Thoracic Surgery in the Presence of Pulmonary Insufficiency and Disability

The advances accomplished during the past two decades in anesthesia, surgical technique, pre-and postoperative care and the understanding of pathologic physiology have rendered it possible to perform successful thoracotomies and lung resections on patients with low pulmonary function. The following cases will illustrate some of these points. Case 1: A 32 year old woman had severe sacculocylindrical bronchiectasis of the right lower and middle lobes (FIgs. 1 and 2). Removal of the diseased and contracted lobes did not alter significantly her low pulmonary function tests (Table I). The Importance of clearing secretions and having the patient In optimal condition before the determination of these tests Is stressed. The postoperative change in the arterial oxygen saturation, although slight and within the limits of error, may reflect the elimination of venous blood passing through the diseased lobes without being properly oxygenated. Measurement of partial pressures of oxygen may have shown greater changes.’ The postoperative course was complicated by a severe transfusion reaction, bleeding, paralytic Ileus and empyema. The Immediate postoperative bleeding necessitated re-exploration and the empyema which occurred later responded to rib resection and open drainage. With a maximum breathing capacity of about 43 liters and a one second vital capacity of 28 per cent and careful postoperative tracheo-bronchlal toilet she withstood well the surgical procedures and complications and was in good health when last seen In our clinic. Case 2: A 53 year old man had his left lung removed because of extensive fibrocaseous tuberculosis. His preoperative maximum breathing capacity was only of 31 liters and about 32 per cent of his predicted value. Such a low value is always accompanied by a low arterial pressure of oxygen’ and denotes pulmonary insufficiency bordering disability. The decrease in maximum breathing capacity is proportionately more than the decrease in vital capacity pointing towards an element of dysfunction of the obstructive type.’ Despite such low pulmonary function, the left lung was removed. It was reasoned that its contribution to pulmonary function was extremely limited and probably detrimental. That proved to be so both subjectively and objectively (Table II). Case 3: A 65 year old man suffered from bullous emphysema and had severe pulmonary disability manifested by his inability to walk more than a couple of steps at a time. His maximum breathing capacity was of 15 liters and his one second vital capacity of 29 per cent. Because of the presence of huge lung cysts particularly on the left (Fig. 3), a left postero-lateral thoracotomy was performed, two huge air cysts were excised and the visible bronchial openings closed. Parletal pleurectomy was done, the remainder of the lung being studded with subpleural blebs. The postoperative course was uneventful. The use of bronchodilators, tracheo-bronchial hygiene and antibiotics enabled us to successfully carry through a thoracotomy on a patient with such a severe degree of pulmonary disability. He did feel better for a while, before succumbing to his basic disease about a month later, cor pulmonale and heart failure being the dominant features.