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Ann Thorac Surg 2009;87:880-885. doi:10.1016/j.athoracsur.2008.12.071
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Thoracoscopic Bleb Resection Using Two-Lung Ventilation Anesthesia With Low Tidal Volume for Primary Spontaneous Pneumothorax

Heezoo Kim, MD, PhDa, Hyun Koo Kim, MD, PhDb,*, Young Ho Choi, MD, PhDb, Sang Ho Lim, MD, PhDa

a Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
b Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea

Accepted for publication December 22, 2008.

* Address correspondence to Dr Hyun Koo Kim, Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, 97, Gurodong-gil, Guro-gu, Seoul, 152-703, Korea (Email: kimhyunkoo{at}korea.ac.kr).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: We performed thoracoscopic surgery for pneumothorax using two-lung ventilation with low tidal volume and evaluated the feasibility and safety of this procedure.

Methods: Forty-six patients (mean age, 23.6 ± 10.47 years) each with a primary spontaneous pneumothorax underwent wedge resection with chemical and mechanical pleurodesis. Two-lung ventilation anesthesia was performed with a single-lumen endotracheal tube, and the tidal volume was reduced to 4 mL/kg; the respiratory rate was increased to 24 cycles/min. Airway pressure, end-tidal CO2, and the results of blood gas analysis were obtained right after endotracheal intubation and during the operation, and were compared.

Results: The tidal volume was 496.2 ± 94.33 mL at anesthesia induction, which decreased to 243.9 ± 34.43 mL during the two-lung ventilation. In 5 patients, the tidal volume was additionally decreased by 32.5 ± 12.58 mL (p = 0.014) to obtain an optimal working field. The differences between the airway pressure, pH, partial pressure of carbon dioxide, and partial pressure of oxygen were significant between the two measurement times. However, all of the values of the arterial blood gas analysis were within normal range. The oxygen saturation (99.9% ± 0.69% versus 99.8 ± 0.72%; p = 0.160) and end-tidal CO2 (33.2 ± 3.74 mm Hg versus 34.1 ± 4.19 mm Hg; p = 0.157) were not significantly different. The time from intubation before the incision was 17.1 ± 4.18 minutes, the operation time was 31.9 ± 14.48 minutes, and the total anesthesia time was 65.8 ± 15.02 minutes.

Conclusions: Thoracoscopic surgery for primary spontaneous pneumothorax using two-lung ventilation with low tidal volume was technically feasible.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
The surgical strategy for the treatment of a spontaneous pneumothorax is resection of the blebs and bullae and obliteration of the pleural space by pleurectomy or pleural abrasion, alone or in combination [1]. An open thoracotomy, such as the transaxillary thoracotomy, has been the standard surgical approach [2]. However, the use of video-assisted thoracoscopic surgery (VATS) has become widespread and is now more commonly used than the open thoracotomy owing to its minimal invasiveness and the associated low morbidity [3], since the first VATS was reported in 1990 [4].

One-lung ventilation is a commonly used technique that facilitates surgical visualization during thoracic surgical procedures. In particular, during VATS, one-lung ventilation may play a pivotal role in the successful completion of a planned procedure [5, 6]. However, it has the disadvantages of causing hypoxemia, tracheobronchial trauma, and oxidative stress [7]. In addition to these complications, it may add additional time and cost because of the need to verify the proper position of the tube by fiberoptic bronchoscopy [8].

Recently, Cerfolio and colleagues [9] reported that in patents with a malignant pleural effusion or effusions of unknown cause, VATS with two-lung ventilation was possible and it afforded excellent visualization of the pleural space, allowing pleural biopsies and talc insufflation; as a result, it was recommended for use in cases requiring wedge resection of the lung for interstitial lung disease. We occasionally used two-lung ventilation during a VATS for primary spontaneous pneumothorax, during a one-lung ventilation procedure, to identify an air leak or collapsed bleb or bullae. At first, we partially clamped the bronchial lumen of the double-lumen endotracheal tube (DLT), on the side undergoing surgery. Then, we placed the DLT but inflated both lungs and used a low tidal volume. Next, we started to place a single-lumen tube in all cases during the VATS for a primary spontaneous pneumothorax, starting in April 2007. In this study we evaluated the safety and feasibility of two-lung ventilation anesthesia with low tidal volume during VATS for primary spontaneous pneumothorax.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patient Population
A consecutive series of 46 patients with primary spontaneous pneumothorax underwent VATS using two-lung ventilation anesthesia from April to September 2007 at the Korea University Guro Hospital. After approval by the Ethics Committee of the Korea University Guro Hospital, written informed consent was obtained from all patients. All patients were initially managed with chest tube placement; a chest computerized tomography (CT) was performed before surgery. Surgery was indicated if the first episode of pneumothorax was complicated, if blebs or bullae were observed on the chest CT, or in cases with recurrent pneumothorax. Patients without blebs or bullae on the chest CT or with their first pneumothorax and patients with a secondary spontaneous pneumothorax were excluded from this study. In addition, if patients refused the operation or if moderate-to-severe pleural adhesions were found on the chest roentgenograph or chest CT, the patient was excluded.

