperative periods are caused by nicotine, carbon of pulmonary disease may include: preoperative pulmonary
monoxide, and other elements that induce inflammatory function tests (PFTs), calculation of predicted postoperative
and oxidative stress. The pro-inflammatory effects of (ppo) PFT, measures of gas exchange, and exercise
cigarette smoke increase the risk of cardiac and infectious testing (12). Evaluation of preoperative exercise tolerance
complications (7). can be a strong predictor of outcome, particularly in the
Tobacco smoking is a shared risk factor for both lung geriatric population (13). The actual perioperative risks are
cancer and COPD. In patients with lung cancer caused by affected by patient factors (age, comorbidities), management
cigarette smoking, cardiovascular disease is also common. of complications and surgical procedure [thoracotomy vs.
The prevalence of underlying coronary artery disease in this video-assisted thoracoscopic surgery (VATS)]. VATS is a less
patient population is about 11–17%. Postoperative cardiac invasive surgical technique whereby multiple laparoscopic
complications, including cardiac arrest or pulmonary edema, ports and instruments are introduced into the hemithorax
occur as frequently as 2–3% following lung resection (8,9). instead of making a large incision for surgical access. The
General anesthesia is also considered to be a risk factor preoperative evaluation provides communication between
for postoperative pulmonary complications due to the physicians and patients about the risks and benefits of
numerous effects on the respiratory system. Prolonged treatment options to allow for informed decision-making.
exposure to general anesthetics can cause a reduced Although the Revised Cardiac Risk Index (RCRI) has
production of surfactant, increased alveolar-capillary been recommended as the preferable cardiac risk score for

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Annals of Translational Medicine, Vol 7, No 15 August 2019 Page 3 of 11

non-cardiac surgery by the American Heart Association/ functional or unobstructed lung segments to be removed
American College of Cardiology (14) and European Society and z is the total number of functional segments. The
of Cardiology/European Society of Anesthesiology (15), patient is considered to be at low risk if both the ppoFEV1
this score was recently recalibrated by Brunelli et al. to and ppoDLCO values are greater than 60% (19,23). This
better predict the post-operative cardiac risk of candidates correlates to an expected risk of mortality below 1% for
undergoing lung resection (9). The resulting score, named cardiopulmonary complications and perioperative death
Thoracic RCRI (ThRCRI), is a simplified weighted score, after lung resection, including pneumonectomy. However,
in which four factors are associated with major cardiac if either the ppoFEV1 or the ppoDLCO values are within
morbidity. The four factors are: previous ischemic heart 30–60% of predicted, a low technology exercise test, such
disease: 1.5 points, history of stroke or TIA: 1.5 points, as the stair-climbing or shuttle-walking test should be
serum creatinine level greater than 2 mg/mL: 1 point, and performed to determine surgical risk.
pneumonectomy: 1.5 points. Patients with the highest score If the ppoFEV1 or ppoDLCO is <30% or if the stair-
and therefore the highest risk, experience major cardiac climbing test or shuttle walking test is not satisfactory,
events as frequently as 23% vs. 1.5% in those with the a high technology test [e.g., cardiopulmonary exercise
lowest score. This recalibrated score has been validated test (CPET)] is recommended. CPET evaluates exercise
by several studies to be more accurate than the traditional capacity and maximum oxygen consumption (VO 2max).
RCRI in this population (9,16,17). The American College According to the European Respiratory Society and
of Chest Physicians (ACCP) has since updated their the European Society of Thoracic Surgeons joint task
cardiac algorithm to include these parameters. Patients force, CPET is inversely correlated with post-operative
with ThRCRI ≥2 or a newly diagnosed or existing cardiac morbidity and mortality. VO2max >20 mL/kg/min or >75%
condition requiring medication or limited exercise tolerance predicted indicates a low risk. If VO2max is between 10 and
should have a cardiac consultation including noninvasive 20 mL/kg/min or 35–75%, the patients are at moderate risk.
testing (18). The morbidity and mortality rates vary depending upon the
According to both the ACCP and the British Thoracic extent of resection, exercise tolerance, and values of split
Society (BTS), spirometry testing to measure the forced lung functions Alternatively, VO2max <10 mL/kg/min or
expiratory volume in one second (FEV1) is recommended <35% predicted implies a risk of mortality as high as >10%,
in patients scheduled for pulmonary resection (18,19). In which may cause significant risk of residual functional
patients with a normal FEV1, the diffusing capacity of the loss and severe cardiopulmonary morbidity. At this
lung for carbon monoxide (DLCO) was established for point, patients should be counseled about other available
predicting postoperative complications (20). A reduced options such as minimally invasive surgery or nonsurgical
ppoDLCO correlates most closely with the risk of options (19,23).
pulmonary complications and mortality following lung
resection. In patients with compromised preoperative
Neoadjuvant therapy
respiratory status, (ppoFEV1 between 30–40%) ppoDLCO
is the best predictor of a patient’s candidacy for surgical Patients with locally advanced lung cancer may require
resection (21,22). preoperative chemotherapy prior to surgical resection.
For patients requiring pneumonectomy, ventilation/ Evidence suggests that chemotherapy can be associated with
perfusion scan (V/Q scan) method was suggested to a 10% to 20% reduction in DLCO regardless of apparent
calculate the ppo values of FEV1 or DLCO: improvement in spirometry values (24). Drug-induced
ppo values = Preoperative values × (1 − Fraction of total structural lung damage has been linked to an increase in
perfusion for the resected lung) PPCs. Therefore, it is suggested to repeat PFTs with DLCO
where the preoperative values are taken as the best testing after completion of neoadjuvant therapy to reassess
measured post-bronchodilator values. For patients requiring the operative risk after potentially damaging lung tissue (25).
lobectomy, ppo values of FEV1 or DLCO was calculated by
segmental counting:
Intraoperative anesthetic management for lung
ppo values = Preoperative values × (1 – y/z)
resection
where the preoperative values are taken as the best
measured post-bronchodilator value, y is the number of The anesthesiologist’s goal in addition to providing

