Introduction: Manypatients withemphysemawill develop cystic air spaces in the lung parenchymaknownas bullae. Positive pressureventilation increases the pressure in a bulla and increases the risk of rupture and tension pneumothorax. Therefore, anesthesiamanagement, for surgeries other than lung volume reduction surgery (LVRS), is challenging in these patients.Case Presentation: A 62-year-old male patient was brought to the emergency department due to a fall resulting in head trauma anda leak of CSF from a previous surgical site of a CP (cerebellopontine) angle tumor. The chest CT scan depicted bilateral bullae in thelungs. Anesthesia was induced and maintained with an inhalational method using Sevoflurane and spontaneous mask ventilation.Conclusions: Patients with bilateral bullae could be managed with spontaneous ventilation; one of the safe choices is inhalationalinduction and maintenance with Sevoflurane

Asadi, Saman

Mottaghi, Kamran

Nashibi, Masoud

Safari, Farhad

English

Journals Portal, Shahid Beheshti University of Medical Sciences

Ann Anesth Crit Care . 2016 December; 1(1):e10190.Published online 2016 December 28.doi: 10.5812/aacc.10190.Case ReportAnesthesia Management of Bullous Emphysema in Patient Candidatefor CraniotomyKamran Mottaghi,1 Saman Asadi,2 Farhad Safari,1 and Masoud Nashibi1,*1Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran2Department of Anesthesiology, Shiraz University of Medical Sciences, Shiraz, Iran*Corresponding author: Masoud Nashibi, Makhsous St, Kamali St, South Kargar Ave, Tehran, Iran. Tel: +98-2155424040, E-mail: masoudnashibi@sbmu.ac.irReceived 2016 October 30; Accepted 2016 December 20.AbstractIntroduction: Many patients with emphysema will develop cystic air spaces in the lung parenchyma known as bullae. Positive pres-sure ventilation increases the pressure in a bulla and increases the risk of rupture and tension pneumothorax. Therefore, anesthesiamanagement, for surgeries other than lung volume reduction surgery (LVRS), is challenging in these patients.CasePresentation: A 62-year-old male patient was brought to the emergency department due to a fall resulting in head trauma anda leak of CSF from a previous surgical site of a CP (cerebellopontine) angle tumor. The chest CT scan depicted bilateral bullae in thelungs. Anesthesia was induced and maintained with an inhalational method using Sevoflurane and spontaneous mask ventilation.Conclusions: Patients with bilateral bullae could be managed with spontaneous ventilation; one of the safe choices is inhalationalinduction and maintenance with Sevoflurane.Keywords: Anesthesia, Bullous Emphysema, Craniotomy, Spontaneous Ventilation1. IntroductionMany patients with emphysema will develop cystic airspaces in the lung parenchyma known as bullae. Bulla for-mation is due to loss of structural support tissue in thelung causing elastic recoil of surrounding parenchyma (1,2). Whenever positive pressure ventilation is used, thepressure in bullae will become positive in relation to theadjacent lung tissue and the bullae will expand with an in-creased risk of rupture and tension pneumothorax (1-3).Although many studies have been performed regard-ing the medical or surgical management and anestheticconsiderations in the surgical treatment of bullae, knownas lung volume reduction surgery (LVRS), there are, how-ever, limited reports about anesthesia management insurgeries other than LVRS in patients with bullous emphy-sema (2, 4).Here we present a case of a patient with bilateral bul-lae, who was a candidate for craniotomy, which led to thechallenge of providing him with induction as well as main-tenance anesthesia.2. Case PresentationA 62-year-old male patient was brought to the emer-gency department with loss of consciousness due to ex-periencing a fall leading to head trauma, but without anyconvulsions. The patient had a history of a cerebellopon-tine (CP) angle tumor resection surgery 12 months prior.Vital signs included a blood pressure of 120/95 mmHg,a pulse rate of 90 beat/min, a room air SpO2 of 94% and arespiratory rate of 16 b/min.Echocardiography variables were: normal left ventri-cle (LV) size, good LV systolic and diastolic function, LV ejec-tion fraction of 55%, no regional wall motion abnormal-ity at rest, mild tricuspid regurgitation, mild aortic insuf-ficiency, mild mitral regurgitation and a pulmonary arterypressure (PAP) of 26 mmHg. All