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Ann Thorac Surg 1996;62:251-257
© 1996 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Morbidity and Mortality After Thoracoscopic Pneumonoplasty

Richard A. Fujita, MD, Gregory B. Barnes, MD

Department of Anesthesiology, Chapman Medical Center, Orange, California

Accepted for publication March 4, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background. Both video-assisted thoracic surgery and open pneumonoplasty procedures have been used to achieve lung reduction in emphysema patients.

Methods. The surgical and hospital course of 339 patients with a mean forced expiratory volume in 1 second of 750 mL and a mean ratio of forced expiratory volume in 1 second to forced vital capacity of 35% undergoing video-assisted thoracic surgical laser pneumonoplasty was analyzed.

Results. The incidence of myocardial infarctions was 0.9% and the hospital mortality rate was 4.1%.

Conclusions. Factors leading to increased morbidity and mortality were advanced age (65 years and greater, especially greater than 75 years), sex (men greater than women), carbon dioxide retention in the resting state (especially an arterial carbon dioxide tension greater than 55 mm Hg), forced expiratory volume in 1 second less than 700 mL for men and 500 mL for women, maximum voluntary ventilation less than 25% predicted, and a ratio of residual volume/total lung capacity greater than 60%.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Lung reduction surgery has become an accepted treatment for bullous emphysema. Little and associates [1] performed reduction pneumonoplasty in 55 patients with advanced symptomatic emphysema. They reported significant associated hospital morbidity and a 5.5% mortality. Eugene and colleagues [2] performed 28 procedures in patients with an average forced expiratory volume in 1 second (FEV1) of 0.68 ± 0.05 L. Although there were no operative deaths, three late deaths occurred 36 to 90 days postoperatively. The evaluation of surgical and anesthetic risk factors for these patients undergoing lung reduction operations has remained vague. An analysis of our first 339 cases operated on by Dr Wakabayashi at our institution from September 1991 to May 1993 has resulted in the identification of risk factors associated with increased morbidity and mortality after thoracoscopic laser pneumonoplasty.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Of 314 patients, 292 underwent unilateral lung reduction. Twenty-two patients had bilateral lung reduction operations at different times. One patient had the operation performed on both lungs and one side repeated. A total of 339 procedures were performed. The timing of the procedure on the opposite side varied between 2 and 13 months. Preoperative assessment included complete pulmonary function tests, treadmill stress test, and arterial blood gas analysis before and after exercise. No patient was excluded because of the severity of coexisting medical problems.

In addition to routine monitoring, all patients received radial artery catheters. Sixty-five of the first 78 patients had pulmonary artery (PA) catheters inserted, and the remaining patients had triple-lumen central venous catheters. Of the next 91 patients, 90 had triple-lumen central venous catheters inserted and 1 patient had a PA catheter. Four central venous catheters and five PA catheters were inserted in patients 170 to 339.

Induction of anesthesia was achieved using 0 to 7 µg/kg of intravenous fentanyl and 1.5 to 5.5 mg/kg of sodium thiopental. Intubation was facilitated using succinylcholine, vecuronium, or pipecuronium. A left-sided double-lumen endotracheal tube (Mallinckrodt Bronchocath, St. Louis, MO) was inserted using direct visualization. Proper positioning of the double-lumen endotracheal tube was confirmed using an Olympus LF-2 fiberoptic bronchoscope (Olympus, Lake Success, NY) displayed on a video monitor. When the patient was turned to the lateral decubitus position, the bronchoscope was again used to confirm proper positioning of the double-lumen endotracheal tube. The lungs were ventilated using a Siemens Servo ventilator 900C (Siemens Life Support Systems, Solna, Sweden) in the pressure-control mode. Inspiratory pressures greater than 30 cm H2O were avoided. Anesthesia was maintained using isoflurane in oxygen or additional fentanyl (6 to 24 µg/kg total dose for the entire procedure) and isoflurane in oxygen as required.

