Version July 2025
INTRODUCTION —
Open pulmonary resection is most commonly performed to treat a known intrathoracic malignancy such as lung cancer or to diagnose pathology of a suspicious nodule or mass. Other indications for pulmonary resection include management of thoracic trauma, pulmonary infection, and bronchopleural fistula.
Surgical procedures for these indications include sublobar resection (segmentectomy, wedge resection), lobectomy, or removal of more than one lobe (bilobectomy, lobectomy plus segmentectomy). A pneumonectomy involves removal of the entire lung. Extrapleural pneumonectomy involves resection of the diseased lung, as well as mediastinal lymph nodes, ipsilateral pericardium, hemidiaphragm, or parietal or visceral pleura. Although an open thoracotomy may be selected for many of these procedures, a pneumonectomy or any procedure requiring conducting airway resection (eg, carinal resection) involves higher risk for intra- and postoperative complications compared with wedge resection of a small nodule. Surgical procedures for simple and complex pulmonary resections are reviewed elsewhere. (See "Overview of pulmonary resection" and "Surgical management of chest wall tumors".)
This topic reviews anesthetic management of patients undergoing thoracotomy for open pulmonary resection, including preanesthetic consultation and preparation, intraoperative anesthetic management, and postoperative pain management. Anesthetic care of patients undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary resection is discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection" and "Overview of minimally invasive thoracic surgery".)
Lung isolation techniques that are typically required for any of these procedures and management of one lung ventilation (OLV) are discussed separately. (See "Intraoperative one-lung ventilation" and "Techniques to achieve lung isolation during general anesthesia".)
Enhanced recovery after thoracic surgery (ERATS) focuses on multidisciplinary standardization of perioperative care to expedite recovery, decrease hospital length of stay, reduce complications, and improve outcomes following pulmonary resection and other thoracic procedures, as discussed separately. (See "Overview of enhanced recovery after cardiothoracic surgery".)
PREANESTHETIC CONSULTATION
History and examination — The preoperative consultation focuses on assessment of pulmonary and cardiovascular risks:
●Pulmonary risk – Patients with chronic obstructive pulmonary disease (COPD) and lung cancer have a worse prognosis than those without parenchymal lung disease, with a higher risk of bronchopleural fistula, pneumonia, prolonged air leakage, and prolonged mechanical ventilation after pulmonary resection [1]. Preoperative pulmonary evaluation for lung resection and the preanesthesia consultation for patients with COPD are discussed in separate topics. (See "Preoperative physiologic pulmonary evaluation for lung resection" and "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Preanesthesia consultation'.)
●Cardiovascular risk – Patients with lung cancer may have comorbid cardiovascular disease. Evaluation of perioperative cardiovascular risk is discussed separately. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
In addition, the anesthesiologist notes the presence or absence of:
●Dyspnea due to generalized weakness or metastatic disease. Patients with severe dyspnea or weakness from any cause may require temporary controlled ventilation in the postoperative period.
●Tumor invasion into adjacent structures causing shoulder and arm pain or neurologic deficits due to brachial plexus compression. Such preexisting abnormalities should be documented since the lateral decubitus and other patient positions employed for lung resection surgery may cause brachial plexus injury. (See "Patient positioning for surgery and anesthesia in adults".)
●Facial and/or upper extremity edema suggesting obstruction of the superior vena cava (SVC) by a large mass or associated mediastinal lymphadenopathy. SVC syndrome may affect vascular access and airway control during induction of anesthesia. (See "Anesthesia for patients with an anterior mediastinal mass".)
●Pleuritic chest pain due to pleural invasion by the tumor or chronic pain due to metastatic disease. Baseline pain may impact efficacy of postoperative pain management strategies. (See 'Post-thoracotomy pain management' below.)
●Frailty is recognized as a predictor of poor postoperative outcomes after lung resection [2], and is independently associated with increased in-hospital mortality, morbidity, and use of resources, especially after pneumonectomy [3]. Integration of standardized frailty scores in preoperative risk assessment may provide insight into expected clinical outcomes after lung resection. (See "Anesthesia for the older adult", section on 'Assessment for frailty'.)
Preoperative prehabilitation programs emphasizing nutritional supplementation, smoking cessation, physical and cognitive exercise, and stress reduction may be beneficial for selected thoracic surgical patients with higher risk due to frailty, older age, concurrent comorbid diseases, and/or poor functional capacity due to malignancy or malnutrition is discussed elsewhere. (See "Overview of enhanced recovery after cardiothoracic surgery", section on 'Prehabilitation for selected patients' and "Overview of prehabilitation for surgical patients".)
Preoperative tests
●Pulmonary function tests – Preoperative forced expiratory volume in one second (FEV1) and the diffusing capacity for carbon monoxide (DLCO) are useful to predict potential difficulty with extubation and the risk of postoperative pulmonary complications. Preoperative tests of pulmonary function are discussed in detail elsewhere. (See "Preoperative physiologic pulmonary evaluation for lung resection", section on 'Preoperative pulmonary function'.)
●Imaging – Available imaging studies are reviewed for evidence of:
•Tumor obstructing the tracheal or bronchial lumens or altered airway anatomy due to previous surgery or radiotherapy, which may affect airway management planning and endobronchial intubation techniques. (See "Techniques to achieve lung isolation during general anesthesia".)
•Pleural effusions, which may affect oxygenation during one lung ventilation (OLV). (See "Intraoperative one-lung ventilation".)
•Pericardial effusion, since cardiac tamponade may cause hypotension or even cardiac arrest during induction of general anesthesia. (See "Anesthesia for patients with pericardial disease and/or cardiac tamponade", section on 'Induction of anesthesia'.)
●Laboratory studies – Routine laboratory tests typically obtained prior to open pulmonary resection include complete blood count; tests of hemostasis, electrolytes, and glucose; and tests of kidney function. Preexisting kidney function impairment is associated with postoperative acute kidney injury, pulmonary complications, and mortality after open pulmonary resection [4-6].
Abnormalities in hemostasis are noted as these may be a contraindication for some neuraxial and regional anesthetic techniques for pain management:
•Thoracic epidural analgesia (TEA) or intrathecal techniques – (See 'Post-thoracotomy pain management' below and "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication", section on 'Spinal epidural hematoma (SEH)'.)