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Page 4 of 11 Lederman et al. Anesthesia for lung resection

analgesia, loss of consciousness, stable hemodynamics, with high tidal volumes, excessive fluids, or hypoxia.
and when indicated, single lung ventilation should strive The process is more complex, with mechanisms for ALI
to minimize ventilator-associated lung injury (ALI) differing for the dependent and operative lungs in OLV, and
in surgical patients undergoing total or partial lung requires additional research to identify etiologies leading
resection. As thoracic surgical procedures have become to this major cause of morbidity in up to 15% of patients,
more minimally invasive, video-assisted laparoscopic and determined by the extent of their lung resection surgery.
robotic-assisted procedures have become the preferred Other stresses on the lungs during and immediately after
methods of thoracic surgery, necessitating more frequent OLV include oxidative stress, ischemia-reperfusion injury,
use of one-lung ventilation (OLV). The rapid advances in as well as capillary shear stress secondary to hyperperfusion,
VATS and robotics has increased the incidence of ALI that can be seen in both the dependent and operative lung and
accompanies OLV, the primary cause of mortality following may be unavoidable (30).
lung resection. Until the last decade, open thoracotomy for Although far more evidence exists regarding lung
intrathoracic surgery allowed the surgeon to visualize the protective strategies in two-lung ventilation (TLV),
surgical field, manipulate the lung, and control movement particularly in critical care literature of acute respiratory
within the surgical field, with or without intermittent distress syndrome (ARDS) patients, many studies are
ventilation. Insufflation of the hemithorax was not a concern emerging with specific strategies for OLV (31). Much of
and OLV had fewer absolute indications. The purpose of the evidence surrounding lung injury is extrapolated from
OLV is to collapse and isolate the operative lung in order landmark trials in the ARDS Network (30). This evidence
to provide the surgeon with optimal surgical exposure. One includes lung protective parameters that have largely
of the effects of OLV is a significant shunt which can affect become the standard of care among anesthesiologists, in
gas exchange. In the lateral decubitus position required OLV and TLV, such as low tidal volume ventilation based
for thoracic surgery, gravity primarily causes perfusion to on ideal body weight (4–5 mL/kg) and relatively high
go to the dependent lung. Ventilation will initially go to PEEP to maintain oxygenation. Blank et al. suggested that
the operative lung with the patient in this position due to large tidal volume (VT), high peak inspiratory pressures
decreased compliance in the dependent lung. Commencing and low or no PEEP during OLV are associated with
with OLV by collapsing the operative lung favorably increased post-operative pulmonary complications and a
influences this shunt through a process called hypoxic higher mortality (30,31). This study suggested that there is
pulmonary vasoconstriction (HPV). HPV will cause a time- a reduction in pulmonary and systemic inflammation, lung
dependent decrease in blood flow to the poorly ventilated edema, pulmonary complications, and hospital stay when
lung (the operative lung) and therefore will improve the utilizing protective OLV (reduced VT and moderate PEEP),
(V/Q) mismatch. The alveolar partial pressure of oxygen while others further expanded on this protective strategy,
prompts this physiologic response (26). incorporating limiting ventilator pressures and recruitment
Historically, anesthesiologists sought to prevent hypoxia maneuvers during OLV (32,33). These studies do not
and ensure adequate gas exchange by using high tidal elucidate which ventilatory parameter, low VT, moderate
volumes, zero positive end expiratory pressure (PEEP), PEEP, lower airway pressure, or recruitment maneuvers, if
and high inspired oxygen fractions (FIO2). Unfortunately, any, is more likely to predict an improved outcome (32). In
these practices have been implicated as contributing to contrast, a recent prospective observational study by Amar
barotrauma (high pressures on the lung), volutrauma et al. found no difference, for example, in the incidence of
(overdistention of the lung), atelectotrauma (repetitive pneumonia and/or ARDS between patients undergoing
opening and closing of alveoli), and biotrauma (local lung resection with tidal volumes <8 or ≥8 mL/kg (predicted
inflammatory mediators) (27). Independent risk factors body weight), implying that the clinical impact of protective
including high intraoperative ventilatory pressure (high lung strategies is small (27). Until there is a consensus, our
peak and plateau airway pressures), high intraoperative tidal practice is to use VT 5–7 mL/kg, PEEP 5–7 cmH2O, and
volumes (with low or no PEEP), excessive fluid infusion ventilatory plateau pressures below 30 cmH2O whenever
with pneumonectomy, and preoperative alcohol abuse have possible. We use recruitment maneuvers as needed.
also been implicated in contributing to acute lung injury Minimizing surgical time and OLV time are also important
(28,29). factors in our goal to decrease the incidence of PPC.
The mechanisms of injury behind ALI do not end The anesthetic management for lung resection surgery