The operative lung was collapsed before Dr Wakabayashi began the surgical procedure. The surgical procedure has been described in great detail [3]. Each patient underwent laser shrinkage with or without staple resection of lung tissue [4]. At the completion of the surgical procedure, the trachea was reintubated with a standard endotracheal tube. All patients were transferred directly to the intensive care unit. Total control of ventilation was maintained using the pressure-control mode.

Data were compiled and analyzed using StatView Version 1.0 (Brainpower, Calabasas, CA). The variables from different populations were compared using the unpaired Student's t test. A p value less than 0.05 was considered significant.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Three hundred fourteen patients (245 men and 94 women) underwent 339 procedures. The mean age ± standard deviation was 66.5 ± 7.3 years (range, 39 to 94 years). All patients were former cigarette smokers. Eight patients also had {alpha}1-antitrypsin deficiencies. All patients were American Society of Anesthesiologists physical status 3 or 4. In addition to severe lung dysfunction, many patients had coexisting cardiovascular disease (eg, dysrhythmias, cor pulmonale, hypertension, diabetes mellitus). One hundred fifty-eight of the 339 patients required continuous oxygen supplementation. Sixty-eight patients required supplemental oxygen on an as-needed basis. In 86 of the 339 cases the patient was confined to a wheelchair, and 7 patients were bedridden. One of the bedridden patients was taken to operation intubated and in respiratory failure. One hundred fourteen patients were receiving prednisone (10.9 ± 7.2 mg per day; range, 2.5 to 40 mg). The mean arterial carbon dioxide tension (PaCO2) was 43 ± 9 mm Hg (range, 26 to 81 mm Hg). The mean preoperative FEV1 was 0.75 ± 0.43 L (range, 0.18 to 3.95 L) and the mean FEV1/forced vital capacity (FVC) was 35% ± 10% (range, 16% to 93%). The mean maximum voluntary ventilation (MVV) was 29% ± 14% of predicted (range, 5% to 100%). The mean residual volume (RV)/total lung capacity (TLC) was 63% ± 9% (range, 31% to 86%). A difference between sexes existed (Table 1Go).


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  		Table 1. . Preoperative Patient Characteristics
 
The analysis of postoperative ventilation is shown in Table 2Go. The mean length of postoperative mechanical ventilation was 21.9 ± 52.5 hours (range, 0 to 504 hours) for all patients. Two hundred ninety patients were extubated within 24 hours and had a mean mechanical ventilation time of 10.9 ± 6.1 hours. Forty-four patients (13.2%) required greater than 24 hours of postoperative mechanical ventilation and had a mean time of 93.7 ± 122 hours. Although the mean resting PaCO2 values were different, the difference was not statistically significant. Patients who were extubated within 24 hours stayed in the hospital 5 days less (p < 0.025) and their mortality rate was 1.4%. Patients who had prolonged mechanical ventilation (>24 hours) had higher rates of reintubation (11.4% versus 2.1%) and mortality (22.7% versus 1.4%). Eleven patients originally met standard extubation criteria but had subsequent development of respiratory failure requiring reintubation. Six of these patients (45%) eventually died.


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  		Table 2. . Comparison by Mechanical Ventilation Time
 
The in-hospital mortality rate was 4.1% (14 in-hospital deaths per 339 cases). The mortality rate was 2.1% for women and 4.9% for men. Eleven patients died of respiratory failure. One patient died of a tension pneumothorax. One patient died secondary to an aspiration pneumonitis. The overall incidence of myocardial infarctions was 0.9% (3 per 339 procedures): 1 patient died of a myocardial infarction and 2 others suffered uncomplicated postoperative myocardial infarctions. The 3-month survival rate was 92.7% (25 deaths per 339 cases). After discharge from the hospital, 11 patients died. Seven died as a result of tension pneumothoraces and 4 died of respiratory failure.