Anesthetic Techniques
General anesthesia was induced with 2.5% thiopental sodium 5 mg/kg (Choongwae Pharma Corporation, Hwasung, Gyeonggi, South Korea) and rocuronium 0.6 mg/kg (Zemuron; Organon Inc, Kenilworth, NJ). Soon after loss of consciousness was achieved, the radial artery was cannulated for intermittent arterial blood gas analysis. Patients were intubated with a single-lumen endotracheal tube (Sheridan/CF Tracheal Tubes; Hudson RCI, Durham, NC) and ventilated with a tidal volume of 8 mL/kg and a respiratory rate of 12 cycles/min at a fraction of inspired oxygen of 0.5. The inspiratory-to-expiratory ratio was fixed at 1:2, and the flow rate of O2 and N2O were 1.5 mL/min. Positive end expiratory pressure was not used during the operation. Before entering the thoracic cavity, the tidal volume was reduced to 4 mL/kg, and the respiratory rate was increased to 24 cycles/min to maintain the same amount of minute volume as was present initially. Whenever the operator notified the anesthesiologist of an inadequate surgical field, the tidal volume was gradually reduced by 10 mL until the operator had adequate visualization for the surgery (Fig 1). During the surgery, the arterial blood gas analysis was performed two times at full (before the pleura was opened) and low tidal volumes (after the pleura was opened). We recorded the airway pressure, end-tidal CO2, and the oxygen saturation. When the patient was ventilated at low tidal volume, a pulse oximetry O2 saturation of 90% was considered the minimal level allowed. In addition, the time from intubation to the incision, the operation time, and total time for anesthesia were measured. For all procedures, we prepared the wire-guided endobronchial blocker (WEB, Arndt blocker; Cook Critical Care, Bloomington, IN) for one-lung ventilation in case we failed to obtain adequate surgical visualization with the low tidal volume used for the two-lung ventilation.


Figure 1
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  		Fig 1. Operative field of two-lung ventilation with normal (A) and low tidal volume (B) in video-assisted thoracoscopic surgery for primary spontaneous pneumothorax.

 
Operative Techniques
The patients were placed in the lateral decubitus position. Initially, a 5-mm thoracoscope with a 0-degree lens was introduced into the thoracic cavity through an 11.5-mm port at the sixth or seventh intercostal space on the anterior axillary line (previous closed thoracostomy site) to examine whether there were any dense adhesions, blebs, or bullae. If there were moderate-to-severe pleural adhesions in the thoracic cavity, two-lung ventilation was converted to one-lung ventilation, or the VATS was abandoned. In the cases in which the VATS was continued, a 5.5-mm thoracoscopic port at the fifth or sixth intercostal space on the midaxillary line and another 5.5-mm port for the endograsper at the fifth or sixth intercostal space on the posterior axillary line were made. The bleb resections were performed using one or two endostaplers through an 11.5-mm port used for securing the pulmonary margins; the resected blebs were removed from the 11.5-mm port. After confirming that there was no hemorrhaging from the stapler line, an air leakage test was performed under a pressure load of 20 cm H2O. The stapler line was covered with fibrin sealant (Beriplast P Combi-Set; CSL Behring GmbH, Marburg, Germany) and Surgicel (Johnson & Johnson Medical Limited, Gargrave, North Yorkshire, UK) to close the stapler line. Mechanical and chemical pleurodesis, with iodine-soaked cotton, were performed at the apical area of the visceral and parietal pleurae through an 11.5-mm port. On completion of the operation, a 28F chest tube was inserted through the 11.5-mm port.