•Most clinicians consider anticoagulation to be a relative contraindication to thoracic paravertebral block (TPVB) placement due to the deep and noncompressible location of the paravertebral space [7]. (See "Thoracic paravertebral block procedure guide" and "Thoracic nerve block techniques".)
•Other regional nerve blocks (eg, erector spinae plane block, intercostal nerve blocks, serratus anterior plane or pectoralis nerve blocks) can usually be performed using ultrasound guidance, although the risks of performing these blocks in patients with coagulation abnormalities have not been established. (See "Thoracic nerve block techniques" and "Erector spinae plane block procedure guide".)
A type and screen for red blood cell (RBC) transfusion is performed for all anatomic pulmonary resections, including segmentectomies. If the antibody screen is positive, at least two units of RBCs should be available, as clinically significant hemorrhage from pulmonary or bronchial vessels may occur during dissection. Otherwise, availability of crossmatched units is based on the patient's medical comorbidities (eg, coronary disease, anemia) and the surgical risk of major hemorrhage. (See "Pretransfusion testing for red blood cell transfusion".)
●Electrocardiogram (ECG) – A preoperative ECG is typically obtained prior to intrathoracic surgery. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Electrocardiogram for some patients'.)
Planning for postoperative analgesia — Establishing a plan for postoperative analgesia is important for patients undergoing a large incision (eg, large lateral or anterior thoracotomy, clamshell incision) (see "Overview of pulmonary resection", section on 'Open approaches'). Postoperative analgesic options are discussed with the patient, and anatomical sites for regional analgesic techniques are examined. TEA and TPVB analgesia are effective techniques that are used when feasible. Thrombocytopenia or chronically administered anticoagulant and/or antiplatelet medications may affect the timing of safe placement of an epidural or paravertebral catheter, as discussed separately (see "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication"). Alternative analgesic techniques are discussed with the patient if neither TEA nor TPVB is appropriate, or if attempted preoperative placement of a TEA or TPVB catheter might be unsuccessful. (See 'Post-thoracotomy pain management' below.)
PREANESTHETIC PREPARATION
●Preparation for airway control – Preoperative preparation includes (see 'Airway control' below):
•An assortment of specialized endotracheal tubes (ETTs), including a variety of double-lumen ETTs (DLTs) and/or bronchial blockers for one lung ventilation (OLV). Single-lumen endobronchial tubes may be useful for facilitating lung isolation in surgeries involving the carina and/or mainstem bronchus.
•A flexible bronchoscope.
•A circuit for delivering continuous positive airway pressure (CPAP) to the nonventilated lung to manage hypoxemia.
Lung isolation techniques are discussed in detail separately. (See "Techniques to achieve lung isolation during general anesthesia".)
●Preparation for hemodynamic monitoring – (See 'Monitoring' below.)
●Preparation of warming devices – Equipment to prevent hypothermia is prepared, including warming devices for fluid and/or blood administration, and forced air or other body warming devices. Risk for hypothermia begins shortly after induction due to exposure of most of the total body surface area to cold ambient temperatures during positioning and surgical prepping. Subsequently, the large intrathoracic incision limits warming efforts.
●Regional analgesic technique – Preparation for placement of a catheter for thoracic epidural analgesia (TEA), thoracic paravertebral block (TPVB) analgesia, or an alternate technique is necessary. These catheters are typically placed in the immediate preoperative period, or in the operating room shortly before induction of general anesthesia (see 'Thoracic epidural analgesia' below and 'Thoracic paravertebral block' below). However, a TPVB technique may be accomplished after induction or directly in the open chest during surgery. Preparations are made in advance for one of these techniques (see 'Post-thoracotomy pain management' below). This includes ensuring availability of equipment for the selected regional technique and analgesic agents for bolus dosing and/or continuous infusion.
●Enhanced recovery pathways – Day-of-surgery strategies for enhanced recovery after thoracic surgery are applicable. These include limiting fasting to allow clear fluids up until two hours before the procedure, and minimizing or avoiding benzodiazepines. (See "Overview of enhanced recovery after cardiothoracic surgery", section on 'Limit fasting' and "Overview of enhanced recovery after cardiothoracic surgery", section on 'Preoperative medication management'.)
INTRAOPERATIVE ANESTHETIC MANAGEMENT
Monitoring — All noninvasive and invasive monitors are secured to avoid displacement during repositioning, surgical prepping, and draping. After positioning, access to these may be limited. (See 'Positioning' below.)
●Noninvasive monitors – Unique considerations for noninvasive monitoring during open pulmonary resection include:
•Electrocardiography (ECG) – ECG leads may become dislodged, inaccessible, wet with prep solution, or nonfunctional during repositioning (eg, to the lateral decubitus position). (See 'Positioning' below.)
For left-sided thoracotomy cases, the V5 lead is typically placed in the V1 position, in the second interspace, just to the right of the sternum, to avoid contamination of the surgical field. Sensitivity of ECG monitoring for ischemic events may be reduced when the combination of leads II and V5 is unavailable [8]. (See "Anesthesia for noncardiac surgery in patients with ischemic heart disease", section on 'Monitoring for myocardial ischemia'.)
•Pulse oximetry – Continuous pulse oximetry is important in patients with pulmonary disease, particularly during one lung ventilation (OLV). Some clinicians place two pulse oximetry probes (eg, on two extremities) during final positioning. However, direct measurement of partial pressure of oxygen (PaO2) via arterial blood gas measurements provides a more useful estimate of the margin of safety above desaturation (ie, oxygen saturation [SpO2] <90 percent).
●Capnography – Continuous capnography aids in maintaining adequate ventilation and may detect malposition of the double-lumen tube (DLT) or bronchial blocker. However, large gradients between arterial carbon dioxide tension (PaCO2) and end-tidal CO2 (ETCO2) are common in patients with preexisting pulmonary disease, and this gradient worsens during OLV. Thus, intermittent arterial blood gas analysis is also used to detect hypercarbia during OLV.
•Noninvasive blood pressure (BP) cuff – A loose-fitting cuff may become dislodged and nonfunctional during patient repositioning. (See 'Positioning' below.)
•Noninvasive continuous arterial BP monitoring - Continuous noninvasive arterial BP monitoring using a volume clamp methodology has provided practitioners with the option of monitoring arterial BP (including arterial BP waveform) without the need for intra-arterial cannulation. This option is available in some institutions for selected patients and cases if arterial blood sampling is not likely to be necessary [9].
