Bronchoplasty Periprocedural Care

Updated: May 09, 2014
  • Author: Dharani Kumari Narendra, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
  • Print
Periprocedural Care

Pre-Procedure Planning

Comorbidities have significant influence on survival, patients chosen to undergo bronchoplastic operations should be selected with caution. [12]

Factors that increase postoperative risk for any thoracic surgery include the following:

  • Advanced age
  • Coronary artery disease
  • Chronic obstructive pulmonary disease or asthma
  • Extensive lung resection
  • Immunocompromised status
  • Morbid obesity
  • Prolonged surgery
  • Smoking history
  • American Society of Anesthesiologists Physical Status class 2 or higher

Preoperative workup for thoracic surgeries should include the following:

  • Complete history and physical
  • Routine blood test
  • Type and matched blood
  • Pulmonary function test (lung volumes, FEV1 is the most important, and gas transfer D LCO)
  • Arterial blood gas
  • Cardiopulmonary exercise test

Cardiac workup

Patients who are completely asymptomatic and have no risk factors for coronary artery disease regardless of age do not need testing. Patients with symptomatic heart disease or evidence of a cardiac dysfunction need further assessments like a stress test.

Imaging

Depending on the type of pathology and procedure performed, metastatic workup should include CT of the chest, brain, and upper abdomen; positron emission tomography (PET) scanning; and MRI brain.

In malignant lung conditions, accurate TNM staging is a prerequisite; this may require bronchoscopy, mediastinoscopy, or PET scanning.

Patient education and consent

An informed consent should be obtained from all patients.

Next:

Equipment

Personal protective equipment

See the list below:

  • Sterile gown
  • Sterile gloves
  • Mask
  • Sterile drapes

Equipment for thoracotomy

See the list below:

  • Scalpel
  • Mayo scissors and Metzenbaum scissors
  • Rib spreaders
  • DeBakey forceps
  • Retractors
  • Electrocautery
  • Lung grasper (Duval lung clamp)
  • Satinsky vascular clamps (large and small)
  • Long and short needle holder
  • Sutures (silk, Vicryl)
  • Kelly and tonsil clamp
  • Endoscopic stapler
  • Mixter dissecting forceps
  • Skin stapler
  • High-volume suction device
  • Laparotomy packs
  • Chest tube, 28-32F
  • Water seal drainage system

Equipment for VATS

See the list below:

  • Thoracotomy tray (above)
  • Video thoracoscope 5-10 mm
  • Carbon dioxide insufflation
  • Trocar cannulas
  • Endoshears
  • Endoscopic hook
  • Mixter dissecting forceps
  • Forester lung clamp
  • Endoscopic stapler
  • Endoscopic biopsy forceps
  • EndoCatch bag

Equipment for balloon bronchoplasty

See the list below:

  • Flexible fiberoptic bronchoscope (outer diameter 6.3-7 mm, working channel 2.8-3.2 mm)
  • Bronchial balloons for bronchoplasty (balloons have variable expandable diameters of 6-7-8 mm, 8-9-10 mm, 10-11-12 mm, 12-13.5-15 mm, 15-16.5-18 mm)
  • SEMS-self expanding metal stent
  • Bronchial biopsy forceps for positioning of SEM
  • Silicon lubricant

Equipment for bronchial thermoplasty

See the list below:

  • Flexible Fiberoptic bronchoscope
  • Alair catheter
  • Alair Controller system
Previous
Next:

Patient Preparation

Anesthesia

For bronchoplastic procedures, general anesthesia is maintained with a double-lumen tube. Double-lumen endotracheal tubes also protect the opposite lung from contamination by purulent secretions. Single-lung ventilation is started before bronchotomy and switched back to normal ventilation after bronchial continuity is restored. For carinal procedures, direct surgical intubation of distal trachea using new sterile tube may be required.

Flexible bronchoscopy is performed under local anesthesia and conscious sedation. Rigid bronchoscopy requires intravenous or inhalation general anesthesia.

Positioning

The patient is placed in the lateral decubitus position with the nonoperative lung in the dependent position and the operated side of lung unventilated. The operating table is flexed to expand intercostal space.

Previous
Next:

Monitoring & Follow-up

Monitoring

Close intraoperative monitoring should be performed with continuos pulse oximetry; capnography; and placement of an arterial line for measurement of mean arterial pressure, oxygen, and carbon dioxide content.

Follow up

Postsurgery early extubation is the goal. However, based on duration and extent of surgery, some may require prolonged ventilatory support. Patients are monitored postoperatively in the surgical ICU for 24-48 hours or until stabilization of any postoperative complications.

Epidural analgesia and opioids are generally used for pain management in the postoperative period. Chest tubes are left in place until the air leak is resolved and the lung is fully expanded. Chest radiographs are performed daily to evaluate for pneumothorax, effusion, or parenchymal disease. The median time for removal of the chest tube is 2 days. [1, 2]

Median time to discharge is 7 days. Bronchoscopy is used liberally for pulmonary toilet and to ensure an intact anastomosis. Repeat bronchoscopy is required at time of discharge to confirm no dehiscence, stenosis, or strictures. After discharge, annual chest radiography and bronchoscopy are required to monitor for stenosis or recurrence of malignancy.

Balloon and thermal bronchoplasty

Monitoring pulse oximetry, heart rate, and blood pressure is essential during the procedure.

Chest radiography is performed after the procedure to ensure no pneumothorax exists. Most patients are discharged the same day after being monitored for a few hours.

Previous