Anesthetic management for thoracoscopic bilateral bullectomy in a patient with stage III pneumoconiosis, bilateral giant bullous emphysema, stage IV chronic obstructive pulmonary disease and profoundly impaired pulmonary function: a rare case report

Introduction

Pneumoconiosis is a chronic occupational lung disease caused by long-term inhalation and deposition of mineral dust, leading to progressive diffuse pulmonary fibrosis (1). As the disease progresses, lung tissue fibrosis may lead to vesicular emphysema, which can fuse into bullae and exacerbate clinical symptoms, significantly reducing quality of life or even causing death (2,3). The coexistence of bilateral giant bullous emphysema (GBE) with severely impaired lung function, chronic hypercapnia, and cor pulmonale in pneumoconiosis patients is exceedingly rare. Such a clinical profile presents formidable anesthetic challenges due to minimal cardiopulmonary reserve, high risk of hypoxemia during one-lung ventilation (OLV), and increased susceptibility to postoperative respiratory failure. Video-assisted thoracoscopic surgery (VATS) bullectomy can provide symptomatic and functional improvement in patients with giant bullae (4), but its safety and feasibility in those with profoundly compromised pulmonary function remain uncertain.

We report a rare case of stage III pneumoconiosis with bilateral GBE, stage IV chronic obstructive pulmonary disease (COPD), percentage of predicted forced expiratory volume in one second (FEV₁%) <20%, and cor pulmonale undergoing staged VATS bullectomy, emphasizing tailored anesthetic management strategies. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-284/rc).

Case presentation

A 67-year-old male patient was treated at the Thoracic Surgery Department of Emergency General Hospital (Beijing, China) and presented with progressive exertional dyspnea and chest tightness since 2006, which worsened with recurrent cough and dyspnea after 2013. By 2016, he required continuous 100% oxygen supplementation and was admitted for surgical management. All procedures performed in this case were in accordance with the ethical standards of the Ethics Committee of Emergency General Hospital, and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

On admission, chest computed tomography demonstrated stage III pneumoconiosis, bilateral multiple GBE, emphysema, and pulmonary infection (Figures 1,2). Arterial blood gas (ABG) analysis on 4 L/min nasal oxygen revealed pH 7.43, partial pressure of arterial oxygen (PaO₂) 54 mmHg, partial pressure of arterial carbon dioxide (PaCO₂) 58 mmHg, and pulse oxygen saturation (SpO₂) 89%. Pulmonary function testing showed FEV₁ 0.59 L (19.22% predicted), forced vital capacity (FVC) 1.19 L, and FEV₁/FVC 49.6%. Echocardiography demonstrated right atrial enlargement and pulmonary hypertension (53 mmHg). After multidisciplinary discussion, a staged surgical approach was selected: right-sided VATS bullectomy first, followed by contralateral surgery depending on postoperative recovery.

Figure 1 Chest X-radiography images before and after bilateral bullectomy. (A) Preoperative chest X-radiograph demonstrates bilateral multiple giant bullous emphysema with pneumoconiosis and emphysematous changes. (B) Follow-up chest X-radiograph obtained 2 years after bilateral bullectomy shows improved lung expansion compared with the preoperative image.

Figure 2 Representative chest computed tomography images before and after thoracoscopic bullectomy. (A,B) Preoperative computed tomography scans demonstrate bilateral multiple giant bullous emphysema with underlying pneumoconiosis and emphysematous changes, resulting in marked compression of the adjacent lung parenchyma. (C,D) Follow-up computed tomography scans obtained 2 years after bullectomy show satisfactory re-expansion of both lungs with improved lung inflation compared with the preoperative images.

Anesthesia plan

Unique clinical features included: (I) coexisting stage III pneumoconiosis, bilateral GBE, stage IV COPD, and cor pulmonale, a rarely reported multimorbidity pattern; (II) severely impaired lung function (FEV₁% 19.22%) with 24-hour oxygen dependence, far below the conventional surgical threshold; and (III) chronic hypercapnia with pulmonary hypertension and right atrial enlargement, indicating cardiopulmonary dysfunction and high perioperative risk.

OLV under general anesthesia was planned using the pressure-controlled ventilation-volume guaranteed (PCV-VG) mode. Selective continuous positive airway pressure (CPAP) was applied to the non-ventilated (operated) lung when SpO₂ decreased below 90% during OLV. If hypoxemia persisted with SpO₂ continuously below 80%, temporary bilateral lung ventilation was considered. Extracorporeal membrane oxygenation (ECMO) standby was arranged with predefined activation criteria, including refractory hypoxemia (SpO₂ <80% despite optimized OLV and CPAP, or bilateral lung ventilation) or uncompensated hypercapnia (PaCO₂ >80 mmHg with pH <7.20).