●Invasive monitoring – Invasive monitors used in patients undergoing major pulmonary resection procedures (eg, lobectomy or pneumonectomy) include an intra-arterial catheter and a bladder catheter.
•Monitoring with an intra-arterial catheter – The intra-arterial catheter may be inserted before or after induction of anesthesia, while the bladder catheter is typically inserted after induction but before repositioning the patient for surgery. Healthy patients undergoing a short procedure (eg, simple wedge resection of a localized lesion in the pulmonary periphery) generally do not require either of these invasive monitors.
-Continuous monitoring of arterial BP – Hemodynamic instability due to compression of the heart or major vessels, hemorrhage, hypoxia, hypercarbia, or high airway pressures is immediately and reliably recognized.
-Intermittent sampling for arterial blood gases – Intermittent arterial blood gas analysis for direct measurement of PaO2 and PaCO2 is important in patients at risk for desaturation during procedures requiring OLV. Measurements may be obtained during two lung ventilation (baseline) following induction of general anesthesia and every 15 to 60 minutes during OLV, as needed. Final measurements may be obtained after completion of lung resection and reexpansion of the nonventilated lung to assess respiratory reserve before extubation.
-Respirophasic variations in the arterial pressure waveform – Dynamic hemodynamic parameters based on analysis of respirophasic variation in the continuous arterial pressure waveform during positive pressure ventilation are often used to provide goal-directed fluid therapy for major surgical procedures. However, these parameters are not predictive of fluid responsiveness and hence not useful during open thoracotomy [10,11]. (See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness' and "Intraoperative fluid management", section on 'Goal-directed fluid therapy'.)
•Bladder catheter monitors
-Urine output – Urine output is typically measured in procedures expected to last longer than two hours.
-Temperature – Temperature is continuously monitored to avoid hypothermia. (See "Perioperative temperature management", section on 'Site selection for monitoring'.)
•Other monitors – Infrequently used invasive monitors include:
-Central venous catheter – We do not insert a central venous catheter (CVC) in patients with normal cardiovascular function and adequate peripheral venous access. Central venous pressure (CVP) monitoring is a poor predictor of intravascular volume and fluid responsiveness [12]. (See 'Fluid and hemodynamic management' below.)
Central venous access may be useful for transfusion of blood products and maintenance of intravascular volume and hemodynamic stability if adequate vascular access for volume resuscitation is not otherwise available. (See "Intraoperative use of vasoactive agents", section on 'Vasopressor and positive inotropic agents'.)
-Transesophageal echocardiography – Transesophageal echocardiography (TEE) is not used routinely. However, patients with moderate-to-severe pulmonary hypertension, severe right ventricular (RV) dysfunction, significant valvular heart disease, or intracardiac shunting may benefit from TEE monitoring, particularly during pulmonary artery clamping, which may cause RV dysfunction [13]. (See "Intraoperative transesophageal echocardiography for noncardiac surgery".)
Also, TEE may be urgently employed to rapidly diagnose unanticipated causes of severe hemodynamic instability (eg, hypovolemia or hypervolemia, myocardial ischemia, severe left ventricular or RV dysfunction, or tumor compression or embolization to the heart) [14-17]. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)
-Pulmonary artery catheter – Use of a pulmonary artery catheter (PAC) is rare but may be helpful in the setting of severe RV dysfunction or severe pulmonary hypertension. (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults", section on 'Indications'.)
Airway control — Airway control involves placement of a device to achieve lung isolation for OLV, with final positioning of the device using flexible intubating bronchoscopic guidance. The choice of lung isolation device ultimately depends on the nature and specific location of the planned resection procedure, upper and lower airway anatomy, and practitioner skill and preferences. Advantages and disadvantages of devices used to achieve OLV and the clinical approach to device selection are discussed in detail separately. (See "Techniques to achieve lung isolation during general anesthesia".)
●Double-lumen endotracheal tube (DLT) – Most commonly, a DLT is inserted as part of the induction and endotracheal intubation sequence. DLTs facilitate easy access to each main bronchus for the purposes of ventilation, CPAP, suction, and/or bronchoscopy and are the first choice for most major lung resection cases. Furthermore, a DLT may be required to avoid the operative side if the surgical plan includes resection of the bronchus, if an endobronchial mass would preclude blocker placement, or for tracheobronchial anomaly (eg, anomalous right upper lobe orifice). In addition, a DLT is selected for most cases with absolute indications for lung isolation and a need for protection of the other lung (unilateral purulent pulmonary infection or hemorrhage, bronchopleural fistula, physiologic need for independent lung ventilation). (See "Techniques to achieve lung isolation during general anesthesia", section on 'Types of lung isolation devices'.)
●Bronchial blockers – A bronchial blocker may be selected in patients with anticipated or known difficult upper airway anatomy and is typically placed through a single-lumen endotracheal tube (ETT). Bronchial blockers are versatile and can deployed outside an ETT, via a tracheostomy tube, or through a supraglottic airway (SGA) device if necessary. These devices are also a reasonable means of lung isolation, particularly for left-sided procedures. The likelihood of the need for postoperative controlled ventilation is also considered. A bronchial blocker inserted through a single-lumen ETT can be withdrawn at the end of surgery, leaving the single-lumen ETT in place for the postoperative period. (See 'Planned postoperative ventilation' below and "Techniques to achieve lung isolation during general anesthesia".)
●Single-lumen endobronchial tube – In complex resections involving a mainstem bronchus or carina, a single-lumen tube specifically designed for bronchial positioning, may be selected rather than a DLT or a bronchial blocker.
Induction and maintenance — Selection of agents and techniques for induction of anesthesia is based on coexisting disease (eg, chronic obstructive pulmonary disease). (See "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Induction and airway management'.)
During the maintenance phase, the patient must remain anesthetized, paralyzed, and mechanically ventilated to provide optimal surgical conditions for open pulmonary resection. Typically, a balanced anesthetic technique that includes combinations of a volatile inhalation agent and intravenous agents is used. (See "Maintenance of general anesthesia".)
There is currently insufficient evidence to support the superiority of techniques based on the administration of a volatile inhalation anesthetic agent compared with a propofol-based total intravenous anesthetic (TIVA) technique with respect to improving outcomes after open pulmonary resection. The bronchodilatory and anti-inflammatory effects of potent volatile agents and their rapid elimination during emergence may be advantageous in some patients [18]. However, studies of specific anesthetic techniques for lung resection surgery note inconsistent results. Two randomized trials comparing a propofol-based TIVA technique with anesthetic techniques based on sevoflurane or desflurane administration did not find differences in complications after lung resection surgery [19,20]. A smaller randomized trial in 180 patients undergoing lung resection noted a lower incidence of mortality and postoperative pulmonary complications with a sevoflurane-based anesthetic technique compared with a propofol-based TIVA technique [21].
