• Detailed clinical history & examination
• Full blood panel including infection and inflammation screen
• CT thorax (+/- PET scan)
• Bronchoscopy
• Biopsy (bronchoscopic or CT guided)

• BTS recommends a tripartite risk assessment model when assessing fitness for lung resection surgery including:
  • Risk of operative mortality
  • Risk of perioperative myocardial events
  • Risk of postoperative dyspnoea
• These can be used to discuss individual risks with the patient and MDT

• Lung isolation to provide optimal surgical field
• Minimisation of acute lung injury during one-lung ventilation
• Safe positioning and careful management of pressure points
• Multimodal analgesia to facilitate postoperative breathing and physiotherapy
• Restrictive fluid therapy and support of haemodynamics

Airway Management

• Usually requires lung isolation with either:
  • Double lumen tube (most surgeries performed on L sided tube unless chance of left-sided pneumonectomy in which case R sided tube necessitated
  • Single lumen tube and bronchial blocker
• Wedge resection can be performed in selected circumstances with spontaneously breathing patient using a supraglottic airway device

Monitoring

• Lines usually placed on site of surgery where possible to allow easier access
• Ensure wide-bore peripheral access
• Arterial line usually used for blood pressure monitoring and arterial sampling intraoperatively
• Central line may be recommended on a case by case basis for vasopressor infusions given goal of limited fluid therapy, particularly for larger resections such as pneumonectomy
• Catheter and temperature probe essential

Positioning

• Left or right decubitus position with a table break
• Requires fastidious checking of eye protection, pressure points, and neck position
• Tube position should be rechecked with bronchoscopy after positioning
• Compressions stockings and intermittent pneumatic calf compression devices should be used for DVT prophylaxis

Conduct

• Rigid bronchoscope may be performed prior to pneumonectomy
• Requires isolation and one-lung ventilation for surgical access
• Ventilation should be performed to minimise the risk of lung injury:
  • Low tidal volumes based on ideal body weight
  • Relatively high PEEP
  • Low driving pressures
  • Avoidance of hyperoxia

Fluids & Haemodynamics

• Fluids should be restricted whilst avoiding hypovolaemia:
  • Excess fluid independent risk factor for postoperative pulmonary oedema
  • No clear evidence for benefits of goal directed fluid therapy in lung resection surgery
• In the event of hypotension:
  • Haemorrhage must be excluded
  • Hypotension secondary to epidural infusion should be treated with vasoactive drugs

Analgesia

• Regional anaesthesia useful for intraoperative and postoperative analgesia:
  • Single shot:
    • Paravertebral block (anaesthetist or surgeon)
    • Intercostal blocks
    • Erector spinae plane block
    • Serratus anterior block
    • Retrolaminar block
    • Intrapleural analgesia (via drain)
  • Continuous:
    • Paravertebral infusion
    • Epidural infusion
      Intrapleural Infusion

Location & Review

• Traditionally managed in a high dependency environment
• Immediate management on specialist thoracic ward increasingly recognised as safe for low-risk patients

Monitoring & Investigations

• Close monitoring required to allow early recognition of complications

Supportive Care

• Fluids should be restricted whilst avoiding hypovolaemia:
  • Excess fluid independent risk factor for post-operative pulmonary oedema
  • Fluid balance within the first 24 h should not exceed 20 ml/kg
  • Fluid rate often limited to previous hour's urine output plus 20 ml in the immediate postoperative period
• Ongoing analgesia to allow effective cough and secretion clearance:
  • Opioid PCA
  • Epidural or paravertebral catheters
  • Adjunctive analgesics
• Early and intensive physiotherapy to promote secretion clearance and prevent atelectasis