A comparison of outcome based on age is shown in Table 3Go. We compared patients less than 65 years of age and those greater than 65 years; a subgroup of patients 75 years old and older was also examined. The patients did not differ significantly in preoperative values of PaCO2, FEV1, FEV1/FVC, MVV, and RV/TLC. There was no statistical difference based on age in the length of postoperative mechanical ventilation or length of hospital stay. There were no in-hospital deaths in patients less than 65 years old, and their rate of reintubation was significantly less than that in patients older than 65 years: 0.8% versus 4.5%, respectively. Patients greater than 65 years of age had a 6.4% death rate, with those patients older than 75 years having a 10% death rate.


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  		Table 3. . Comparison by Age
 
A comparison of resting PaCO2 and outcome is shown in Table 4Go. As the PaCO2 increased, the FEV1 decreased, the FEV1/FVC decreased, the MVV decreased, and the RV/TLC increased for all groups. The mean length of mechanical ventilation (58.3 ± 110 hours) was significantly greater for the group with a PaCO2 of more than 55 mm Hg (p < 0.005). Compared with overall figures, patients with a resting PaCO2 greater than 55 mm Hg experienced a fivefold increase in the rate of reintubation (16.1%) and a twofold increase in mortality (9.6%). The differences between the sexes were also examined. Women with a PaCO2 of more than 55 mm Hg had a greater chance of reintubation (25%) compared with the other group of women. The men with a PaCO2 of more than 55 mm Hg had a greater chance of reintubation (10.5%) and mortality (15.8%) compared with the other men.


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  		Table 4. . Comparison by Arterial Carbon Dioxide Tension
 
The MVV was determined in 269 patients. It should be noted that complete pulmonary function testing was obtained for all patients unless physical limitations precluded collection of data. The MVV data were divided into three groups: MVV of 25% predicted or less, MVV of 26% to 50% predicted, and MVV greater than 50% predicted (Table 5Go). As the MVV decreased, PaCO2 increased, the FEV1 decreased, the FEV1/FVC decreased, and the RV/TLC increased. The rate of reintubation increased as the MVV decreased. The death rate also increased as the MVV decreased. The patients with an MVV less than 25% predicted had a greater rate of reintubation (3.8%) and death (6.9%). This mortality rate was eight times greater than that of the patients with an MVV greater than 25% predicted. Similar findings were observed when the separate sexes were examined. The group with MVV greater than 50% predicted had one death (6.3% death rate). This death was the result of an aspiration pneumonitis.


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  		Table 5. . Comparison by Maximum Voluntary Ventilation
 
The RV/TLC was determined in 268 patients and divided into four groups (Table 6Go). As the RV/TLC increased, the PaCO2 increased and the FEV1 decreased. The length of mechanical ventilation and hospital stay were not significantly different. As RV/TLC increased to more than 60%, the death rate increased. The death in the RV/TLC 51% to 60% group was due to an aspiration pneumonitis.


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  		Table 6. . Comparison by Residual Volume/Total Lung Capacity
 
The initial evaluation for FEV1 divided patients into two groups (Table 7Go): FEV1 less than 700 mL and FEV1 of 700 mL or greater. Patients with an FEV1 less than 700 mL had a longer hospital stay (p < 0.025) compared with those individuals with an FEV1 greater than 700 mL. They were also seven times more likely to require reinstitution of mechanical ventilation and two times more likely to die compared with those individuals with an FEV1 greater than 700 mL. The patient population was then divided into groups by 100-mL increments, and analysis of the data revealed that rates of reintubation and death were greatest for the patients with an FEV1 less than 500 mL. Two patients died with an FEV1 greater than 1 L. One death was due to aspiration pneumonitis and one to respiratory failure. From Table 1Go, we observed a difference in the mean FEV1 for men and women. The FEV1 values for men and women were divided into 100-mL increments. The critical value for women appeared to be an FEV1 less than 500 mL. The rates of reintubation (5.5% versus 0%) and mortality (2.8% versus 0%) were greater in women with an FEV1 less than 500 mL compared with the women with an FEV1 greater than 500 mL. When the FEV1 decreased to less than 500 mL, the mean resting PaCO2 increased to more than 45 mm Hg. The critical value for men appeared to be an FEV1 less than 700 mL. The rate of reintubation was 6.4% and mortality was 10.0% compared with 0.9% and 2.6%, respectively, for men with an FEV1 greater than 700 mL. Based on mean PaCO2 values, carbon dioxide retention occurred in men when the FEV1 decreased to less than 600 mL.