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Annals of Translational Medicine, Vol 7, No 15 August 2019 Page 5 of 11

must incorporate several factors: the nature of the planned the degree of impairment of the surgeon’s visualization of
thoracic procedure, the percentage loss of functional lung the field. Alternative options include increasing the inspired
parenchyma and the physiologic and hemodynamic effects fraction of oxygen, checking and repositioning the DLT
of mechanical ventilation, particularly with respect to or endobronchial blocker, and decreasing the inhalational
OLV. OLV poses many challenges, for example, atelectasis, agent or starting vasopressors or inotropes to improve
V/Q mismatch, barotrauma and alveolar injury. Atelectasis cardiac output. In addition, recruitment of the atelectatic
is a significant consequence during all anesthetics and in zones of the dependent lung can be attempted (36)
mechanically ventilated patients, but during OLV its effects with PEEP being added to the dependent lung (38) and/
may be compounded due to the use of higher inspiratory or continuous positive airway pressure (CPAP) 1–2 cm
oxygen fraction (absorption atelectasis) and the greater H 2O being applied to the operative lung (39). While a
potential for dependent lung compression (compression high inspired oxygen concentration is often required to
atelectasis) (32,34). The presence of atelectasis has the alleviate intraoperative hypoxemia, this is not without risk,
potential to cause inflammation and alveolar injury in since oxidative stress caused by a high FIO2 for an extended
adjacent healthy lung parenchyma and can promote bacterial period of time, has been implicated in ALI (31).
translocation, increasing the risk for pneumonia (35). The inhaled volatile agents, commonly used as the
Atelectasis can be attenuated by the presence of PEEP mainstay of an anesthetic, when employed at greater than
to promote lung protection and function and to decrease one minimum alveolar concentration (MAC) will interfere
morbidity. It appears that the specific pairing of low VT and with HPV, a pulmonary compensatory mechanism relied
moderate to high PEEP, has shown benefit in preventing on to reduce the V/Q mismatch caused by OLV (31,36).
pathophysiologic sequelae of atelectasis, overdistension, and Sevoflurane potentially reduces ALI by inhibiting the
tidal recruitment/decruitment (32). release of proinflammatory mediators during OLV and lung
When employing OLV during intrathoracic surgery, the resection and increases bronchodilation (40). de la Gala
anesthesiologist is at times faced with hypoxemia. Given et al. demonstrated a lower one year mortality and PPC using
the unavoidable Alveolar-arterial (A-a) gradient and V-Q Sevoflurane vs. a total intravenous anesthetic (TIVA) (41).
mismatch created by OLV, it is essential that in patients with Another study by Wigmore et al. showed that a propofol-
poor cardiopulmonary reserve, the preoperative hemoglobin based TIVA technique for general anesthesia may provide
and oxygenation be optimized prior to surgery (36). anti-inflammatory and anti-oxidant properties and may
In our practice, preoperative oxygenation is evaluated on preserve natural killer cell function (42). Currently, there is
room air whenever possible, to determine baseline oxygen no sufficient evidence to support one anesthetic technique
saturation and PaO2. Patients undergoing lung resection as being definitively advantageous over the other.
may have significant pulmonary disease manifested by Narcotics can be used an important adjuvant anesthetic
a decreased functional residual capacity, impaired gas in anesthetizing patients with compromised cardiac function
exchange, and V/Q mismatch. Smoking cessation for by decreasing the agents administered that are myocardial
4–6 weeks, the use of an incentive spirometer and treatment depressants, particularly the volatile anesthetic agents.
of any underlying pulmonary disease, such as asthma or When using a short-acting narcotic, such as remifentanil, a
COPD, using steroids and Beta 2 agonists is recommended more rapid emergence is facilitated. This can be invaluable
to improve lung function prior to surgery (37). Anemia when anesthetizing patients with cardiomyopathies, left
can negatively impact demand ischemia, which may not be ventricular hypertrophy, and valvular disease, in particular
tolerated well by patients at risk for myocardial ischemia. aortic stenosis. Pulmonary hypertension poses a dilemma
A preoperative hemoglobin is determined for our patients and requires different anesthetic management when it
and blood is readily available in the event of unanticipated involves right (pulmonary) vs. left heart disease. Ketamine
blood loss or inadequate perfusion as determined by a rising can be useful in patients with right ventricular dysfunction
lactate on arterial blood gas, a compensatory tachycardia and pulmonary hypertension secondary to COPD. It is
or hypotension. We rarely transfuse preoperatively unless a known for its sympathomimetic effects and will maintain
patient is actively bleeding. or increase contractility while avoiding a decrease in
It may be necessary intraoperatively to intermittently systemic vascular resistance (SVR) associated with inhaled
reinstitute TLV to improve the oxygen saturation. Using anesthetics. Its effect on pulmonary vascular resistance
TLV during a procedure is limited by the procedure and (PVR) is controversial, although some studies have