Also, available evidence does not support superiority of using either a technique based on volatile anesthetic agents or a TIVA technique during surgery for cancer treatment with respect to impact on long-term outcomes, including cancer recurrence. These data are discussed separately. (See "Anesthesia and cancer recurrence", section on 'Intravenous versus volatile anesthetics'.)
Use of neuraxial agents — If a thoracic epidural analgesia (TEA) catheter or thoracic paravertebral block (TPVB) is placed prior to induction, a local anesthetic agent may be administered to supplement inhalation and/or intravenous (IV) general anesthetic agents (see 'Thoracic epidural analgesia' below and 'Thoracic paravertebral block' below). This option is often used in hemodynamically stable patients if they have a high anesthetic requirement. Use of neuraxial analgesia to supplement general anesthesia does not have a clinically significant effect on oxygenation during OLV.
We typically administer 5 mL of 0.2% ropivacaine or 0.125% bupivacaine as a bolus, with readministration approximately every 45 minutes if BP is stable. Lower concentrations of these local anesthetics may be less effective; however, administration of higher concentrations via a thoracic epidural may cause hypotension. Combinations of local anesthetic plus opioid (eg, 0.1% bupivacaine with fentanyl 5 mcg/mL) are often administered via an infusion that is initiated before conclusion of surgery. During the postoperative period, such combinations achieve a balance between analgesic efficacy and the adverse side effects of each agent [22,23]. Epinephrine (eg, 2 mcg/mL) may be included to enhance analgesia by reducing systemic uptake of epidural opioids because of vasoconstriction of epidural vessels [24]. Typical combinations are institution specific.
Existing evidence, including several randomized trials, suggests that the use of regional anesthesia techniques does not affect the risk of cancer recurrence. (See "Anesthesia and cancer recurrence", section on 'Regional anesthesia or analgesia'.)
Positioning — Induction of general anesthesia and airway management are accomplished while the patient is supine, and the patient is then repositioned as desired by the surgeon. The lateral decubitus or flexed-lateral positions are most commonly used for open pulmonary resection (figure 1 and figure 2). However, the supine, semisupine, or semiprone positions are used for selected intrathoracic procedures, depending on the planned technique and the preferences of the surgeon.
Position change is managed by the anesthesiologist, with care to avoid patient injury and to prevent displacement of airway devices, monitors, and vascular cannulae. After a position change, it is particularly important to reassess the integrity of the ETT and ensure correct positioning of the lung isolation device (double-lumen tube or bronchial blocker). Late injuries related to improper positioning include peripheral nerve damage (particularly the brachial plexus), compartment syndrome (particularly in the dependent arm), and vision loss (due to external compression). Prevention of injury in various surgical positions is discussed separately. (See "Patient positioning for surgery and anesthesia in adults".)
Fluid and hemodynamic management
●Maintenance of normovolemia – We maintain normovolemia (ie, euvolemia), rather than using a restrictive or liberal fluid management strategy. We monitor dynamic hemodynamic parameters to assess fluid responsiveness. In most patients, we administer a fluid challenge, typically 100 to 250 mL of a balanced crystalloid solution, if indicated to maintain normovolemia and optimal CO (ie, goal-directed therapy). (See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness'.)
Although very restrictive limitations of crystalloid solutions may facilitate early extubation and reduce pulmonary complications [25-29], concern for hypovolemia with impaired tissue perfusion and acute kidney injury has led to the development of moderate goal-directed strategies to maintain normovolemia as a component of protocols for enhanced recovery after thoracic surgery (ERATS) [30,31]. While the fluid regimen should be individualized to optimize cardiac output (CO) and O2 delivery, we avoid excessive fluid administration (ie, >3 L in the 24 hours of the perioperative period) as this is associated with acute lung injury and delayed recovery after open thoracic surgery [25-27,32-38]. In one retrospective study, the risk of acute lung injury increased for each 500 mL increment of perioperative fluid (odds ratio [OR] 1.17, 95% CI 1.00-1.36) [26]. Furthermore, attempts to improve oliguria do not improve outcomes. In a 2016 meta-analysis of 28 trials in surgical and critically ill patients, goal-directed therapy without targeting oliguria resulted in less renal dysfunction than fluid management strategies that employed targeted reversal of oliguria (OR 0.45, 95% CI 0.34-0.61) [39]. (See "Intraoperative fluid management", section on 'Major invasive surgery'.)
●Crystalloids versus colloids – We administer a balanced crystalloid solution during open pulmonary resection. (See "Intraoperative fluid management", section on 'Crystalloid solutions'.)
Colloids may be used to replace an equivalent volume of blood loss, while red blood cells (RBCs) are transfused only if necessary to maintain hemoglobin ≥8 g/dL [28,29,33,40]. We use albumin selectively in critically ill patients, those who are hypoalbuminemic and/or require rapid volume expansion [41]. However, use of albumin is controversial because it has not been unambiguously demonstrated to be superior to crystalloids for volume expansion, it may elicit allergic reactions, and it is expensive [42].
Hydroxyethyl starch (HES) solutions are generally avoided due to concerns regarding coagulopathy [43] and kidney dysfunction. HES administration has been associated with the development of acute kidney injury (AKI) in retrospective studies of patients undergoing pulmonary resection [4,44]. The use of albumin for volume expansion is controversial. (See "Intraoperative fluid management", section on 'Hydroxyethyl starches' and "Intraoperative fluid management", section on 'Albumin'.)
●Fluid warming – All parenteral fluids are warmed to avoid hypothermia, a common complication of intrathoracic surgery.
●Use of vasopressors – The combination of general anesthesia and thoracic epidural analgesia can cause mild to moderate hypotension. Rather than administering additional fluid to support BP in a euvolemic patient, we use an infusion of a low dose of a vasopressor agent, if necessary, typically phenylephrine or norepinephrine (table 1).