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  		Table 7. . Comparison by Forced Expiratory Volume in 1 Second
 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Both open and video-assisted pneumonoplasty procedures are used to achieve lung volume reduction in patients with emphysema [1, 2, 4, 5]. This article reviews our experience using a video-assisted thoracic surgical approach to determine which factors influence perioperative morbidity and mortality. Examination of the first 339 cases performed by Dr Wakabayashi at our institution from September 1991 to May 1993 identified risk factors associated with increased morbidity and mortality. Important emphasis must be given to the fact that despite coexisting medical problems (eg, cardiomyopathy with severe left ventricular dysfunction and end-stage renal disease in a patient on dialysis), no patient was excluded.

The anesthetic management for patients with severe chronic obstructive pulmonary disease undergoing thoracoscopic contraction of bullous emphysema was first described by Barker and associates [6]. Because there was little information in the literature on how to anesthetize these individuals, we used the protocol designed by Barker and associates. As our experience with these patients grew, the original protocol was modified. One hundred eight cases were performed using only isoflurane for the maintenance of anesthesia (averaging 2.5 minimal alveolar concentration hours). Two hundred thirty-one cases were performed using intravenous fentanyl (total dose, 6 to 24 µg/kg) and low concentrations of isoflurane (1/2 minimal alveolar concentration or less). The anesthetic technique did not appear to affect the postoperative mechanical ventilation time, the length of the hospital stay, or the mortality rate. We observed that routine insertion of PA catheters or central venous catheters was not necessary for every patient. The absence of the catheters did not affect the length of the hospital stay, nor did it increase the mortality rate. Pulmonary artery catheters are now inserted when an indication exists.

Many reports that predict the risk of postoperative respiratory failure adapted the findings by Olsen and colleagues [7]. Olsen and colleagues established the criteria to determine which patients would tolerate a pneumonectomy or lobectomy. The criteria were an FEV1 greater than 2 L, FEV1/FVC greater than 50%, MVV greater than 50% of predicted, and a ratio of RV/TLC less than 50%. Authors have used the above data to predict in which group of patients postoperative respiratory failure would most likely develop after other types of procedures (eg, surgical incisions involving the upper abdomen and thoracotomies). Our patients' mean values were as follows: FEV1, 0.75 ± 0.43 L, FEV1/FVC, 35% ± 10%; MVV, 29% ± 14% predicted; and RV/TLC, 63% ± 9%. The preceding values indicated that our patients would have been poor risks for pneumonectomy. The data show that patients at poor risk for pneumonectomy can tolerate video-assisted thoracic surgical pneumonoplasty.