other lab data were normal.On the third day after intensive care unit (ICU) ad-mission, the patient developed a cerebrospinal fluid (CSF)leak and therefore became a candidate for surgical repair.The leak emerged from his previous surgical site. Both aclinical examination and a computerized tomography (CT)scan did not show any signs of a raised intracranial pres-sure (ICP).During the preoperative visit, a chest X-ray (CXR) dis-played large emphysematous bullae. A chest CT scan alsodepicted bilateral bullae in the apical area of the lungs (Fig-ures 1-3). The patient did not have a lung infection duringthe preoperative visit.2.1. AnesthesiaThe surgery was planned to be performed in supineposition. All the standard monitoring was attached in-cluding electrocardiography, non-invasive blood pressuremonitoring, end-tidal CO2, pulse oximetry, and cerebralstate monitoring (CSM) for determining the depth of anes-thesia.Copyright © 2016, Iranian Society of Anesthesiology and Critical Care. This is an open-access article distributed under the terms of the Creative CommonsAttribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just innoncommercial usages, provided the original work is properly cited.Mottaghi K et al.Figure 1. Chest X-RayFigure 2. Chest CT ScanThe challenge for the anesthesia team was inductionand maintenance of general anesthesia, and maintainingthe airway, while avoiding positive pressure ventilation(PPV) to prevent bullae rupture.Anesthesia was induced by inhalational method usingSevoflurane via spontaneous mask ventilation. By increas-ing Sevoflurane and the spontaneous mask ventilation, thedepth of anesthesia was gradually increased to an appro-priate level. At this point, the patient had a regular sponta-neous breathing, fixed pupils at the midline and a CSM ofFigure 3. Chest CT Scan35. Afterwards, Lidocaine 1 mg/kg/IV was administered andthe trachea intubated under direct laryngoscopy using an8 mm ID spiral endotracheal tube. The patient had nomovement or bucking during intubation. Anesthesia wasmaintained with Sevoflurane in order to keep the depthof anesthesia at a cerebral state index (CSI) of 40 - 50 withspontaneous ventilation. We asked the surgeon to use 5 mlof Bupivicaine to provide local anesthesia at the incisionline. Duration of surgery was 45 minutes and the patienthad no movement or bucking during the entire procedure.No muscle relaxant was required. End tidal CO2 monitor-ing (EtCO2) revealed that the patient did not have hyper-capnia.After craniotomy, the site of the CSF leak was coveredwith a dural patch and the surgical procedure was termi-nated after the dura and the cranium had been closed. Atthe end of surgery, Sevoflurane was discontinued and thetrachea extubated. The patient was transferred to the ICUand a control CXR was performed. The patient did not de-velop any pneumothorax during the postoperative period.3. DiscussionDifferent etiologies have been suggested as the prob-able origin of bullae such as smoking, cocaine abuse,sarcoidosis, Marfan’s syndrome, Ehlers-Danlos syndrome,cadmium exposure (5), Marijuana abuse (6), and apnea div-ing activity during young adult ages (7).2 Ann Anesth Crit Care . 2016; 1(1):e10190.Mottaghi K et al.Bullae are thin-walled air-filled intraparenchymal lungspaces induced by the loss of alveolar structural tissue. Gi-ant bullous emphysema (GBE) refers to bullae greater than1 cm in diameter. Bullae do not take part in gas exchangeand cause hypoxia and dyspnea (8). In the usual sponta-neous ventilation in tidal volume range, bullae are morecompliant than normal lung and preferentially fill dur-ing spontaneous ventilation. However, beyond the normaltidal volume range, bullae become much less compliantand the intra-bulla pressure rises acutely as airway pres-sure increases (9).During spontaneous ventilation, the intra-bulla pres-sure is negative with respect to surrounding lung tissue(10). However, whenever positive pressure is used, theintra-bulla pressure will rise in relation to surroundinglung regions. There is a risk of hyperinflation and rupturewhenever positive pressure is used (1-3, 8). Bulla rupturecould be life threatening due to hemodynamic collapsefrom a tension pneumothorax or inadequate ventilationdue to a resultant bronchopleural fistula (1-3, 11).Inhalational and intravenous anesthetic agents havebeen used for the induction and maintenance of anesthe-sia in