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Page 6 of 11 Lederman et al. Anesthesia for lung resection

documented a decrease in PVR (43-45). Achieving lung isolation

In patients with severe pulmonary hypertension,
For procedures in the thoracic cavity, the use of lung
inhaled pulmonary vasodilators including nitric oxide
isolation techniques facilitates a collapsed lung for maximal
(10–40 ppm) or nebulized prostaglandins (prostacyclin,
surgical exposure and a motionless surgical field. Options
50 ng/kg/min) should be considered along with a
to achieve this goal are the double lumen tube (DLT) (we
vasoconstrictor to maintain SVR while improving the
use the Robertshaw DLT), considered the gold standard
pulmonary artery pressure (PAP)/systemic blood pressure
for lung separation, or the Univent tube (Fuji Corp.,
(SBP) ratio (36).
Tokyo, Japan), which is a 9-Fr endobronchial blocker
In addition to standard American Society of
with a steering mechanism. Alternatively, the EZ-Blocker
Anesthesiologists (ASA) non-invasive monitoring (46),
(Teleflex Medical Inc., Research Triangle Park, NC, USA)
an arterial line is often indicated intraoperatively to
can be used, which is a 7-Fr catheter designed with a Y
measure blood pressure as well as for arterial blood gas
shape and two distal extensions that ride over the carina,
determination. It is controversial whether a dynamic
preload indicator such as stroke volume variation (SVV) and each lung can be selectively deflated. Regardless
in conjunction with cardiac index, using a FloTrac System of the system chosen to isolate the lung, a fiberoptic
(Edward Lifescience, Irvine, CA, USA), can predict fluid bronchoscope must be used by the anesthesiologist to
responsiveness in OLV for thoracic surgery. SVV is a ensure proper placement and adequate lung isolation, both
dynamic factor and is based on the arterial waveform in after positioning the device and again after positioning the
relationship to various factors such as positive pressure patient (26,36).
ventilation, OLV, changes in intrathoracic pressure, preload There are advantages and disadvantages to DLT’s vs.
status, arrhythmias, tidal volume, chest wall compliance, the use of an endobronchial blocker. DLT’s provide better
lung manipulation and compliance, and vasopressor isolation of each lung when a lung contaminated with blood
administration. Xu et al. used SVV and cardiac index goal or pus is involved. Pulmonary suctioning is more easily
directed fluid restriction to improve hemodynamics and accomplished since each lung can be suctioned throughout
lung mechanics during OLV. They found it decreased the the procedure, whereas an endobronchial blocker would
incidence of PPC and the length of hospital stay, although need to be deflated in order to suction the operative lung.
it did not decrease the overall incidence of inflammation as Bilateral procedures do not require replacement of or
indicated by measuring serum cytokines (47). Jeong et al.’s repositioning of the DLT. Disadvantages of the DLT to
study found that SVV did not predict fluid responsiveness consider are: it takes longer and requires more skill to place
in OLV (48). Parenteral fluid administration is usually limited a DLT as opposed to a single lumen endotracheal tube
in lung resection surgery. In our practice, we primarily use (SLT). Often patients coming to the operating room from
crystalloid (Plasmalyte or Normal Saline) for maintenance an intensive care unit (ICU) already have a SLT in place
fluid and have packed red blood cells available in case of through which an endobronchial blocker can be positioned.
significant blood loss to maintain hemodynamics and tissue After using a DLT for a procedure, there may be laryngeal
perfusion. Pulmonary edema, particularly in pneumonectomy, edema and replacement of the DLT with a SLT can be
is not uncommon after excessive fluid administration. The challenging. There is also a higher incidence of airway
exact etiology has not been determined (31). injury using a DLT including hoarseness, vocal cord injury,
Infrequently, other invasive lines may be necessary. A esophageal injury and tracheal or mainstem bronchial injury
central line may be considered for vasoactive drugs and (36,50).
central venous pressure or a pulmonary artery catheter
for pulmonary artery pressures, cardiac output and for
Post-operative management
therapeutic guidance in pulmonary hypertension. However,
these invasive monitors have not been shown to improve The role of well-planned pain management cannot be
outcome (49). The use of intraoperative transesophageal overemphasized after major thoracic surgery for lung
or transthoracic echocardiography may be considered to resection. Post thoracotomy pain is one of the most severe
monitor intraoperative cardiac function, although employing of all surgical procedures, ranking highest on the visual
these point-of-care modalities may prove to be logistically analog pain scale. There are many intraoperative factors
difficult due to positioning and limited access to the patient. which contribute to postoperative pain including surgical