Anesthetic management

In the operating room, standard monitoring including ECG, arterial pressure, respiratory rate, SpO₂, bispectral index (BIS), was applied. General anesthesia were induced with 150 mg propofol, 10 µg sufentanil, and 50 mg rocuronium, followed by intubation with a No. 39 left double-lumen tube (Mallinckrodt-Endobronchial Tube, Ireland) confirmed by bronchoscopy. Maintenance was achieved with propofol (5–8 mg·kg⁻¹·h⁻¹) and remifentanil (0.2–0.3 µg·kg⁻¹·min⁻¹), targeting BIS 40–60. PCV-VG mode was selected to limit airway pressures (<30 cmH₂O). Initial OLV settings were tidal volume 350 mL, respiratory rate 18 bpm, I:E ratio 1:1.5 and fraction of inspiration oxygen (FiO₂) was 100%.

During OLV, progressive desaturation occurred after 10 minutes and was managed by applying CPAP to the non-ventilated (operative) lung, combined with right pulmonary vein clamping to reduce shunt fraction, which successfully stabilized SpO₂ above 90%. No CPAP was applied to the dependent ventilated lung. Permissive hypercapnia was accepted, with PaCO₂ fluctuating between 60–80 mmHg while maintaining pH >7.25. Thoracoscopy revealed dense adhesions and multiple bullae; seven bullae were resected. OLV duration was 115 minutes.

At the end of surgery, local infiltration analgesia was administered. The patient was extubated once awake but developed transient tachypnea (40–60 breaths/min) and dyspnea, which improved within 40 minutes under mask oxygen therapy in a semi-reclining position. The patient was transferred to intensive care unit with SpO₂ 91–96%. On postoperative day 1, subcutaneous emphysema, appearing in the right anterior thoracic, neck and trunk, developed and managed with chest drainage, and resolved gradually by day 9 without surgical intervention. It was a self-limited postoperative air leak rather than persistent pneumothorax, and left mild residual emphysema for 6 months. Details of ABG analysis were shown in Table 1.

Second-stage surgery and follow-up

Three months later, left-sided VATS bullectomy was performed with the same anesthetic strategy. In contrast to the first procedure, staple line reinforcement was applied to reduce the risk of postoperative air leakage. Three bullae were excised, OLV lasted 70 minutes, and intraoperative SpO₂ remained >95%. Post-extubation, PaCO₂ transiently increased from 55 to 90 mmHg but decreased spontaneously to 70 mmHg within 20 minutes without reintubation. Details of ABG analysis were shown in Table 2.

The patient was transferred back to ward and discharged 2 weeks later. At 2-year follow-up, he reported improved functional status, being able to walk without supplemental oxygen. Pulmonary function showed significant improvement, with FEV₁% increasing from 19.22% preoperatively to 28.62% postoperatively (Table 3).

Discussion

Pneumoconiosis is the leading cause of invalidity among occupational respiratory diseases. Although different countries have been promulgating various laws to protect the health of workers, it is still China’s most notified respiratory pathology (5,6). Tuberculosis, emphysema and bullous are pneumoconiosis complications and promote each other (7). GBE, referred to as vanishing lung syndrome, leads to pneumothorax, which is an acute life-threaten complication (8). A previous study revealed that the incidence of bullous in stage I, II, III of pneumoconiosis were 6.46%, 9.38%, and 42.50%, respectively (9). Although emphysema is frequently observed in pneumoconiosis, the coexistence of bilateral GBE, severely impaired pulmonary function (FEV₁% <20%), chronic hypercapnia, and cor pulmonale is exceedingly uncommon. To our knowledge, very few reports have described anesthetic management in such high-risk patients.

Although awake non-intubated VATS has been increasingly advocated for selected thoracic procedures (10), this strategy was considered unsuitable in this patient during multidisciplinary evaluation. However, given the patient’s profound chronic hypercapnia, pulmonary hypertension, and extremely limited ventilatory reserve made the patient highly vulnerable to hypoventilation and CO₂ retention under sedation. Moreover, coughing or respiratory distress during bullectomy could have precipitated bulla rupture or uncontrolled air leak. Therefore, a controlled intubated general anesthesia strategy with protective OLV was considered safer in this specific setting.

Several studies have reported increased mortality and morbidity when FEV₁% falls below 35–40% (11,12). A review concluded that those patients with an FEV₁% less than 35% may not benefit much from VATS (13). This case exemplifies the intricate anesthetic management required for a high-risk patient presenting with a rare multimorbidity pattern. The perioperative course was marked by several critical challenges, each demanding tailored interventions to ensure patient safety and surgical feasibility.

The foremost intraoperative challenge was maintaining adequate oxygenation during OLV in a patient with virtually no pulmonary reserve. In practice, we initiated OLV using PCV-VG mode. This mode was selected over traditional volume-controlled ventilation for its theoretical advantage in delivering a set tidal volume with a lower peak airway pressure, thereby reducing the risk of barotrauma to the compliant but fragile bullous lung tissue (14,15).

