CHAPTER 27

ANAESTHESIA FOR CHEST SURGERY

(Thoracic Anaesthesia)

Outline: (This topic will be considered only briefly)

Introduction

Problems associated with chest surgery:

The open chest
Secretions
Air leak
General state of the patient
Blood loss
Cardiac problems
Atelectasis
(Only the first two of these will be dealt with in the text following. For more
detail consult a specialist text)

Anaesthetic management of a patient for chest surgery

The underwater drain

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INTRODUCTION

Chest surgery may be elective or emergency surgery and may involve

operations on the following structures:
• Chest wall: for instance for a tumour, or repair of chest wall injury
• Lungs, e.g. Lobectomy (removal of a lobe)
Pneumonectomy (removal of a lung)
Closure of a bronchopleural fistula (i.e. of a communication
between the bronchus and the pleural cavity)
• Heart + great vessels
• Oesophagus
• Diaphragmatic hernia
• Others eg pleurectomy, drainage of abscesses, decortication.

PROBLEMS ASSOCIATED WITH CHEST SURGERY

The problems of the open chest

Collapse of the lung. When the chest is opened the negative pressure in the
pleural cavity is replaced by atmospheric pressure. This positive pressure
collapses the lung. If the chest is opened and the patient breathes
spontaneously, two other strange phenomena occur, paradoxical respiration
and mediastinal flap.

Paradoxical respiration. Here, air passes from the collapsed lung into the
healthy lung during inspiration. During expiration air passes out from the
healthy lung, not into the atmosphere but back into the collapsed lung.
This cycle is repeated. It leads to hypoxia and hypercarbia, if the patient
continues to breathe spontaneously.

Mediastinal flap. The mediastinum is the space between the two lungs. It is
centrally situated and contains the heart, great vessels, oesophagus etc. It is
kept central by the equal pressures on the two sides of the chest. If the chest
cavity is opened on one side, the negative pressure is replaced by a positive
pressure. During inspiration the negative pressure on the healthy side
increases and this negative pressure draws the mediastinum towards the
healthy lung. During expiration the negative pressure (on the healthy side)
decreases and this pushes the mediastinum away from it. The mediastinum
therefore moves to and fro with each respiration. This is called mediastinal
flap.

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Mediastinal flap has two effects:
• The pressure of the mediastinum against the sound lung during
inspiration interferes with the exchange of gases in this lung. The
patient therefore becomes even more hypoxic and hypercarbic.
• This intermittent movement causes obstruction of the great vessels
(inferior and superior vena cava) at the opening into the heart. The
patient therefore becomes hypotensive.

Respiration is affected by collapse, paradoxical respiration and mediastinal

flap.

Circulation is affected by mediastinal flap and also by the absence of

negative pressure in the chest and the position of the patient.
For all forms of chest surgery, where the chest is opened, IPPV must be
used. IPPV will distribute the gases equally on both sides of the chest. This
will eliminate the problems of paradoxical respiration and mediastinal flap.
Further, it will prevent the collapse of the lung on the side of the open chest.

Secretions
This is another major problem with chest surgery. The affected lung may
contain pus, blood or secretions and these may contaminate the unaffected
side. Various techniques are used to reduce the danger of contamination:
• Position
• Suction
• An endobronchial tube (thus anaesthetising only the healthy lung)
• A bronchial blocker
• A double lumen tube.
These techniques are simply mentioned. A textbook of anaesthesia should
be consulted for more details.

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ANAESTHETIC MANAGEMENT OF A PATIENT FOR CHEST
SURGERY
Consultation with the surgeon is necessary in planning the anaesthetic
and choice of tube
Pre-operative care
Assess the patient’s general condition. Especially check the patient for
secretions and for pneumothorax/bronchopleural fistula.
Premedication: Oral benzodiazepine or opioids + atropine or
glycopyrrolate.
Intra-operative care
Induction: Use thiopentone, propofol or ketamine IV depending on the
state of the patient, followed by suxamethonium and intubation.
Use an ordinary PVC cuffed ETT.
If a special tube (e.g. double lumen) is required, it must only be used by
someone experienced.
Maintenance:
Ether/Air/O2/opioid/non-depolarising muscle relaxant. (EMO)
OR
Air or N2O/O2/ volatile/opioid/non-depolarising relaxant.
Analgesia can be supplemented by intercostal nerve blocks performed by
the surgeon under direct vision.
Good analgesia helps the patient cough up secretions post-operatively.
Reversal: If the chest is closed without a drain, inflate the collapsed lung
before the last few stitches are inserted.
Post-operative care
If an underwater drain is inserted, it must be checked regularly, in addition
to other post-operative observations.

THE UNDERWATER DRAIN

This has been devised to prevent air entering the pleural space, at the same
time allowing free drainage of fluid and air (if the intrapleural pressure rises
above atmospheric level).

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Apparatus
A large wide-mouthed bottle (Winchester bottle) with a rubber stopper
through which two glass tubes pass.
The upper end of the longer tube is connected to the drainage tube or
catheter by rubber or plastic tubing and a glass connection. The lower end
of the tube should be below the level of the sterile solution in the bottle.
The shorter tube is open to the atmosphere and its lower end projects just
beyond the rubber stopper. It allows air to escape naturally, or it could be
connected to a suction pump.
There are also disposable commercially produced units available for chest
drainage (e.g. Thoraseal).
If a clear passage exists between the bottle and the pleural space, the
column of liquid will swing.
If the pressure in the intrapleural space is below atmospheric pressure, a
column of liquid will be drawn up the tube. This column will swing during
respiration.

Fig 27.1 Underwater seal chest drainage system

If a broncho-pleural fistula exists the intrapleural pressure becomes

positive at the end of each expiration and air will bubble through the end of
the tube. If the patient coughs, a continuous stream of bubbles in the bottle
suggests a fistula is present.

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Obstruction of the drainage system
This is suggested by the absence of the respiratory swing in the tube.
Commonest sites of obstruction:
• In the dressings or bedding. These two sites of obstruction must be
investigated first.
• In the tube from outside, by pressure from the chest wall, the tubing
being too thin. In the lumen, a slough or a clot.
• At the end of the tube, debris causing occlusion against re-expanding
lung.
Management of blocked tube:
• Check for the site of blockage.
• Milk the tube in either direction or readjust its position but be careful
not to push it further into the chest as this may introduce infection.
• Irrigate with sterile saline.
• If these measures fail, remove the tube and replace it with a fresh one.

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