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Annals of Translational Medicine, Vol 7, No 15 August 2019 Page 7 of 11

retraction, resection, dislocation of costovertebral joints, challenge in patients with marginal lung function and must
incidental rib fractures, injury of intercostal nerves, as be carefully titrated. Excessive sedation can also increase
well as pleuritic pain caused by chest tubes. Pain control, the risk of pulmonary complications such as respiratory
however, is of the utmost importance in both open depression, sputum retention and infection (57).
thoracotomy and VATS procedures (although VATS Intercostal nerve blockade (ICNB) is used routinely
are significantly less painful) to prevent postoperative in some centers. The surgeons perform single shot
complications as a consequence of splinting of expiratory injection of two dermatomes above, two below, and one
muscles by patients. Patients experiencing severe pain at the site of the incision before closure. Since a single-
postoperatively will have a poor respiratory effort and shot ICNB is not very effective, some surgeons place
a decreased functional residual capacity. It will also be indwelling catheters in a subpleural/extrapleural pocket.
challenging for the recovering patient to cough and clear Intraoperative cryoneurolysis of the intercostal nerves
secretions. These pulmonary complications result in airway prior to closure of the chest incision is another option.
closure, atelectasis, shunting and tissue hypoxemia (51). Endoneurial and perineural connective tissue are preserved
Therefore, both an acute and chronic pain management using this technique, thereby allowing restoration of nerve
plan is crucial for these high-risk patients in whom pain structure occurs 1–3 months after freezing. Although this
can potentially last for months to years. Even low levels has been shown to be an effective method in decreasing
of pain can affect a patient’s quality of life, especially from the amount of postoperative pain and analgesics
chronic post thoracotomy pain syndrome (CPTPS) (52). prescribed, in the long term, there was a high incidence of
The incidence of long-term post thoracotomy pain has developing neuropathic pain, dysesthesia, and intercostal
been reported to be as high as 80% at 3 months, 75% at 6 muscle paralysis (58,59).
months, and 61% at 1 year after surgery. Severe pain occurs There has been a renewed interest in paravertebral nerve
in 3–5% of patients, and 50% of patients report pain that blocks (PVB) in the last decade as an alternative technique
interferes with their daily routine (53). that may offer comparable analgesic effectiveness with a
There are a number of techniques available to help more desirable side-effect profile. These blocks generally
patients maintain their functional residual capacity by deep last 18–24 h and are considered by some authors nearly
breathing and avoiding development of CPTPS. Continuous equivalent in efficacy to epidural analgesia in the first 24 h
thoracic epidural analgesia (TEA) remains the gold without the detrimental effects of bilateral sympathectomy
standard for post thoracotomy pain control and has been (54,57). It proves most helpful in patients who are not
shown to provide superior analgesia both at rest and during candidates for TEA. The disadvantage of PVB includes a
movement with highest degree of patient satisfaction (54). relatively high failure rate of up to 10%, possibly due to
A thoracic epidural provides excellent continuous analgesia the interference by the endothoracic, fascia which may
while allowing decreased use of parenteral opioids, and hinder diffusion of the local anesthetic (60). It should be
therefore can significantly decrease the incidence of noted that paravertebral catheter placement has the same
pulmonary morbidity (55). In addition, epidural analgesia is contraindications in anticoagulated patients as does an
associated with lower need of rescue analgesia. Limitations epidural. Also, fewer practitioners are trained to perform
of TEA include hypotension, bradycardia, urinary retention, PVB. Those clinicians who are proponents of PVB claim it
incomplete (or failed) block, neurological injury and rarely, is a simple, safe, and easy to learn block with a low incidence
paraplegia due to epidural hematoma. In addition, resulting of complications (61,62).
hypotension with epidural analgesia must be carefully In addition to PVB, some centers have been performing
managed in patients who are at risk for cardiovascular serratus anterior plane blocks (SAPB) as an alternative
complications (55,56). to TEA. The SAPB blocks the lateral branches of the
Opioids are an important component of treatment intercostal nerves. The effectiveness was demonstrated in
regiments and can be administered via various routes. a small randomized control trial which compared serratus
Intravenous patient-controlled analgesia (IV PCA) is anterior block with TEA using mean arterial blood pressure
the simplest and one of the most common methods for after SAPB and TEA, as well as determination of level
postoperative pain management (54). IV PCA is ideal of pain, narcotic use and nausea and vomiting in the first
in achieving a balance between comfort and respiratory 24 hours post-operatively. In addition, the SAPB avoids the
depression. Parenteral narcotics, however, present a autonomic complications of TEA (63).

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Page 8 of 11 Lederman et al. Anesthesia for lung resection