However, in this specific case, the PCV-VG strategy alone proved insufficient after 10 minutes, as evidenced by progressive desaturation. This prompted the implementation of a pre-planned rescue strategy: applying CPAP to the non-ventilated lung (16). From a physiological perspective, CPAP works by providing a constant pressure that prevents the complete collapse of the non-ventilated lung, thereby recruiting alveoli and reducing the intrapulmonary shunt fraction, which is the primary cause of hypoxemia during OLV (17). This clinical maneuver was combined with an intraoperative surgical technique, clamping the ipsilateral pulmonary vein. This action further improved oxygenation by directly reducing the blood flow to the non-ventilated lung, thereby decreasing the volume of shunt blood.

The management of ventilation deliberately embraced the strategy of permissive hypercapnia (18-20). The patient’s chronic respiratory acidosis provided a physiological rationale for tolerating further acute elevations in PaCO₂, which was up to 80 mmHg intraoperatively and 90 mmHg postoperatively. The clinical approach was not to aggressively normalize PaCO₂ through increased minute ventilation, which would risk volutrauma and barotrauma, but rather to prioritize lung-protective ventilation and accept a respiratory acidosis as long as the pH remains above 7.25. The theoretical basis for this safety is that the associated respiratory acidosis is generally well-tolerated hemodynamically, with evidence suggesting potential protective effects (21). The spontaneous resolution of severe hypercapnia post-extubation without intervention reinforces the safety of this monitored approach in selected patients with chronic hypercapnia.

A common complication following bullectomy in emphysematous lungs is a prolonged air leak. The technical refinement of using staple line reinforcement during the second surgery likely contributed to minimizing the risk of postoperative air leakage, as staple-line reinforcement has been associated with reduced staple-line air leakage and shorter chest drainage duration in pulmonary resection (22). In this case, the patient developed significant subcutaneous emphysema after the first operation, which is a clinical sign indicating communication between the airway and the subcutaneous tissue. The practical management involved ensuring the patency and suction of the chest drainage system, which successfully controlled the air leak and led to gradual resolution. This highlights the importance of anticipating and proactively managing this complication in the postoperative period.

The decision to perform a staged bilateral procedure was a key element of success. From a clinical perspective, a 3-month interval between right- and left-sided bullectomy allowed the patient to recover from the first operation and benefit from the functional improvement in the right lung before subjecting him to the stress of a second surgery. This was evident by the fact that the right-sided OLV was better tolerated, with SpO₂ maintained above 95% without requiring CPAP during the second anesthetic. This improvement can be attributed to the reduced cumulative surgical stress and the enhanced contribution of the newly expanded right lung to gas exchange during the left-sided procedure. Furthermore, the technical refinement of using staple line reinforcement during the second surgery likely contributed to minimizing air leak risk.

While ECMO remains a viable rescue option (23,24), its invasiveness and cost limit its applicability. According to the predefined ECMO activation protocol, ECMO would have been initiated in the presence of refractory hypoxemia or uncompensated hypercapnia. In this patient, after the application of CPAP to the non-ventilated lung and pulmonary vein clamping, SpO₂ remained above 90% and arterial pH remained above 7.25 despite transient hypercapnia. Therefore, the objective activation thresholds for ECMO were never reached. Moreover, it may also worsen bleeding and increase the duration of mechanical ventilation, especially in pneumoconiosis with poor pulmonary blood supply. Multidisciplinary consultation discussed and decided ECMO as possible option in emergency. Therefore, mastering and systematizing these sophisticated anesthetics techniques are essential, particularly in non-ECMO centers, to offer life-improving surgery to a broader population of high-risk patients.

Finally, post-operation FEV₁% increased from 19.22% to 28.62% and the patient’s subjective symptoms were relieved effectively after operation. The successful outcome underscores that a deeply individualized strategy, integrating precise clinical maneuvers with sound physiological principles, are paramount in high-risk patients.

As a single-case report, the findings of this study cannot be generalized. The observed outcome may be influenced by patient-specific disease characteristics, surgical expertise, and institutional resources. The absence of a comparative strategy with awake VATS or ECMO-assisted surgery, also limits conclusions regarding optimal management. In addition, the success of the anesthetic strategy depended on close multidisciplinary collaboration and experienced thoracic and anesthesia teams, which may not be universally available. Nevertheless, the detailed anesthetic decision-making framework presented here may provide practical guidance for managing similarly high-risk patients.

Conclusions

This case report details a successful anesthetic management of a rare and critically ill patient with pneumoconiosis, bilateral GBE, and profoundly compromised lung function. By implementing a staged surgical approach and employing a sophisticated OLV strategy, which adeptly utilized CPAP to the non-ventilated lung combined with pulmonary vein clamping to counteract refractory hypoxemia, we provided safe and effective anesthetic care. Therefore, developing a meticulously tailored anesthesia management strategy is essential to ensure the smooth execution of the surgical procedure, and ultimately led to a significant improvement in the patient’s pulmonary function and functional status.

Acknowledgments

We would like to thank the patient and his family for their cooperation and trust throughout the treatment process.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-284/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-284/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-284/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this case were in accordance with the ethical standards of the Ethics Committee of Emergency General Hospital, and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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