Overview of anesthetic management for patients with pleural disease

INTRODUCTION — A variety of medical conditions and postsurgical complications cause pleural disease that may require surgical intervention. These include the presence of fluid (pleural effusion), air (pneumothorax), blood (hemothorax), chyle (chylothorax), purulent material (empyema), or tumor in the pleural space, as well as fibrosis of the pleural space (fibrothorax), or formation of an alveolopleural or bronchopleural fistula.

This topic addresses anesthetic considerations for patients requiring anesthetic care during surgical or other major invasive interventions to treat a pleural disease process. Other topics address medical and surgical management of specific pleural diseases, as noted in each section below.

Details regarding anesthetic considerations for open thoracotomy for pulmonary resection or for video-assisted thoracoscopic surgery (VATS) are discussed in separate topics:

●(See "Anesthesia for open pulmonary resection".)

●(See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

GENERAL CONSIDERATIONS

Preanesthetic assessment — The preanesthetic consultation includes assessment of etiology of pleural disease, such as presence of malignant or nonmalignant fluid (pleural effusion), air (pneumothorax), chyle (chylothorax), blood (hemothorax), or purulent material (empyema), as well as fibrosis of the pleural space (fibrothorax) or formation of an alveolopleural or bronchopleural fistula [1].

Elective surgical procedures — Chronic comorbid conditions are noted and managed (eg, underlying pulmonary disease, anemia, frailty):

●Pulmonary comorbidities are managed to minimize risk of pulmonary complications. (See "Evaluation of perioperative pulmonary risk" and "Strategies to reduce postoperative pulmonary complications in adults".)

If relevant for the specific procedure (see 'Anesthetic management for specific procedures' below), the patient's ability to tolerate one lung ventilation (OLV) is also assessed. (See "One lung ventilation: General principles", section on 'Indications' and "One lung ventilation: General principles", section on 'Contraindications'.).

●Preoperative anemia is treated when feasible (see "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia'). For selected procedures with expected significant blood loss (eg, decortication), crossmatching for 2 to 4 units of red blood cells is performed. (See 'Empyectomy, pleurectomy, or decortication' below.)

●Prehabilitation may be considered for older frail patients with functional dependence and weight loss [2,3]. (See "Overview of prehabilitation for surgical patients" and "Anesthesia for the older adult", section on 'Assessment for frailty'.)

Special considerations are applicable for selected patients with:

●Empyema – Antibiotic therapy is continued during the perioperative period to treat infectious empyema, and hemodynamic status should be assessed. (See "Management and prognosis of parapneumonic pleural effusion and empyema in adults", section on 'Antibiotic therapy'.)

●Chylothorax – Chylothorax is an accumulation of chyle leaking from the lymphatics into the pleural space. Malignant causes include lymphoma, chronic lymphocytic leukemia, bronchogenic carcinoma, and metastatic cancer. Nonmalignant causes involve disruption or obstruction of the thoracic duct or its tributaries due to trauma including complications of surgical procedures such as esophagectomy or lung resection with lymph node dissection [4-7]. (See "Etiology, clinical presentation, and diagnosis of chylothorax".)

Hypovolemia, electrolyte abnormalities, and malnutrition may be present in patients with chylothorax who have been managed by continuous drainage of chylous pleural fluid. Serum electrolytes, lymphocyte counts, albumin, and total protein are checked in the preoperative period. Euvolemic intravascular volume status and optimal nutrition support should be ensured before elective surgery.

A fatty food such as cream or olive oil may be administered orally or via an orogastric tube a few hours before surgery to facilitate intraoperative location of the chyle leak [4-6]. An alternative method is delivery via an orogastric tube following induction of anesthesia; typically, the cream is visible in the location of the chyle leak after approximately 20 minutes. (See "Management of chylothorax".)

●Pleural effusion – Patients may have a large volume of new or reaccumulated pleural fluid due to malignant or nonmalignant etiologies (figure 1). (See "Mechanisms of pleural liquid accumulation in disease".)