Enhanced recovery after thoracic surgery (ERATS) Footnote

ERATS aims to decrease postoperative complications and Conflicts of Interest: The authors have no conflicts of interest
hospital stay while improving organ function, using evidence- to declare.
based perioperative recommendations for preadmission,
admission, intraoperative and postoperative care of
References
the patient, to achieve better patient outcomes. These
recommendations are endorsed by the Enhanced Recovery 1. Graham EA, Singer JJ. Successful removal of an entire lung
after Surgery Society and the European Society for Thoracic or carcinoma of the bronchus. JAMA 1933;101:1371-4.
Surgery. They include, but are not limited to, preoperative 2. Sharafkhaneh A, Falk JA, Minai OA, et al. Overview of
counseling, nutritional screening, smoking cessation, the perioperative management of lung volume reduction
avoidance of fasting, use of preoperative carbohydrate drinks, surgery patients. Proc Am Thorac Soc 2008;5:438-41.
avoidance of preoperative sedatives, venous thromboembolism 3. Reeve JC, Nicol K, Stiller K, et al. Does physiotherapy
prophylaxis, prevention of hypothermia, use of short-acting reduce the incidence of postoperative pulmonary
anesthetics, use of regional anesthesia, minimally-invasive complications following pulmonary resection via open
procedures, and early postoperative mobilization. Many of thoracotomy? A preliminary randomized single-bling
these recommendations are based on enhanced recovery after clinical trial. Eur J Cardiothorac Surg 2010;37:1158-66.
surgery (ERAS) from established colorectal surgery guidelines, 4. Rodriguez-Larrad A, Vellosillo-Ortega JM, Ruiz-Muneta
but it is quickly becoming evident that incorporating these C, et al. Postoperative Respiratory Exercises Reduce
elements into the care of thoracic patients, improves patient the Risk of Developing Pulmonary Complications in
satisfaction and outcome (64). Patients Undergoing Lobectomy. Arch Bronconeumol
2016;52:347-53.
5. Agostini P, Cieslik H, Rathinam S, et al. Postoperative
Conclusions
pulmonary complications following thoracic surgery: are
Lung resection surgery is very complicated and requires there any modifiable risk factors? Thorax 2010;65:815-8.
a team effort including the surgeon, the anesthesiologist, 6. Loganathan RS, Stover DE, Shi W, et al. Prevalence of
the pulmonologist and other specialists, to choose the best COPD in women compared to men around the time of
therapy given an individual’s presentation, comorbidities diagnosis of primary lung cancer. Chest 2006;129:1305-12.
and risk stratification. The patient’s preoperative assessment 7. Licker M, Schweizer A, Ellenberger C, et al. Perioperative
must include PFTs, a complete physical exam and an medical management of patients with COPD. Int J Chron
evaluation of independent indicators such as exercise Obstruct Pulmon Dis 2007;2:493-515.
tolerance, comorbidities, smoking and alcohol use. The 8. Brunelli A, Cassivi SD, Fibla J, et al. External validation
extent and type of surgery must be taken into account to be of the recalibrated thoracic revised cardiac risk index for
able to stratify the patient’s perioperative risk vs. the long- predicting the risk of major cardiac complications after
term pulmonary risk. Pain management is also a pertinent lung resection. Ann Thorac Surg 2011;92:445-8.
factor in determining a patient’s postoperative comfort, 9. Brunelli A, Varela G, Salati M, et al. Recalibration of the
morbidity, and ultimately, quality of life. Chronic pain revised cardiac risk index in lung resection candidates. Ann
syndromes can negatively affect a patient’s daily activities Thorac Surg. 2010;90:199-203.
but may be preventable with adequate, early pain control 10. Degani-Costa LH, Maresin SM, dos Reis Falcao LF.
using a variety of techniques. Preoperative evaluation, Preoperative evaluation of the patient with pulmonary
intraoperative anesthetic management, postoperative disease. Braz J Anesthesiol 2014;64:22-34.
analgesia and incorporating ERATS into the plan for lung 11. Damhuis RA, Schutte PR. Resection rates and
resection are crucial elements to consider in ensuring the postoperative mortality in 7,899 patients with lung cancer.
best care and outcome for the patient. Eur Respir J 1996;9:7-10.
12. Stanzani F, Paisani Dde M, Oliveira A, et al. Morbidity,
mortality, and categorization of the risk of perioperative
Acknowledgments
complications in lung cancer patients. J Bras Pneumol
None. 2014;40:21-9.

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Annals of Translational Medicine, Vol 7, No 15 August 2019 Page 9 of 11