Data Collection and Analysis
The medical records were reviewed including the history of the primary spontaneous pneumothorax. Information on the duration of the operation and the postoperative hospital stay were also reviewed. Statistical analysis was carried out using statistical software (SPSS for Windows, release 12.0; SPSS; Chicago, IL). Probability values less than 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
A total of 85 patients were treated for primary spontaneous pneumothorax during the study period. Nineteen patients among them without blebs or bullae on the chest CT or with their first pneumothorax and 11 patients who refused the operation were treated only with closed thoracostomy. Chest roentgenographic findings or chest CT findings revealed that 9 patients with pneumothorax had moderate-to-severe pleural adhesions, and all these 9 patients had one-lung ventilation used from the start of anesthesia induction. No patient initially underwent surgery through a thoracotomy. There was no case in which VATS was converted to an open thoracotomy or in which two-lung ventilation was converted to one-lung ventilation. There were 40 men (87.0%) and 6 women (13.0%) enrolled with a mean age of 23.6 ± 10.47 years (range, 14 to 77 years). The most common indications for the VATS in cases with a primary spontaneous pneumothorax were a visible bleb on the chest CT or a recurrent pneumothorax on the same side (Table 1). The right lung was involved in 28 patients (60.9%), and the left lung was involved in 18 patients (39.1%).


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  		Table 1 Indications for Surgery in Patients With Primary Spontaneous Pneumothorax
 
The tidal volume was 496.2 ± 94.33 mL at anesthesia induction, which was decreased to 243.9 ± 34.43 mL during the two-lung ventilation with low tidal volume. To maintain the minute volume during the operation (5.3 ± 1.03 L) similar to the induction values (5.9 ± 0.91 L), the respiratory rate was increased from 12 to 23.3 ± 1.57 cycles/min (Table 2). When all the thoracoscopic instruments were set in the operative field, if the working field was not adequate for visualization we additionally decreased the tidal volume without delay. Soon after the endotracheal intubation and blood sampling for arterial blood gas analysis, the tidal volume was reduced. The time from the start of the low tidal volume to the start of the operation was approximately 15 minutes, which was enough time to acquire an optimal operative field. In 5 patients, the tidal volume was additionally decreased by 32.5 ± 12.58 mL (p = 0.014) to obtain an optimal working field. The average number of stepwise reductions was 3.4 ± 1.14 (range, 2 to 5). We waited 3 minutes after every 10-mL reduction of tidal volume; therefore 10.2 ± 3.42 minutes (6 to 15 minutes) of added operation time was needed in 5 patients.


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  		Table 2 Ventilator Setting and Arterial Blood Gas Analysis at Anesthesia Induction and During Surgery a
 
The airway pressure, pH, partial pressure of carbon dioxide, and partial pressure of oxygen were compared between the two times and were significantly different; however, these differences had no negative impact on the pulmonary status of the patients. Other indicators for the patient's ventilation status during the procedure such as oxygen saturation (99.9% ± 0.69% versus 99.8% ± 0.72%; p = 0.160) and end-tidal CO2 (33.2 ± 3.74 mm Hg versus 34.1 ± 4.19 mm Hg; p = 0.157) were not significantly different (Table 2).

The time from endotracheal intubation to the incision was 17.1 ± 4.18 minutes (range, 10 to 27 minutes), the operation time was 31.9 ± 14.48 minutes (range, 15 to 77 minutes), and the total time under anesthesia was 65.8 ± 15.02 minutes (range, 45 to 110 minutes). In all patients, thoracoscopic bleb resection with pleurodesis was performed successfully. Two patients with bilateral pneumothorax underwent thoracoscopic bilateral bleb resection using two-lung ventilation in the right and then left lateral decubitus position, respectively. Three patients had air leakage until the third day postoperatively, but the chest tube could be withdrawn by the fifth day after surgery by managing this complication with talcum pleurodesis. There were no wound infections, early recurrences, or readmissions. The chest tube was removed on average at postoperative day 3.5 ± 1.1 (range, 2 to 5 days), and patients were discharged from the hospital without complications on average at postoperative day 4.6 ± 1.2 (range, 3 to 6 days). During the follow-up period (11.2 ± 3.3 months, range 9 to 14 months), there was no recurrence on the side that underwent surgery.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax has several advantages over conventional or limited axillary thoracotomy, including less postoperative pain, better cosmesis, reduced physiologic trauma, and improved postoperative pulmonary function, as well as the economic advantages [3, 10]. The minimal invasiveness of VATS has changed the treatment strategy for primary spontaneous pneumothorax. Sawada and associates [11] recommended VATS not only for patients with recurrence or prolonged air leakage but also for the first pneumothorax episode in patients with bullae on the chest CT. Margolis and coworkers [12] suggested that VATS may be an effective first-line treatment for primary spontaneous pneumothorax in young adult patients regardless of the chest CT findings. In our hospital the indications for VATS, for the first episode of a primary spontaneous pneumothorax are similar to those reported by Sawada and colleagues [11]. For the first episode in patients in which blebs or bullae are not detected by CT, a conservative approach is the first-line treatment. However, first episodes with blebs or bullae noted on the CT are treated by VATS.