Ventilation — Anesthesia with OLV for open pulmonary resection can result in ventilation-induced lung injury and, in extreme cases, acute respiratory distress syndrome (ARDS). The incidence of clinically overt acute lung injury following lung resection generally ranges from 2 to 4 percent [25,26,45], though it is higher after larger resections, particularly pneumonectomy, at 8 to 12 percent [45,46]. Mortality from acute lung injury is approximately 40 percent [47,48].
To minimize this risk, a lung protective ventilation (LPV) strategy is used during both OLV and two lung ventilation, which includes maintenance of a lower tidal volume (TV; 4 to 6 mL/kg during OLV, adjusted from 6 to 8 mL/kg during two lung ventilation) [37,49,50], low airway pressure with low positive end-expiratory pressure (PEEP) [51-54], as well as minimum O2 concentrations, and, in selected patients, permissive hypercapnia. Further details and evidence of efficacy for lung protective ventilation during OLV and two lung ventilation are discussed in separate topics. (See "Intraoperative one-lung ventilation", section on 'Lung-protective ventilation strategies during OLV' and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)
Use of such LPV has been associated with a reduction in pulmonary complications after pulmonary resection compared with the use of higher TV with no PEEP [55,56]. Individualizing LPV during open pulmonary resection surgery is likely the optimal strategy. A 2024 trial that included 1308 patients undergoing lung resection noted that individualizing LPV with the use of an alveolar recruitment maneuver to 40 cm H2O of end-inspiratory pressure, followed by individualized PEEP titrated to best respiratory system compliance, as well as individualized postoperative respiratory support with high-flow oxygen therapy resulted in fewer postoperative pulmonary complications (a composite of atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure, acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema) compared with standard LPV (40 [6 percent] versus 97 [15 percent], relative risk [RR] 0.39, 95% CI, 0.28-0·56), with an absolute risk difference of -9.23 (95% CI -12.55 to -5.92) [57]. Furthermore, a 2024 meta-analysis of randomized trials in 1055 patients undergoing lung resection demonstrated an association of pulmonary complications with higher values for the calculated time-weighted average mechanical power parameter (ie, mechanical energy delivery calculated using tidal volume, airway pressures, and respiratory rates) [58]. The time-weighted average mechanical power parameter was 1146 (811 to 1530) J in those developing pulmonary complications, compared with 924 (730 to 1240) J in those who did not (431/1055 patients; adjusted odds ratio [aOR] 1.44, 95% CI 1.16-1.80) [58].
Hypoxemia (SpO2 <90 percent) may develop during OLV. Prediction of hypoxemia and detailed management strategies are discussed separately. (See "Intraoperative one-lung ventilation", section on 'Management of hypoxemia'.)
When the pulmonary resection is complete, but before chest closure, blood and secretions are suctioned from the trachea and major bronchi. Except in the case of pneumonectomy, reexpansion of the nonventilated lung is necessary to reinflate all atelectatic areas and to check for significant air leaks at bronchial anastomotic sites. Reexpansion techniques are discussed separately. (See "Intraoperative one-lung ventilation", section on 'Re-expanding the nonventilated lung'.)
Final bronchoscopy before emergence — At the end of the procedure, the patient is returned to the supine position for final bronchoscopy, if necessary, followed by emergence and extubation.
Often, the surgeon performs a final fiberoptic bronchoscopic examination to ensure that the bronchial passageways are patent, to remove residual blood and secretions, and to examine any bronchial stumps.
If a DLT has been used, the surgeon may perform bronchoscopy via this DLT, or it may be exchanged for a single-lumen ETT or a laryngeal mask airway (LMA) to accommodate a large bronchoscope or for surgeon-specific preferences. If ETT exchange is planned, strategies to prevent loss of airway control or laryngospasm include first assessing and ensuring for adequate muscle relaxation and administering 100% oxygen.
Further considerations include:
●Use of a tube exchange catheter to maintain access to the airway
●Use of a flexible intubating bronchoscope to visualize the passage of the ETT through the vocal cords
●Administration of IV remifentanil or other IV anesthetic such as propofol or lidocaine to blunt airway reflexes and to reduce the risk of laryngospasm
●Placement of an LMA with subsequent insertion of the bronchoscope through the LMA to avoid the need for exchange of the ETT
If laryngospasm occurs during attempted ETT exchange, gentle positive-pressure ventilation is employed via a facemask or LMA. If desaturation develops, it may be necessary to administer a small dose of succinylcholine (0.1 mg/kg IV) to relax the vocal cords or a full intubating dose of succinylcholine plus an anesthetic induction agent to accomplish urgent reintubation. (See "Rapid sequence intubation in adults for emergency medicine and critical care".)
Emergence and postoperative airway management
Planned extubation — For most patients undergoing open pulmonary resection, tracheal extubation is planned at the end of the surgical procedure and can be transferred to a regular hospital ward [59]. The patient is placed in a Semi-Fowler's position (partially sitting with the head of the bed up at a 30- to 45-degree angle) for emergence from anesthesia. When the usual criteria have been satisfied, including reversal of any residual neuromuscular blockade, the patient may be extubated. (See "Maintenance of general anesthesia", section on 'Transition to the emergence phase'.)
In selected patients, noninvasive mechanical ventilation (NIV) or high-flow nasal cannula (HFNC) oxygen therapy is used cautiously to treat hypoxemia after extubation in the early postoperative period [60,61]. While not routinely used after pulmonary resection, continuous positive airway pressure (CPAP) is reasonable if otherwise indicated (eg, patients with obstructive sleep apnea). In small studies, CPAP appears to improve oxygenation and forced expiratory volume in one second (FEV1) without increasing air leakage through the chest drain or the incidence of other complications [62,63]. Details are discussed in other topics:
Planned postoperative ventilation — Some patients may require a period of postoperative controlled mechanical ventilation. Examples include patients with marginal respiratory reserve, hemodynamic instability, unexpected blood loss, hypothermia, or those who had complex lung resection with or without chest wall resection. (See "Overview of pulmonary resection" and "Surgical management of chest wall tumors".)
If a DLT was used to achieve OLV, it is usually exchanged for a single-lumen tube at the end of the procedure before leaving the operating room. A tube exchanger is employed to maintain access to the airway during this exchange of a DLT for a single-lumen tube. This is described separately. (See "Management of the anatomically difficult airway for general anesthesia in adults", section on 'Extubation'.)
