Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax

Abstract

Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation.

Keywords: Thoracic surgery; anesthesia; epidural; mechanical; pneumothorax; ventilation; video-assisted.

Figure 1

From left to right: (Up) Dr. F. Lirio (Thoracic Surgery Resident), Dr. C. Gálvez (Surgeon), Mrs M. Perez (Nurse), Dr. M.J. Rivera (Anesthesiologist), Dr. J. Navarro-Martínez (Anestesiologist), Dr. S. Bolufer (Surgeon); (Down) Mrs. Fini Rey (Care Assistant), Dr. M. Galiana (Anesthesiologist), Mrs. Eva Ortuño (Nurse).

Figure 2

CT scan of right secondary spontaneous pneumothorax due to underlying severe emphysema with multiple bullas.

Figure 3

Diaphragm motion in the operative lung during NI-VATS procedures. Keeping diaphragm motion preserves the compliance in the non-operative lung, which in addition to a better perfusion favored by gravity minimizes the disruption in the match of ventilation/perfusion thus decreasing the risk of hypoxemia in patients with pulmonary underlying disease (13). Available online: http://www.asvide.com/articles/496

Figure 4

Devices used for oxygen supplementation during spontaneous breathing procedures: nasal prongs, facial mask, high-flow oxygen devices and intranasal multi-perforated cannula.

Figure 5

Resecting apical bullous complex with endostapler in a patient with underlying moderate emphysema.