We were able to identify variables that increased risk of morbidity and mortality. Age was a factor. Patients greater than 65 years of age had a significantly increased risk of mortality (see Table 3Go). They were also five times more likely to have postoperative respiratory failure. We further found that risk was even greater in patients who were 75 years and older. These patients had a 10% mortality, which was more than double the overall mortality rate. Increased resting preoperative PaCO2 was also associated with worse outcome (see Table 4Go). Patients with resting PaCO2 greater than 55 mm Hg were five times more likely to suffer postoperative respiratory failure requiring reintubation of the trachea. These patients also had significantly increased risk of mortality at 9.7%. We have shown that patients with severely diminished preoperative pulmonary function have an increased risk of mortality and postoperative respiratory failure. Patients with an MVV less than 25% had increased mortality and postoperative respiratory failure. Men with an FEV1 less than 700 mL had a longer hospital stay (p < 0.025), an increased rate of reintubation, and an increased death rate compared with men with an FEV1 greater than 700 mL. For women, the rates for reintubation and mortality were greater if the FEV1 was less than 500 mL. Examination of mean PaCO2 values revealed that carbon dioxide retention occurred when the FEV1 decreased to less than 600 mL for men and less than 500 mL for women. A previous report indicated that significant resting CO2 retention occurred when the FEV1 decreased to less than 800 mL [8]. Patients with an RV/TLC greater than 60% also showed increased risk of respiratory failure.

In conclusion, our data should assist the clinician in determining perioperative risk for patients undergoing thoracoscopic pneumonoplasty. Despite severe lung dysfunction, the probability of suffering a perioperative myocardial infarction was 0.9% (3 per 339 cases). The overall mortality rate was 4.1% (14 deaths in 339 cases). The overall rate of reintubation of the trachea and reinstitution of mechanical ventilation was 3.2%. The anesthetic technique (inhalation versus balanced) did not appear to affect patient outcome. Thoracoscopic laser pneumonoplasty was not an absolute indication for insertion of a PA catheter. We identified several factors that contributed to an increased morbidity and mortality for patients with severe chronic obstructive pulmonary disease undergoing thoracoscopic pneumonoplasty. These factors were advanced age (65 years and greater, especially greater than 75 years), sex (men greater than women), carbon dioxide retention in the resting state (especially a PaCO2 of more than 55 mm Hg), FEV1 less than 700 mL, MVV less than 25% predicted, and a ratio of RV/TLC greater than 60%. Early extubation appears to be a key goal. Patients requiring prolonged mechanical ventilation (>24 hours) had a mortality rate of 22.7%. When a patient originally met standard extubation criteria and then had development of respiratory failure, the mortality rate increased to 45%.


   Acknowledgments
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The patients in this report were all operated on by Dr A. Wakabayashi.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Address reprint requests to Dr Fujita, Chapman Medical Center, 2601 East Chapman Ave, Orange, CA 92669.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Little AG, Swain JA, Nino JJ, Prabhu RD, Schlater MD, Barcia TC. Reduction pneumonoplasty for emphysema. Early results. Ann Surg 1995;222:365–74.[Medline]
  2. Eugene J, Ott RA, Gogia HS, Dos Santos C, Zeit R, Kayaleh RA. Video-thoracic surgery for treatment of end-stage bullous emphysema and chronic obstructive pulmonary disease. Am Surg 1995;61:934–6.[Medline]
  3. Wakabayashi A. Thoracoscopic treatment of spontaneous pneumothorax. Chest Surg Clin North Am 1993;3:233–9.
  4. Wakabayashi A. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema. Ann Thorac Surg 1995;60:936–42.[Abstract/Free Full Text]
  5. Lewis RJ, Caccavale RJ, Sisler GE. VATS-argon beam coagulator treatment of diffuse end-stage bilateral bullous disease of the lung. Ann Thorac Surg 1993;55:1394–9.[Abstract]
  6. Barker SJ, Clarke C, Trivedi N, Hyatt J, Fynes M, Roessler P. Anesthesia for thoracoscopic laser ablation of bullous emphysema. Anesthesiology 1993;78:44–50.[Medline]
  7. Olsen GN, Block AJ, Swenson EW, Castle JR, Wynne JW. Pulmonary function evaluation of the lung resection candidate: a prospective study. Am Rev Respir Dis 1975;111:379–87.[Medline]
  8. Cherniack NS. The clinical assessment of the chemical regulation of ventilation. Chest 1976;70(Suppl):274–81.[Free Full Text]



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