In patients who develop airway and facial edema due to fluid administration and/or dependent head position during surgery, exchange of a DLT for a single-lumen tube may be dangerous. In such cases, if only a short period of postoperative ventilation is needed (one to two hours), we leave a left DLT in place. A right DLT is likely to be displaced with patient movement. Another option is to withdraw the DLT so that both lumens terminate in the trachea above the carina. Generally, extubation can be accomplished after a period of upright positioning and administration of parenteral steroid therapy (4 to 8 mg IV dexamethasone) when the edema has resolved. (See "Extubation management in the adult intensive care unit", section on 'Assess risk for postextubation stridor'.)
POST-THORACOTOMY PAIN MANAGEMENT —
Thoracotomy incisions are very painful [64,65]. Inadequate postoperative analgesia leads to the development of post-thoracotomy pain-related pulmonary complications due to splinting of the operated hemithorax, inadequate coughing, and decreased mucociliary clearance, with shunting and hypoxemia [66-75]. Postoperative respiratory failure can result from these responses to pain together with other pathologic processes (eg, atelectasis due to compression of the dependent lung during lateral positioning, inflammatory, ischemic, and reexpansion insults to lung that was collapsed during lung isolation, and diaphragmatic dysfunction due to surgical injury of the phrenic nerve or diaphragm) [76,77]. Multimodal opioid-sparing strategies are used to effectively control postoperative pain [30,64,65]. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Pain control'.)
Regional anesthesia
Choice of technique — Continuous thoracic epidural analgesia (TEA) with local anesthetic plus an opioid (see 'Thoracic epidural analgesia' below) or continuous thoracic paravertebral block (TPVB) with local anesthetic (see 'Thoracic paravertebral block' below), are the most effective techniques for post-thoracotomy analgesia [66,71,78-81].
The choice between TEA and TPVB is primarily based on clinician expertise and preference. In a 2008 meta-analysis of randomized trials comparing techniques for post-thoracotomy pain management, TEA and TPVB techniques were generally superior to other regional techniques and to systemic opioid analgesia, with regard to pain scores and requirements for supplemental opioid analgesia [66]. Hypotension was more common with TEA compared with systemic opioid analgesia in four studies (odds ratio [OR] 3.8, 95% CI 1.6-9.2).
Limited available data suggest that continuous TPVB analgesia provides comparable pain relief with fewer adverse side effects compared with TEA; however, many clinicians are not familiar with this technique [66,71,78,79,81]. In a 2016 meta-analysis of 14 randomized trials comparing TEA versus TPVB in patients undergoing thoracotomy, these techniques were similar with regard to analgesic efficacy with respect to mortality, major complications, and length of hospital stay [80]. There were fewer minor adverse events with TPVB compared with TEA, including hypotension (risk ratio [RR] 0.16, 95% CI 0.07-0.38), nausea with vomiting (RR 0.48, 95% CI 0.30-0.75), and urinary retention (RR 0.22, 95% CI 0.11-0.46). Other meta-analyses and subsequent studies note similar results [66,79,82,83]. In one retrospective study, TPVB was associated with higher long-term survival in patients undergoing open thoracotomy for lung cancer surgery, compared with either TEA (hazard ratio [HR] 0.58, 95% CI 039-0.87) or PCA with a systemic opioid (HR 0.60, 95% CI 0.45-0.79) [84].
If neither TEA nor TPVB is appropriate due to coagulopathy, anatomic considerations, or patient refusal, or if attempts to place a TEA and/or TPVB catheter are unsuccessful, alternative regional techniques include intercostal nerve blocks and intrathecal opioid analgesia. A systemic opioid analgesic technique, typically patient-controlled analgesia (PCA), may also be necessary [66,71]. (See 'Other regional anesthetic techniques' below and 'Opioid and nonopioid intravenous analgesics' below.)
Thoracic epidural analgesia
●Advantages and disadvantages – Advantages of TEA over other techniques include potential intraoperative use to supplement general anesthesia if the epidural catheter is placed in the preoperative period (see 'Induction and maintenance' above). In the postoperative period, continuous TEA provides reliable and effective analgesia after thoracotomy [66,71,78,79]. A 2020 meta-analysis that included 19 trials with 1062 participants noted that pain intensity was lower 48 and 72 hours after surgery, and the incidence of pain was lower one to six months after surgery when the epidural was preemptively placed before rather than after the thoracotomy incision [85].
Disadvantages of TEA include technical difficulty with catheter placement at the thoracic level, particularly in patients with scoliosis, kyphosis, obesity, and other anatomic abnormalities. Studies report a failure rate of approximately 15 percent [71,73,78,79,86]. Adverse effects of hypotension, nausea and vomiting, and urinary retention may be more common with TEA compared with TPVB, and hypotension is also more common with TEA compared with systemic opioid analgesia. (See 'Choice of technique' above.)
Other potential complications of TEA (eg, epidural hematoma or abscess) are discussed separately [87]. (See "Overview of neuraxial anesthesia", section on 'Adverse effects and complications'.)
●Technique and administration – The technique for placement of an epidural catheter is described separately (figure 3 and figure 4) (see "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Epidural anesthesia technique'). In patients undergoing thoracotomy, the quality of postoperative pain control is equivalent to thoracic epidural catheter threading distances of 3, 5, or 7 cm after entry into the epidural space [88].
For post-thoracotomy pain management, mixtures containing a local anesthetic and an opioid are typically used to achieve a balance between analgesia and side effects (eg, 0.0625 to 0.125% bupivacaine mixed with 5 mcg/mL of fentanyl or 0.01 mg/mL of hydromorphone), administered at a rate of 6 to 10 mL/hour [22,66,78,79,89]. The incidence of hypotension increases if local anesthetic concentration is increased; however, lower concentrations of local anesthetics are less effective. Older adults require approximately 40 percent less epidural solution per hour, due to the positive correlation between patient age and extent of epidural spread, and may also benefit from a more dilute local anesthetic concentration [90]. We use 0.0625% bupivacaine mixed with 10 mcg/mL hydromorphone for older patients, administered at a rate of 6 to 8 mL/hour. (See "Continuous epidural analgesia for postoperative pain: Technique and management".)
TEA infusion for analgesic therapy is typically continued for two to three postoperative days [66,78-80]. If TEA is inadequate (eg, patients for whom the epidural block is partial and/or those with pain outside the surgical dermatomes, such as ipsilateral shoulder or back pain), an alternative approach is to split the epidural infusion. In such cases, a continuous epidural infusion of local anesthetic is used, while intravenous (IV) opioid is administered by PCA. (See "Continuous epidural analgesia for postoperative pain: Technique and management", section on 'Inadequate analgesia'.)
