DP30: PERIOPERATIVE MANAGEMENT AND ANESTHETIC CONSIDERATIONS IN A PATIENT WITH SEVERE BULLOUS EMPHYSEMA
Camila Magalhaes Funatsu, MD; Ruiyang Huang, BSc; Jacqueline Ragheb, MD, FFARCSI, FJFICMI, DipPOM
University of Miami
Introduction/Background: Patients with severe bullous emphysema pose significant anesthetic challenges, particularly when general anesthesia and positive pressure ventilation are required. The presence of large, fragile bullae increases the risk of rupture under pressure, potentially leading to pneumothorax and cardiovascular collapse. Comprehensive preoperative evaluation, judicious anesthetic selection, and meticulous intraoperative management are critical to avoiding serious complications.
Although anesthetic considerations in bullous lung disease have been described, available guidance is limited, particularly for non-thoracic or robotic-assisted surgeries, which present additional intraoperative complexities. This report details the perioperative management of a patient with severe bullous emphysema and COPD initially scheduled for robotic-assisted hernia repair, emphasizing the importance of individualized planning and anesthetic choice to prevent barotrauma.
Case Report (Methods/Results): A 62-year-old man with COPD, hypertension, schizophrenia, and a 40-pack-year smoking history presented for repair of a reducible right inguinal and small umbilical hernia. Preoperative chest CT revealed severe bilateral bullous emphysema with near-complete replacement of the right upper and middle lobes by giant bullae. Pulmonary function testing revealed a severe obstructive pattern, with a diffusion capacity of 50% of predicted. Although clinically stable without oxygen dependence, the risk of bulla rupture during pneumoperitoneum and positive pressure ventilation was deemed high.
After multidisciplinary consultation involving anesthesia, surgery, and pulmonology, the surgical plan was modified from robotic-assisted to open hernia repair. The procedure was performed under spinal anesthesia with propofol sedation and supplemental oxygen via nasal cannula. The patient remained hemodynamically stable, required no ventilatory support intraoperatively or postoperatively, and was discharged on postoperative day two after an uncomplicated recovery.
Discussion/Conclusion: Patients with severe bullous emphysema are at high risk for barotrauma and tension pneumothorax under general anesthesia due to nitrous oxide expansion, mechanical overdistension, or sudden airway pressure fluctuations. Robotic procedures further increase risk through pneumoperitoneum, steep Trendelenburg positioning, and elevated airway pressures. Reported barotrauma rates in ventilated adults range from 6–13%, with a higher incidence in COPD patients.
Preoperative identification and multidisciplinary planning are essential. Standard assessment tools, such as spirometry, may underestimate risk; therefore, imaging modalities like CT and MRI should be reviewed to assess the extent of bullous disease. In selected cases, preoperative interventions such as endobronchial valve placement, bullectomy, or lobectomy may be warranted. Whenever feasible, regional or neuraxial anesthesia should be prioritized to minimize the need for positive pressure ventilation. When general anesthesia is unavoidable, lung-protective strategies and potential lung isolation are advised.
This case demonstrates the importance of early recognition of severe bullous disease and the value of multidisciplinary coordination in perioperative planning. Tailored anesthetic and surgical strategies can significantly reduce the risk of barotrauma and optimize outcomes in patients with advanced emphysematous lung disease.