DP59: ANESTHETIC DECISION-MAKING FOR AMBULATORY BREAST SURGERY IN SEVERE BRONCHIECTASIS
Danielle Chism, DO; Nigel Gillespie, MD; Ryan Chadha, MD
Mayo Clinic Florida
Introduction: Ambulatory surgery in elderly patients with advanced pulmonary disease presents significant anesthetic challenges. Severe bronchiectasis is associated with impaired secretion clearance and an increased risk of perioperative respiratory failure. These risks are magnified in patients with chronic respiratory failure requiring continuous oxygen therapy. Although breast-conserving surgery is commonly performed under general anesthesia with airway instrumentation, alternative approaches that avoid mechanical ventilation may reduce pulmonary complications in high-risk patients. We present a case that highlights anesthetic decision-making for a high-risk patient undergoing partial mastectomy in an ambulatory setting.
Case Presentation: An 87-year-old female with severe chronic bronchiectasis, chronic respiratory failure on 3 L/min continuous oxygen, diastolic heart failure, and marked positional dyspnea presented for a right partial mastectomy for malignant neoplasm of the breast. She was unable to tolerate the supine position due to dyspnea. Preoperative evaluation focused on pulmonary reserve, positional intolerance, and suitability for same-day discharge. Anesthetic options included general anesthesia with an endotracheal tube versus general anesthesia with spontaneous ventilation facilitated by regional blockade.
A right-sided thoracic paravertebral block was performed preoperatively at levels T3-4, T4-5, and T5-6 using 0.5% ropivacaine, 5 mL per level (total 15 mL). Local infiltration with 1% lidocaine (2 mL) and fentanyl 100 mcg were administered for block placement. Intraoperatively, an additional 50 mcg of fentanyl was given prior to incision and sedation was provided with a propofol infusion at 50 mcg/kg/min while maintaining spontaneous ventilation with supplemental oxygen via nasal cannula. The patient was positioned in a ramped, semi-upright position. Periods of unresponsiveness to verbal stimulation were observed, consistent with general anesthesia. Intermittent upper airway obstruction was managed with repositioning.
The surgical procedure involved breast-conserving surgery with limited tissue dissection. An additional 50 mcg of fentanyl was given at the end of the procedure.
Results: The patient tolerated the paravertebral block and general anesthesia without respiratory compromise. Oxygenation and hemodynamics remained stable, and spontaneous ventilation was preserved throughout the procedure. No airway device was required. In the recovery unit, pain scores were 0 without additional opioid requirements. The patient returned to baseline respiratory status without increased oxygen requirements and discharged safely.
Discussion/Conclusion: Severe bronchiectasis is associated with impaired secretion clearance, atelectasis, and an increased risk of perioperative respiratory failure. In this case, general anesthesia was achieved with intravenous agents while preserving spontaneous ventilation and avoiding airway instrumentation. Thoracic paravertebral blockade reduced surgical stimulation and opioid requirements, providing postoperative analgesia while minimizing risk of respiratory depression. Although general anesthesia without a secured airway carries risks of hypoventilation and airway obstruction, careful positioning and airway readiness mitigated these concerns. This case demonstrates that in select high-risk pulmonary patients, spontaneous ventilation under general anesthesia combined with effective regional blockade can allow safe completion of ambulatory breast surgery.