Occasionally, discontinuation of TEA becomes necessary due to hypotension caused by infusion of local anesthetic or adverse effects of epidural opioids such as respiratory depression, urinary retention, and delayed gastric emptying. (See "Continuous epidural analgesia for postoperative pain: Technique and management", section on 'Discontinuation of epidural analgesia'.)
Thoracic paravertebral block
●Advantages and disadvantages – Compared with TEA, catheter-based TPVB with continuous infusion of a local anesthetic agent provides comparable analgesia and may be associated with fewer adverse side effects [66,71,78-81]. (See 'Choice of technique' above.)
When TPVB is performed in the preoperative period, injection of local anesthetic may be used to supplement general anesthesia during the intraoperative period, with effectiveness similar to that of thoracic epidural. Although catheter insertion for TPVB may be performed prior to induction of anesthesia, an alternative is direct placement by the surgeon in the open chest [91]. This flexibility is advantageous when the surgical plan is changed (eg, when video-assisted thoracoscopic surgery [VATS] surgery is initiated, but intraoperative conversion to an open thoracotomy becomes necessary). Another advantage is that open placement on the surgical field may be safely performed in patients with impaired coagulation. In some institutions, operating room efficiency is facilitated by intraoperative placement [91].
Disadvantages of TPVB include a lack of familiarity for many anesthesiologists. Failure may occur due to technical difficulty with catheter placement (even with successful needle placement within the paravertebral space) or insufficient spread within the paravertebral space [91-94]. However, the reported failure rate is low for experienced clinicians: approximately 6 percent [78,79,93,94]. Other complications are rare [81]. (See "Thoracic paravertebral block procedure guide", section on 'Side effects, complications, and contraindications'.)
●Technique and administration – The technique for placement of a TPVB is described separately (picture 1 and picture 2 and picture 3 and picture 4) [81]. (See "Thoracic paravertebral block procedure guide".)
Typical regimens for pulmonary resection surgery include initial administration of a bolus dose of local anesthetic (eg, 0.25% bupivacaine up to 0.3 mL/kg as a loading dose, or 20 mL of either 0.5% ropivacaine or 0.5% bupivacaine if a higher dose is desired to improve analgesia). We reduce the local anesthetic concentration (eg, to 0.2% ropivacaine or 0.25% bupivacaine) and/or the volume (eg, to 10 to 15 mL per side) of the bolus dose if we are performing bilateral blocks, or if the block is used to supplement general anesthesia. Some clinicians add dexmedetomidine as an adjuvant to the local anesthetic infusion (eg, 1 mcg/kg administered over three to five minutes, followed by an infusion of dexmedetomidine 0.2 mcg/kg/hour) [95].
Regimens for postoperative continuous infusion of a local anesthetic agent include 0.1% bupivacaine at 5 to 12 mL/hour, 0.25% bupivacaine at 0.1 mL/kg/hour, or 0.2% ropivacaine at 4 mL/hour. According to one systematic review, continuous infusions administered via a paravertebral catheter are associated with lower pain scores than intermittent boluses; addition of adjuvant clonidine or fentanyl did not improve scores [96]. Duration of continuous TPVB infusion to control postoperative analgesia is typically several postoperative days [66,78-80]. (See "Thoracic paravertebral block procedure guide".)
Other regional anesthetic techniques — If neither TEA nor TPVB is appropriate or if the attempted placement of a TEA or TPVB catheter is unsuccessful, other alternative regional analgesic techniques include the following [97] (see "Thoracic nerve block techniques", section on 'Fascial plane blocks of the chest wall'):
●Thoracic erector spinae plane block – The thoracic erector spinae block (figure 5) is a myofascial plane block that is particularly useful for management of pain after extensive thoracic surgery because it provides analgesia to both the anterior and posterior hemithorax, in contrast with the serratus anterior plane block [98]. Compared with TPVB, erector spinae block provides a similar level of analgesia for approximately 6 to 12 hours and has similar complication rates [99-102]. Block duration may be prolonged by a continuous catheter technique [103]. Further details are available in a separate topic. (See "Erector spinae plane block procedure guide".)
●Serratus anterior plane or pectoral nerve block – Serratus anterior plane block is another technique for treatment of pain after thoracotomy (image 1) [103-106]. The serratus anterior plane block is typically performed in the supine position using ultrasound guidance, thus sparing the patient the discomfort of being placed in the lateral or sitting position for other plane and neuraxial blocks (image 1). Further details are available in a separate topic. (See "Thoracic nerve block techniques", section on 'Serratus plane block' and "Thoracic nerve block techniques", section on 'Interpectoral plane (Pecs I) block' and "Thoracic nerve block techniques", section on 'Interpectoral plane plus pectoserratus (Pecs II) block'.)
●Intercostal nerve blocks – Performance of multiple intercostal nerve blocks is another technique that has been used after thoracotomy procedures (figure 6 and figure 7 and image 2) [103,107-109]. Injections of the intercostal nerve are performed proximal to the incision in interspaces both above and below the injured ribs. While some clinicians advocate blocking intercostal nerves proximal to the midaxillary line (to ensure the blockade of the lateral and anterior cutaneous branches of the intercostal nerve), this should only be necessary when analgesia of the skin is required. Further details are available in a separate topic. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block'.)
Advantages of intercostal nerve blocks include improvement in peak expiratory flow rate as well as arterial oxygen and carbon dioxide tensions [110,111]. Also, intercostal blocks do not produce sedation, respiratory depression, or other side effects associated with systemic or regional opioid administration, and unilateral placement results in minimal hemodynamic effects. Thus, these blocks have been a viable alternative for patients who have contraindications to or unsuccessful attempts for placement of an epidural catheter or TPVB.
Disadvantages of intercostal nerve blocks include an analgesic effect that lasts only a few hours. Furthermore, the placement and maintenance of an intercostal catheter in a precise location to facilitate repeated injections is challenging [112,113]. The use of a liposomal formulation of bupivacaine to provide extended slow release of the local anesthetic may be optimal [114]. Clinical experience is increasingly supporting the use of multilevel intercostal nerve block with liposomal bupivacaine as a component of a multimodal approach for effective post-thoracotomy analgesia [114-118].