The cause of the effusion and severity of coexisting disease processes should be assessed, as these factors may influence anesthetic management. Examples include:

•Nonmalignant pleural effusions – Causes of nonmalignant large pleural effusions include (table 1 and table 2):

-Congestive heart failure

-Nephrotic syndrome

-Pleural inflammation due to infectious or noninfectious causes

-Hepatic hydrothorax in a patient with ascites due to cirrhosis and portal hypertension. (See "Hepatic hydrothorax".)

-Thoracic endometriosis is a rare condition in which endometrial tissue is found in the pleura and/or lung parenchyma, bronchi, or diaphragm. Wedge resections of visible endometrial implants, repair of diaphragmatic defects, and treatment of associated catamenial pneumothorax and/or hemothorax may be necessary. (See "Clinical features, diagnostic approach, and treatment of adults with thoracic endometriosis".)

•Malignant pleural effusions

-Malignant pleural effusions are usually metastatic and may be associated with pleural tumor (usually lymphoma or lung, breast, or ovarian cancer) [8]. (See "Management of malignant pleural effusions".)

-Malignant pleural mesothelioma (MPM) has a poor prognosis, and is the most common primary malignancy of the pleura. Some centers with expertise in management of MPM offer surgery-based therapy including pleurectomy/decortication or extrapleural pneumonectomy. (See "Initial management of malignant pleural mesothelioma", section on 'Epithelioid cancers'.)

Urgent or emergency surgical procedures — Patients with acute pleural effusions or pneumothorax presenting in respiratory distress may require immediate endotracheal intubation in the emergency department or the operating room. If OLV will be necessary during a subsequent emergency surgical procedure, then a lung isolation device such as a double-lumen endotracheal tube (DLT) or a bronchial blocker is inserted. (See "Lung isolation techniques".)

Although subsequent treatment with bedside tube thoracostomy may be adequate, further emergency surgical intervention may be required in patients with:

●Tension pneumothorax – (See "Intraoperative management of shock in adults", section on 'Tension pneumothorax or hemothorax'.)

●Hemothorax – Hemothorax is the presence of blood in the pleural space, usually resulting from thoracic trauma or iatrogenic puncture or transection of a blood vessel (eg, during central line placement, thoracentesis, or chest tube placement). Patients with acute or expanding hemothorax may be hemodynamically unstable, and may need emergency surgical exploration if chest tube output is excessive. (See "Intraoperative management of shock in adults", section on 'Tension pneumothorax or hemothorax'.)

Management of major bleeding from the great vessels, cardiac injury, and hilar injury is discussed in other topics:

•(See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Hemothorax'.)

•(See "Resuscitative thoracotomy: Technique".)

•(See "Surgical management of severe rib fractures".)

•(See "Overview of blunt and penetrating thoracic vascular injury in adults".)

Patients with persistent bleeding may require transfusion before and during the surgical procedure. (See "Intraoperative transfusion and administration of clotting factors".)

●Empyema with septic shock – (See "Intraoperative management of shock in adults", section on 'Septic shock'.)

Monitoring and intravascular access — If a limited surgical intervention is planned (eg, catheter drainage of pleural effusions, pleurodesis, drainage of small empyema[s]), and conversion to open thoracotomy is highly unlikely, then a single large-bore peripheral intravenous (IV) catheter is typically adequate. Invasive hemodynamic monitoring (eg, intra-arterial catheter or central venous catheter placement) is not usually necessary for such minor procedures unless indicated for patient-specific comorbidities.

For major procedures that may involve significant blood loss (eg, decortication/empyectomy or repair of bronchopleural fistula), additional IV access for rapid volume resuscitation is necessary. If hemodynamic instability is anticipated, invasive circulatory system monitoring (eg, an intra-arterial catheter) is established, ideally prior to induction of general anesthesia. (See "Basic patient monitoring during anesthesia", section on 'Circulatory system monitoring'.)

Intraoperative management

General anesthesia — General anesthesia is necessary for most surgical interventions for pleural diseases.

●Airway and ventilation management – If OLV is necessary, a DLT is preferred in most cases to prevent soiling of the airway and the contralateral lung in the lateral decubitus position (figure 2 and figure 3). A lung protective ventilation strategy is employed during ventilation with one or two lungs. Details are discussed in separate topics. (See "Lung isolation techniques" and "One lung ventilation: General principles".)

