Abstract
We report a case of thoracoscopic Nd-YAG laser ablation of bullae in a patient with giant unilateral bullae and bilateral bullous emphysema. The patient was a 67-year-old man. He had very advanced emphysema with severe pulmonary dysfunction (Hugh-Jones IV), and required chronic home oxygen therapy. The patient's preoperative forced vital capacity was 1.3l (37% predicted value), forced expiratory volume in one second was 0.55l (42% predict-ed value), and PaO2, PaCO2, and pH were 73 mmHg, 47 mmHg, and 7.37, respectively. Anesthesia was maintained using isoflurane in 80-100% oxygen and additional fentanyl as required. A left-sided double-lumen endotracheal tube was inserted via direct laryngos-copy. Muscle relaxation was maintained with iv pancuronium. The lungs were ventilated using the Siemens Servo 900C ventilator, which provides pressure-controlled ventilation with high inspiratory flows. Continuous positive airway pressure of 1cm H2O was applied to the non-dependent lung. The PaO2 value was greater than 300 mmHg during surgery. Postoperatively, the patient was maintained on mechanical ventilation, and was successfully weaned from the ventilator 14 hours after surgery. On the 3rd postoperative day, when the patient coughed intensely to clear sputum, a large bronchopleural fistulae occurred. An emergency open thoracotomy was performed to seal the large bronchopleural air leaks. Anesthesia was maintained with sevoflurane in oxygen and thoracic epidural block (1% mepivacaine). A left-sided double-lumen endotracheal tube was extubated in the operating theater after surgery. The patient subsequently reported improvement in symptoms such as shortness of breath on exertion, and did not require supplementary oxygen.