One-lung ventilation is almost always used for VATS. It is usually safe, and it provides superb visualization and an excellent working field for procedures involving the pleura, lung, and mediastinum after the appropriate collapse of the lung [9]. However, during one-lung ventilation, the lung undergoing surgery remains completely collapsed and unventilated; the lung with atelectasis is hypoperfused owing to hypoxic pulmonary vasoconstriction [13]. Therefore, when the one-lung ventilation is completed, the subsequent lung expansion along with tissue perfusion may produce oxygen free radicals [14], which causes reexpansion pulmonary edema [15].

There are several methods used to achieve one-lung ventilation, including the DLT (Broncho-cath, Mallinckrodt Medical, Athlone, Ireland), the Univent (Phycon, Tokyo, Japan), the single-lumen tube with wire-guided endobronchial blocker (WEB, Arndt blocker; Cook Critical Care), the Fogarty catheter (Edwards Lifesciences LLC, CA), and endobronchial intubation using a single-lumen tube. However, the DLT and Univent have some drawbacks such as an increased risk of airway trauma owing to the larger diameter of the tube [16], increasing air flow resistance and ventilation pressure [17], and technical difficulty [18]. For the WEB, it is hard to reposition or redirect the blocker [19]. For the Fogarty catheter, it has the potential risk of herniation of the balloon, airway damage [20], and the possibility of an allergic response to the latex [19]. For endobronchial intubation with a single-lumen tube, it can be difficult to secure an adequate seal for lung deflation [21].

In addition to the potential associated complications, one-lung ventilation requires additional time and cost. The cost of a single-lumen tube and placing it is $50, compared with the $375 cost of placing a DLT in the United States [9]. In our hospital, the price is higher for the DLT (US $98) and Univent (US $179) compared with the single-lumen tube (US $3.37). A bronchoscopic examination is mandatory to confirm the positioning of the endotracheal tube for one-lung ventilation; this adds additional time even in experienced hands [9]. Moreover, on occasion, we have to inflate the lung because of decreasing oxygen saturation, or because the lung remained expanded owing to a migrated or incorrectly positioned endotracheal tube during the one-lung ventilation [9]; these problems add additional time to the procedure. The complications, high cost, and increased time for one-lung ventilation add significant burdens to what is an otherwise very short and simple procedure.

Cerfolio and associates [9] reported that they could obtain an adequate working field with low tidal volumes while both lungs are ventilated during VATS for pleural biopsies and talc pleurodesis. On occasion we would use two-lung ventilation during a VATS for primary spontaneous pneumothorax during a one-lung ventilation procedure to find an air leak, collapsed bleb, or bullae. At first, we partially clamped the bronchial lumen of the DLT, on the side undergoing surgery, with normally set tidal volumes to continue ventilating the lung undergoing surgery. Partial clamping resulted in a substantial decrease in the tidal volume delivered to the operative lung and provided a better working field than the complete two-lung ventilation, without any significant stenosis of the breathing circuit or air trapping. The degree of clamping could not be evaluated because it depends on the practical experience of the anesthesiologist. After several cases with no problems, we placed the DLT but inflated both lungs and used a low tidal volume. Next, we started to place a single-lumen tube in all cases during the VATS for a primary spontaneous pneumothorax. The one-lung ventilation, with low tidal volume during VATS for primary pneumothorax, provided almost the same visibility, and the operation time was not increased compared with the one-lung ventilation procedure. There were only 5 patients in whom an adequate operative field was not achieved in this study; this problem was solved by additional decrease of the tidal volume. Cerfolio and coworkers [9] routinely decreased the tidal volume to 150 to 250 mL in their study. The results of this study showed that a tidal volume of 4 mL/kg was sufficient to obtain an adequate surgical field; this tidal volume maintained optimal pulmonary function without hypoxia or hypercapnia. The most important benefits of this anesthetic procedure were that the time from intubation to the incision was reduced and the cost was dramatically decreased because a bronchoscopy was not needed.

