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. 2023 May 29;12(11):3750.
doi: 10.3390/jcm12113750.

Nonintubated versus Intubated Lung Volume Reduction Surgery in Patients with End-Stage Lung Emphysema and Hypercapnia

Ali Akil  1 , Stephanie Rehers  2 , Stephan Ziegeler  2 , Erik Ernst  3 , Jan Haselmann  1 , Nicolas Johannes Dickgreber  4 , Stefan Fischer  1
Affiliations

Nonintubated versus Intubated Lung Volume Reduction Surgery in Patients with End-Stage Lung Emphysema and Hypercapnia

Ali Akil et al. J Clin Med. .

Abstract

Lung volume reduction surgery (LVRS) represents an important treatment option in carefully selected patients with end-stage lung emphysema. The aim of this study was to assess the efficacy and safety of nonintubated LVRS compared to intubated LVRS in patients with preoperative hypercapnia and lung emphysema. Between April 2019 and February 2021, n = 92 patients with end-stage lung emphysema and preoperative hypercapnia undergoing unilateral video-assisted thoracoscopic LVRS (VATS-LVRS) performed in epidural anesthesia and mild sedation (nonintubated, group 1) or conventional general anesthesia (intubated, control, group 2) were prospectively enrolled in this study. Data were retrospectively analyzed. In all patients, low-flow veno-venous extracorporeal lung support (low-flow VV ECLS) was applied as a bridge through LVRS. Ninety-day mortality was considered as the primary outcome. Secondary endpoints included: chest tube duration, hospital stay, intubation and conversion to general anesthesia. Intergroup analysis showed no significant difference between the baseline data and patients' demographics. N = 36 patients underwent nonintubated surgery. VATS-LVRS under general anesthesia was performed in n = 56 patients. The mean duration of postoperative VV ECLS support was 3 ± 1 day in group 1 compared to 4 ± 1 in group 2. The 90-day mortality rate was 3% in group 1 compared to 7% in group 2. In group 1, all chest tubes were removed 5 ± 1 day (range 4-32 days) and 8 ± 1 day (range 4-44 days) in the control group after the surgery (p < 0.02). Prolonged chest tube therapy (>8 days) was observed in n = 3 patients in group 1 and n = 11 patients in the control group. The mean ICU stay was 4 ± 1 days in group 1 compared to 8 ± 2 days in the control group (p = 0.04). The mean hospital stay was significantly shorter in the nonintubated group 1 (6 ± 2 days vs. 10 ± 4 days, p = 0.01). Conversion to general anesthesia was necessary in one patient due to severe pleural adhesions. Nonintubated VATS-LVRS in patients with end-stage lung emphysema and hypercapnia is effective and well tolerated. Compared to general anesthesia, a reduction in mortality, chest tube duration, ICU and hospital stay and lower rate of prolonged air leak was observed. VV ECLS increases intraoperative safety and mitigates postoperative complications in such "high-risk" patients.

Keywords: LVRS; VV ECLS; hypercapnia; lung emphysema; nonintubated.

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Conflict of interest statement

The authors have no conflict of interest to declare.

Figures

Figure 1
Figure 1
PaCO2 levels pre- and postoperatively (day of discharge) in both groups. In both groups, a significant decrease in PaCO2 levels was observed at the day of discharge compared to preoperative measures.
Figure 2
Figure 2
Performance status (6 MWD). Shows a significant improvement in the walked distance in 6 min in group 1 at the day of discharge. In addition, although not significant, a trend toward better performance compared to preoperative measurements was observed in group 2.
Figure 3
Figure 3
Performance status (exercise capacity). Exercise capacity measured in stair/step climbing improved significantly after surgery in both groups.
Figure 4
Figure 4
Quality of life. Quality of life (QoL) recorded in both groups improved significantly after surgery.
Figure 5
Figure 5
Dyspnea. A postoperative significant improvement was recorded regarding the dyspnea scale in both groups.
See this image and copyright information in PMC

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