13. Slinger P. editor. Principles and Practice of Anesthesia for 24. Rivera MP, Detterbeck FC, Socinski MA, et al. Impact of
Thoracic Surgery. 1st edition. Springer-Verlag New York, preoperative chemotherapy on pulmonary function tests
2011:11. in resectable early-stage non-small cell lung cancer. Chest
14. Fleisher LA, Beckman JA, Brown KA, et al. ACC/ 2009;135:1588-95.
AHA 2007 guidelines on perioperative cardiovascular 25. Leo F, Solli P, Spaggiarai L, et al. Respiratory function
evaluation and care for noncardiac surgery: a report changes after chemotherapy: an additional risk for
of the American College of Cardiology/American postoperative respiratory complications? Ann Thorac Surg
Heart Association Task Force on Practice Guidelines. 2004;77:260-5.
Circulation 2007;116:e418-99. 26. Brassard CL, Lohser J, Donati F, et al. Step-by-
15. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for step clinical management of one-lung ventilation:
preoperative cardiac risk assessment and perioperative continuing professional development. Can J Anaesth
cardiac management in non-cardiac surgery: The Task 2014;61:1103-21.
force for Preoperative Cardiac Risk Assessment and 27. Amar D, Zhang H, Pedoto A, et al. Protective lung
Perioperative Cardiac Management in Non-cardiac ventilation and morbidity after pulmonary resection:
Surgery of the European Society of Cardiology (ESC) A propensity score-matched analysis. Anesth Analg
and endorsed by the European Society of Anaesthesiology 2017;125:190-9.
(ESA). Eur Heart J 2009;30:2769-812. 28. Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors
16. Ferguson MK, Celauro AD, Vigneswaran WT. Validation for acute lung injury after thoracic surgery for lung cancer.
of a modified scoring system for cardiovascular risk Anesth Analg 2003;97:1558-65.
associated with major lung resection. Eur J Cardiothorac 29. Yang M, Ahn HJ, Kim K, et al. Does a protective
Surg 2012;41:598-602. ventilation strategy reduce the risk of pulmonary
17. Ferguson MK, Saha-Chaudhuri P, Mitchell JD, et al. complications after lung cancer surgery? A randomized
Prediction of major cardiovascular events after lung controlled trial. Chest 2011;139:530-7.
resection using a modified scoring system. Ann Thorac 30. Lohser J, Slinger P. Lung Injury After One-Lung
Surg 2014;97:1135-40. Ventilation: A Review of the Pathophysiologic Mechanisms
18. Brunelli A, Kim AW, Berger KI, et al. Physiologic Affecting the Ventilated and the Collapsed Lung. Anesth
evaluation of the patient with lung cancer being considered Analg 2015;121:302-18.
for resectional surgery: Diagnosis and management of 31. Acute Respiratory Distress Syndrome Network, Brower
lung cancer, 3rd ed: American College of Chest Physicians RG, Matthay MA, et al. Ventilation with lower tidal
evidence-based clinical practice guidelines. Chest volumes as compared with traditional tidal volumes
2013;143:e166S. for acute lung injury and the acute respiratory distress
19. British Thoracic Society; Society of Cardiothoracic syndrome. N Engl J Med 2000;342:1301-8.
Surgeons of Great Britain and Ireland Working Party. 32. Blank RS, Colquhoun DA, Durieux ME, et al.
BTS guidelines: guidelines on the selection of patients Management of One-lung Ventilation: Impact of Tidal
with lung cancer for surgery. Thorax 2001;56:89-108. Volume on Complications after Thoracic Surgery.
20. Zhang R, Lee SM, Wigfield C, et al. Lung function Anesthesiology 2016;124:1286-95.
predicts pulmonary complications regardless of surgical 33. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of
approach. Ann Thorac Surg 2015;99:1761. intraoperative low-tidal-volume ventilation in abdominal
21. Ferguson MK, Reeder LB, Mick R. Optimizing selection surgery. N Engl J Med 2013;369:428-37.
of patients for major lung resection. J Thorac Cardiovasc 34. Duggan M, Kavanagh BP. Pulmonary atelectasis:
Surg 1995;109:275-81. A Pathogenic perioperative entity. Anesthesiology
22. Santini M, Fiorello A, Vicidomini G, et al. Role of 2005;102:838-54.
diffusing capacity in predicting complications after 35. Retamal J, Bergamini BC, Carvalho AR et al. Non-
lung resection for cancer. Thorac Cardiovasc Surg Lobar atelectasis generates inflammation and structural
2007;55:391-4. alveolar injury in the surrounding healthy tissues during
23. Li TC, Yang MC, Tseng AH, et al. Prehabilitation and mechanical ventilation. Crit Care 2014;18:505.
Rehabilitation for Surgically Treated Lung Cancer 36. Slinger PD, Neustein SM, Cohen E, et al. The Cardiac
Patients. J Cancer Res Pract 2017;4:89-94. Patient for Thoracic Noncardiac Surgery. In: Kaplan JA.

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Page 10 of 11 Lederman et al. Anesthesia for lung resection

Kaplan's Cardiac Anesthesia: in Cardiac and Noncardiac J Thorac Dis 2017;9:2992-3004.