According to the analysis of the last 50 cases using one-lung ventilation in our hospital, the average time from anesthesia induction to incision, operation time, and total anesthesia time was around 40, 33 and 83 minutes, respectively. The total anesthesia time was reduced by placing only a single-lumen tube; the time from anesthesia induction to incision was reduced without increasing the operation time, which was offset by the time spent altering the tidal volumes to improve visualization.

The patients with moderate-to-severe pleural adhesions on chest roentgenograph or chest CT, before closed thoracostomy, were excluded; this was because these findings require a larger working field to perform the adhesiolysis and to identify the targeted blebs or bullae in detail. In addition, obese patients, those with a small chest, those or without emphysema have reduced working area; in such cases one-lung ventilation should be used.

During this study, we prepared the WEB for one-lung ventilation in case we failed to obtain adequate surgical visualization with low tidal volumes under two-lung ventilation. Under bronchoscopic guidance, the WEB can be inserted through the endotracheal tube with the patient in any position, even the lateral position. This procedure can be performed within 10 minutes at our hospital if VATS with one-lung ventilation failed, and open thoracotomy could be performed. However, there was no case in which two-lung ventilation was converted to one-lung ventilation.

Video-assisted thoracoscopic surgery can be performed on patients who are awake under local anesthesia [22]; however, this is very difficult to do because of tachypnea, anxiety, and poor analgesia [9]. Video-assisted thoracoscopic surgery also can be done with the use of CO2 insufflation; however, this can cause a situation resembling a tension pneumothorax in the closed chest cavity, with a fall in the systolic blood pressure [23, 24]. The results of this study suggest that for a relatively short and simple procedure such as bleb resection, the two-lung ventilation anesthesia with low tidal volume was safe and effective and could provide an alternative option. In addition, this approach might be considered for patients who require obligate one-lung ventilation owing to impaired contralateral (nonoperated) lung function.

Postoperative air leaks occur mainly at the staple lines as a result of stapling problems, the incomplete resection of blebs, emphysematous changes in the resected area, or the crossing of staple lines [25]. Cho and colleagues [26] reported a reinforcement of the visceral pleura around the staple line with fibrin sealant and cellulose mesh in 219 patients with primary spontaneous pneumothorax; this procedure appears to be a reasonable way to prevent postoperative air leaks and recurrent pneumothorax by making visceral pleura thickened and fibrotic. In our hospital, we have performed this procedure routinely [26]. In this study, 3 patients had postoperative air leaks (6.5%), which was not better than in previous reports [27, 28]. However, there was no recurrence on the side that underwent surgery during the follow-up period.

In our hospital, bedside talc pleurodesis has been routinely performed to evaluate patients for postoperative air leaks and to monitor them for early complications such as arrhythmia, hypotension, infection, and respiratory failure [29]. However, the traditional method of treatment for postoperative air leaks, tube thoracostomy with large-bore chest tubes connected to continuous wall suction, requires hospitalization, is expensive, limits patient mobility, and can cause significant patient discomfort [30]. Ambulatory pleurodesis would be a feasible alternative to inpatient sclerosis, especially in patients with strong preferences for outpatient care [31].

Cerfolio and associates [9] reported that patents with a malignant pleural effusion or effusions of unknown cause are candidates for VATS with two-lung ventilation to perform pleural biopsies and talc insufflations. In addition, they recommended this procedure for cases requiring wedge resection of the lung for interstitial lung disease. In addition, it was thought that VATS for simple procedures such as a wedge resection of the lung as well as chemical and mechanical pleurodesis of the apex did not require two-lung ventilation in all patients, especially those who are tall and thin and have large barrel chests from emphysema.

In conclusion, the results of our study showed that VATS for primary spontaneous pneumothorax using two-lung ventilation anesthesia with low tidal volume was technically feasible compared with one-lung ventilation anesthesia.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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H. Kim, H. K. Kim, D.-Y. Kang, D.-K. Lee, Y. H. Choi, and S. H. Lim
A comparative study of two- versus one-lung ventilation for needlescopic bleb resection
Eur. Respir. J., May 1, 2011; 37(5): 1183 - 1188.
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