emphysematous patients, who are candidates forlung volume reduction surgery (LVRS). To achieve the goalof early tracheal extubation, short-acting hypnotics shouldbe used (1).Most reviews and reports are related to anesthesiamanagement and ventilation during LVRS. The anestheticconsiderations for patients with bullae are to prevent rup-ture and pneumothorax. It is best not to place a prophylac-tic chest tube because this may enter the bulla and create afistula (12). These patients could be ventilated using a pres-sure or volume controlled mode. For the ventilation of twolungs, a tidal volume less than 9 mL/kg and for the ventila-tion of one lung, less than 5 ml/kg with a low respiratoryrate and a inspiration to expiration ratio of 1:3 to 1:5 is ad-visable to keep the peak airway pressure under 15 cmH2O (1,2). By applying these adjustments, awareness would not beuncommon, therefore brain function monitoring shouldbe considered (1). Nitrous oxide should be avoided in pa-tients with blebs or bullae (1, 3).In our case, the duration of surgery was 45 minutes,which is suitable for short-term preservation of sponta-neous ventilation. It is important to note that in surgerieswith longer duration, maintenance of spontaneous ven-tilation and appropriate depth of anesthesia at the sametime might be difficult. One good option is using Sevoflu-rane.In conclusion, patients with bilateral bullae could bemanaged with spontaneous ventilation; one of the choicesis inhalational induction and maintenance with Sevoflu-rane. Lung bullae could be complicated by sudden ruptureand development of a tension pneumothorax. Issues re-lated to lung bullae that could arise should be reviewed be-forehand.FootnotesFinancial Disclosure: No disclosures.Funding/Support: None.References1. Brister NW, Barnette RE, Kim V, Keresztury M. Anesthetic consider-ations in candidates for lung volume reduction surgery. Proc AmThorac Soc. 2008;5(4):432–7. doi: 10.1513/pats.200709-149ET. [PubMed:18453351].2. Ruiz Carbonell JR, Soliveres Ripoll J, Solaz Roldan C, Lluch Oltra A.[Anesthetic management in a patient with bullous emphysema]. RevEsp Anestesiol Reanim. 2008;55(4):253–4. [PubMed: 18543512].3. Roberta L, Hines KEM. Stoelting’s anesthesia and co-existing disease.6 ed. Philadelphia: Elsevier/Saunders; 2012.4. Mozanski M, Rustecki B, Kalicki B, Jung A. Thermal imaging evalua-tion of paravertebral block for mastectomy in high risk patient: casereport. J Clin Monit Comput. 2015;29(2):297–9. doi: 10.1007/s10877-014-9599-x. [PubMed: 25059839].5. Henao-Martinez AF, Fernandez JF, Adams SG, Restrepo C. Lung bullaewith air-fluid levels: what is the appropriate therapeutic approach?Respir Care. 2012;57(4):642–5. doi: 10.4187/respcare.01372. [PubMed:22005505].6. Golwala H. Marijuana abuse and bullous emphysema. Lung India.2012;29(1):56–8. doi: 10.4103/0970-2113.92365. [PubMed: 22345916].7. Luttecke-Hecht C, Hirche TO. Bullous emphysema - Not alwaysnicotine-related!: Unusual distribution of emphysema in a patientwith a rare hobby. Respiratory medicine case reports. 2014;12:44–6.8. Van Bael K, La Meir M, Vanoverbeke H. Video-assisted ThoracoscopicResection of a Giant Bulla in Vanishing Lung Syndrome: case re-port and a short literature review. J Cardiothorac Surg. 2014;9:4. doi:10.1186/1749-8090-9-4. [PubMed: 24387696].9. Hau AT, Jones BA, Olutoye OA. Apical bullae and sponta-neous pneumothorax. Anesthesiology. 2013;119(1):201. doi:10.1097/ALN.0b013e31828ce62e. [PubMed: 23435384].10. Chakravarthy M, Jawali V. Differential ventilation with spontaneousrespiration for bilateral emphysema. Asian Cardiovasc Thorac Ann.2007;15(3):35–7. [PubMed: 17540979].11. Schipper PH, Meyers BF, Battafarano RJ, Guthrie TJ, Patter-son GA, Cooper JD. Outcomes after resection of giant em-physematous bullae. Ann Thorac Surg. 2004;78(3):976–82. doi:10.1016/j.athoracsur.2004.04.005. [PubMed: 15337031] discussion976-82.12. Bansal S, Surve RM, Venkatapura RJ. Anesthetic management of aparaparetic patient with multiple lung bullae. J Neurosurg Anesthe-siol. 2014;26(1):85–6. doi: 10.1097/ANA.0b013e3182973366. [PubMed:24256764].Ann Anesth Crit Care . 2016; 1(1):e10190. 3

Anesthesia Management of Bullous Emphysema in Patient Candidate for Craniotomy

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Anesthesia Management of Bullous Emphysema in Patient Candidate for Craniotomy

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