One lobe ventilation post-recent lung resection

Dear Editor,

We present a case of a 25-year-old female with a history of left lower lobectomy done two months ago for a hydatid cyst of the lung, scheduled for right lower lobectomy for the same pathology. Preoperative evaluation, including imaging and pulmonary function tests, confirmed stable left lung function with slight compensatory hyperinflation of the remaining lobe. In the room air, her peripheral oxygen saturation (SPO₂) was 97%. After climbing five flights of stairs, her SPO₂ remained at 96%, with a pulse rate of 166 beats per minute corresponding to a maximal oxygen uptake (VO₂ max) >20 ml/kg/min.^[1] The computed tomography (CT) scan revealed a hydatid cyst occupying the right lower lobe, and a significant reduction in lung function was not anticipated [Figure 1 and 2].

Close

Figure 1:

CECT lung window. CECT: Contrast-enhanced computed tomography

Export to PPT

Close

Figure 2:

CECT mediastinal window. CECT: Contrast-enhanced computed tomography

Export to PPT

The choice of open versus minimal access surgery was discussed with the surgical team. The decision to proceed with video-assisted thoracoscopic surgery was taken due to its perioperative advantages. During surgery, one-lung ventilation (OLV) was employed with the help of a 32 Fr left-sided double-lumen tube (DLT), and careful management was required to ensure adequate oxygenation and ventilation. Adequate steroid coverage with a single dose of intravenous hydrocortisone 100mg was given. Arterial blood gas (ABG) analysis after one hour showed a potential of hydrogen (pH) 7.18, partial pressure of carbon dioxide (pCO₂) 66.9 mmHg, partial pressure of oxygen (pO₂) 92.3 mmHg, , bicarbonate (HCO₃) 20.7 mEq/L, and lactate 0.7 mmol/L.

Given the hypercapnic findings, we minimised dead space in the ventilatory circuit by removing the catheter mount, heat and moisture exchange (HME) filter and Y-piece of the DLT, which reduced the dead space by approximately 80 mL and brought pCO₂ levels to an acceptable range, with ABGs showing pH 7.287, pCO₂ 47.4 mmHg, pO₂ 77.7 mmHg, and HCO₃ 21.9 mEq/L. Hypoxaemia was managed with continuous positive pressure on the operative side with the help of a Jackson Rees (JR) circuit connected to the non-ventilated limb of the DLT. A continuous oxygen flow was connected to the JR circuit, and the open limb of the circuit was partially closed. Oxygen flow was adjusted to maintain an acceptable degree of partial lung inflation while ensuring the surgical field remains unobstructed.

The surgery lasted for four hours. Postoperatively, the patient was transitioned to two-lung ventilation, and a recruitment manoeuvre was used to re-expand the right lung. She was extubated successfully and transferred to the intensive care unit for further management.

Reeves et al have documented the successful management of a patient with a single lobe available for ventilation intraoperatively, but their patient had significant time to develop compensatory hyperinflation changes.^[2] Our case highlights the successful management of OLV in a patient with a recent lung resection. Our patient had undergone the first lung resection surgery only two months back, and the CT scan showed mild compensatory hyperinflation. We anticipated significant hypoxaemia intraoperatively and accordingly, the surgery team was briefed about the requirement of transition to two-lung ventilation intermittently, if deemed necessary, intraoperatively. The decision to go ahead with video-assisted lung resection was taken, and hypoxaemia was managed with continuous positive airway pressure without any need for transition to two-lung ventilation. The perioperative phase was uneventful in contrast to what we had anticipated, probably because the affected pathological segments could not contribute to gas exchange.

Our case highlights the feasibility of one-lobe ventilation in patients with recent lung resection. A clear understanding of the patient’s medical status and pathology, and careful perioperative management, including ventilatory adjustments, can ensure a positive outcome.