Surgery. 7th edition. Elsevier, 2017:1564-81. 48. Jeong DM, Ahn HJ, Park HW, et al. Stroke Volume
37. Azhar N. Pre-operative optimisation of lung function. Variation and Pulse Pressure Variation Are Not Useful
Indian J Anaesth 2015;59:550-6. for Predicting Fluid Responsiveness in Thoracic Surgery.
38. Fujiwara M, Abe K, Mashimo T. The effect of positive Anesth Analg 2017;125:1158-65.
end-expiratory pressure and continuous positive airway 49. Sandham JD, Hull RD, Brant RF, et al. A randomized,
pressure on the oxygenation and shunt fraction during controlled trial of the use of pulmonary-artery catheters in
one-lung ventilation with propofol anesthesia. J Clin high-risk surgical patients. N Engl J Med 2003;348:5-14.
Anesth 2001;13:473-7. 50. Knoll H, Ziegeler S, Schreiber JU, et al. Airway
39. Capan LM, Turndorf H, Patel C, et al. Optimization of injuries after one-lung ventilation: a comparison
arterial oxygenation during one-lung anesthesia. Anesth between double-lumen tube and endobronchial
Analg 1980;59:847-51. blocker: a randomized, prospective, controlled trial.
40. Reid CW, Slinger PD, Lenis S. A comparison of the Anesthesiology 2006;105:471-7.
effects of propofol-alfentanil versus isoflurane anesthesia 51. Chapter 25: Anesthesia for Thoracic Surgery. In:
on arterial oxygenation during one-lung ventilation. J Butterworth JF IV, Mackey DC, Wasnick JD. Morgan &
Cardiothorac Vasc Anesth 1996;10:860-3. Mikhail's Clinical Anesthesiology. 6th edition. NewYork,
41. de la Gala F, Piñeiro P, Reyes A, et al. Postoperative NY: McGrawHill, 2018.
pulmonary complications, pulmonary and systemic 52. Ochroch EA, Gottschalk A, Augostides J, et al. Long-term
inflammatory responses after lung resection surgery with pain and activity during recovery from major thoracotomy
prolonged one-lung ventilation. Randomized controlled using thoracic epidural analgesia. Anesthesiology
trial comparing intravenous and inhalational anaesthesia. 2002;97:1234-44.
Br J Anaesth 2017;119:655-63. 53. Perttunen K, Tasmuth T, Kalso E. Chronic pain after
42. Wigmore TJ, Mohammed K, Jhanji S. Long-term Survival thoracic surgery: a follow-up study. Acta Anaesthesiol
for Patients Undergoing Volatile versus IV Anesthesia for Scand 1999;43:563-7.
Cancer Surgery: A Retrospective Analysis. Anesthesiology 54. Soto RG, Fu ES. Acute pain management for patients
2016;124:69-79. undergoing thoracotomy. Ann Thorac Surg 2003;75:1349-57.
43. Blaise G, Langleben D, Hubert B. Pulmonary arterial 55. Ballantyne JC, Carr DB, deFerranti S, et al. The
hypertension: pathophysiology and anesthetic approach. comparative effects of postoperative analgesic
Anesthesiology 2003;99:1415-32. therapies on pulmonary outcome: cumulative meta-
44. Brown EN, Pavone KJ, Naranjo M. Multimodal analyses of randomized, controlled trials. Anesth Analg
General Anesthesia: Theory and Practice. Anesth Analg 1998;86:598-612.
2018;127:1246-58. 56. Bialka S, Copik M, Daszkiewicz A, et al. Comparison
45. Williams GD, Philip BM, Chu LF, et al. Ketamine does of different methods of postoperative analgesia after
not increase pulmonary vascular resistance in children thoracotomy-a randomized controlled trial. J Thorac Dis
with pulmonary hypertension undergoing sevoflurane 2018;10:4874-82.
anesthesia and spontaneous ventilation. Anesth Analg 57. Rawal N. Current issues in postoperative pain
2007;105:1578-84, table of contents. management. Eur J Anaesthesiol 2016;33:160-71.
46. Standards for Basic Anesthetic Monitoring. Committee 58. Joucken K, Michel L, Schoevaerdts JC, et al. Cryoanalgesi
of Origin: Standards and Practice Parameters (Approved for post-thoracotomy pain relief. Acta Anaesthesiol Belg
by the ASA House of Delegates on October 21, 1986, 1987;38:179-83.
last amended on October 20, 2010, and last affirmed on 59. Ju H, Feng Y, Yang BX, et al. Comparison of epidural
October 28, 2016). Available online: https://www.asahq. analgesia and intercostal nerve cryoanalgesia for post-
org/~/media/Sites/ASAHQ/Files/Public/Resources/ thoracotomy pain control. Eur J Pain 2008;12:378-84.
standards-guidelines/standards-for-basic-anesthetic- 60. Davies RG, Myles PS, Graham JM. A comparison of
monitoring.pdf the analgesic efficacy and side-effects of paravertebral vs
47. Xu H, Shu SH, Wang D, et al. Goal-directed fluid epidural blockade for thoracotomy--a systematic review
restriction using stroke volume variation and cardiac index and meta-analysis of randomized trials. Br J Anaesth
during one-lung ventilation: a randomized controlled trial. 2006;96:418-26.

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67
Annals of Translational Medicine, Vol 7, No 15 August 2019 Page 11 of 11

61. Gerner P. Post-thoracotomy pain management problems. Vasc Anesth 2017;31:152-8.

Anesthesiol Clin 2008;26:355-7. 64. Batchelor TJ, Rasburn NJ, Abdelnour-Berchtold E, et
62. Karmakar MK, Chung DC. Variability of a thoracic al. Guidelines for enhanced recovery after lung surgery:
paravertebral block. Are we ignoring the endothoracic recommendations of the Enhanced Recovery After
fascia? Reg Anesth Pain Med 2000;25:325-7. Surgery (ERAS®) Society and the European Society of
63. Khalil AE, Abdallah NM, Bashandy GM, et al. Ultrasound Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg
guided serratus anterior plane block versus thoracic 2019;55:91-115.
epidural analgesia for thoracotomy pain. J Cardiothorac

Cite this article as: Lederman D, Easwar J, Feldman J, Shapiro

V. Anesthetic considerations for lung resection: preoperative
assessment, intraoperative challenges and postoperative
analgesia. Ann Transl Med 2019;7(15):356. doi: 10.21037/
atm.2019.03.67

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2019;7(15):356 | http://dx.doi.org/10.21037/atm.2019.03.67