●Midpoint transverse process to pleura block – The midpoint transverse process to pleura (MTP) regional anesthetic block has been used as an alternative to TPVB [119]. The MTP block is thought to act via paravertebral spread through septations and fenestrations in the superior costotransverse ligament [120], as well as medial to the free edge of the superior costotransverse ligament. The paravertebral spread ideally would increase the efficacy of the block, while limiting the potential complications of TPVB such as pleural puncture, vascular puncture, and hypotension from epidural spread or even intrathecal spread [121]. Also, since MTP is a peripheral nerve block, there is less concern in patients receiving anticoagulants compared with TPVB. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
●Intrathecal opioid analgesia – Intrathecal morphine analgesia has also been used as a component of multimodal analgesic regimens together with non-opioid analgesic therapies to provide effective short-term analgesia and reduce overall opioid requirement [122-124] (see "Overview of enhanced recovery after cardiothoracic surgery", section on 'Multimodal pain management strategies'). Disadvantages include the possibility of delayed respiratory depression such that postoperative monitoring for inadequate oxygenation and ventilation is necessary [66,71,104]. Also, analgesic duration is typically insufficient. Thus, achieving adequate pain control in a patient with a large thoracotomy incision may require additional intrathecal opioid boluses.
Opioid and nonopioid intravenous analgesics — Nonopioid agents (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], ketamine, gabapentin, and glucocorticoids such as dexamethasone) are often employed after thoracic surgery to maximize comfort and reduce risk for pulmonary complications. However, limited use of an opioid may be necessary as part of a multimodal pain management strategy to provide effective analgesia in the immediate postoperative period, ideally administered with a patient-controlled analgesia (PCA) technique [125]. Further details are available in a separate topic. (See "Approach to the management of acute pain in adults", section on 'Options for managing postoperative analgesia'.)
Management of ipsilateral shoulder pain — Although less severe than incisional pain, ipsilateral shoulder pain (ISP) frequently occurs following pulmonary resection and is described as a dull, stabbing pain of moderate to severe intensity in the region of the deltoid muscle and lateral clavicle on the side of surgery [126-129]. This rarely persists after the second postoperative day [130]. In our experience, NSAIDs are the most effective and convenient method to prevent and treat ISP. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Ipsilateral shoulder pain'.)
SUMMARY AND RECOMMENDATIONS
●Preanesthesia consultation – The preanesthetic consultation focuses on assessment of pulmonary and cardiovascular risks, as well as planning for postoperative analgesia. (See 'Preanesthetic consultation' above.)
●Preanesthetic preparation – Preoperative preparation includes planning for placement of a thoracic epidural catheter (before induction of general anesthesia) or placement of a paravertebral catheter (either before induction or directly into the open chest during surgery) for postoperative pain control. Equipment and devices to achieve one lung ventilation (OLV), hemodynamic monitoring, and fluid warming are also prepared. (See 'Preanesthetic preparation' above and 'Airway control' above.)
●Monitoring – In addition to standard noninvasive monitoring, patients undergoing lobectomy or pneumonectomy require an intra-arterial catheter for continuous monitoring of blood pressure (BP), as well as intermittent arterial blood gas sampling. A bladder catheter is inserted to monitor urine output and temperature. Other invasive monitoring techniques are used selectively. (See 'Monitoring' above.)
●Induction and maintenance of general anesthesia – Selection of agents and techniques for induction of anesthesia is based on coexisting disease (eg, chronic obstructive pulmonary disease). Typically, a balanced anesthetic technique that includes combinations of a volatile inhalation agent and intravenous (IV) agents is used to maintain anesthesia. If a thoracic epidural catheter was placed prior to induction, a local anesthetic agent may be administered to supplement general anesthetic agents. (See 'Induction and maintenance' above and 'Use of neuraxial agents' above.)
●Positioning – Position change after induction, most commonly to the lateral decubitus position (figure 1 and figure 2), is managed by the anesthesiologist, with care to avoid patient injury and prevent displacement of airway devices, monitors, and vascular cannulae. It is particularly important to reassess the integrity of the endotracheal tube (ETT) and correct positioning of the lung isolation device (double-lumen tube [DLT] or bronchial blocker) after any position change. (See 'Positioning' above.)
●Fluid management – We administer a balanced crystalloid solution during open pulmonary resection to maintain normovolemia (ie, euvolemia). We suggest a "moderate" goal-directed fluid management strategy to maintain normovolemia rather than a restrictive or liberal fluid management strategy (Grade 2C). We avoid excessive fluid administration (ie, >3 L in the 24 hours of the perioperative period), as this is associated with acute lung injury and delayed recovery. All fluids are warmed to avoid hypothermia. (See 'Fluid and hemodynamic management' above.)
●Management of ventilation – We employ a lung protective ventilation strategy during both OLV and two lung ventilation to minimize risk of acute lung injury, as discussed in a separate topic. (See "Intraoperative one-lung ventilation", section on 'Lung-protective ventilation strategies during OLV'.)
At the end of the surgical procedure, reexpansion of the nonventilated lung is necessary to reinflate all atelectatic areas and to check for significant air leaks. (See "Intraoperative one-lung ventilation", section on 'Re-expanding the nonventilated lung'.)
●Emergence and extubation – Tracheal extubation is planned for most patients. (See 'Emergence and postoperative airway management' above.)
•Final bronchoscopy before emergence – Often, a final bronchoscopy is performed, either via the DLT or after exchange to a single-lumen ETT or a laryngeal mask airway (LMA). (See 'Final bronchoscopy before emergence' above.)
•Planned postoperative ventilation – If prolonged postoperative ventilation is required, a single-lumen ETT is preferred. A tube exchanger is used to maintain access to the airway when a DLT is exchanged for a single-lumen ETT. (See 'Planned postoperative ventilation' above.)
●Postoperative pain management – For management of post-thoracotomy pain, we suggest continuous thoracic epidural analgesia (TEA) with local anesthetic plus an opioid, or continuous thoracic paravertebral block (TPVB) with local anesthetic, rather than other techniques (Grade 2B). If neither option is appropriate, alternatives include a multimodal approach with other regional anesthetic techniques such as erector spinae block, serratus anterior plane block, or intercostal nerve block. Opioids are used judiciously, and nonopioid agents (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], ketamine, gabapentin, and glucocorticoids such as dexamethasone) are typically employed to limit opioid use. (See 'Post-thoracotomy pain management' above.)