●Maintenance of anesthesia – General anesthesia is typically maintained with a potent volatile inhalation anesthetic agent such as sevoflurane, supplemented with a short-acting IV opioid, and a neuromuscular blocking agent (NMBA).

Nitrous oxide should be avoided to prevent excessive expansion of gas-filled spaces. Patients with empyema or chronic pleural disease are at particular risk because septations or loculations can form closed gas-filled spaces that prevent full chest tube drainage of all pleural space compartments. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Disadvantages and adverse effects'.)

Local anesthesia — Selected video-assisted thoracoscopic surgery (VATS) procedures for pleural diseases may be performed with a local anesthetic technique and monitored anesthesia care (MAC) with sedation as needed. (See "Monitored anesthesia care in adults".)

Details of anesthetic management for nonintubated thoracoscopic surgery are discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Nonintubated thoracoscopic surgery'.)

Postoperative management

●Extubation and recovery – After many pleural surgical procedures, the patient is extubated at the end of the case while still in the operating room or interventional suite. As with other thoracic surgical procedures, decisions to extubate depend on patient-specific and procedure-specific factors (eg, severe preoperative respiratory failure, postoperative need for continuous pulmonary toilet). (See "Anesthesia for open pulmonary resection", section on 'Emergence and postoperative airway management'.)

Transport of patients who remain intubated and sedated to the intensive care unit (ICU) is discussed in a separate topic. (See "Transport of surgical patients".)

●Pain management – Patients undergoing minor procedures such as catheter placement for drainage of a pleural effusion or empyema may not need post-procedure analgesics.

Pleurodesis achieved mechanically is a painful procedure. In the postoperative period, IV and oral opioids are usually necessary to manage pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally avoided due to concerns regarding attenuation of the inflammatory response necessary for successful pleurodesis. However, one clinical trial has noted non-inferiority of NSAIDs compared with opioids for treatment of postoperative pain in this setting [9]. Although rarely used for isolated pleurodesis, thoracic epidural analgesia (TEA) is another option to treat postoperative pain [10].

Pain management techniques after procedures requiring open thoracotomy or VATS procedures (eg, empyectomy, pleurectomy, decortication, or repair of bronchopleural or alveolopleural fistula) are discussed in separate topics:

•(See "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management'.)

•(See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Postoperative pain management'.)

ANESTHETIC MANAGEMENT FOR SPECIFIC PROCEDURES

Catheter drainage of pleural effusions

Procedural considerations — Goals of treatment for pleural effusions include elimination of liquid or air in the pleural space, complete lung re-expansion, and prevention of recurrence. Catheter drainage by tube thoracostomy to manage small amounts of fluid, blood, pus, or air in the pleural space can often be performed with local anesthesia at the bedside without the need for anesthetic care. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" and "Overview of minimally invasive thoracic surgery".)

Larger or recurrent pleural effusions may require more invasive surgical treatments such as insertion of a tunneled indwelling pleural catheter or pleuroperitoneal shunt placement, as discussed in separate topics. (See "Management of malignant pleural effusions" and "Management of nonmalignant pleural effusions in adults".)

Large volume chylothorax or persistent chyle accumulation (more than 1 L accumulates during a 24-hour period) may require surgical management with thoracic duct ligation. The surgeon may select either a minimally invasive thoracoscopic technique or, in some cases, open thoracotomy for this procedure. (See "Management of chylothorax".)

Anesthetic considerations — Anesthetic care is necessary for placement of a tunneled pleural catheter to manage recurrent pleural effusions. These procedures are often accomplished in an interventional pulmonology suite with monitored anesthesia care (MAC). (See "Monitored anesthesia care in adults".)

Anesthetic management for video-assisted thoracoscopic surgery (VATS) is similar to that for VATS procedures for lung resection. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

Anesthetic management for open thoracotomy is similar to that for thoracotomy for lung resection. (See "Anesthesia for open pulmonary resection".)

In selected cases, the anesthesia team must manage intraoperative transesophageal echocardiography (TEE) or transthoracic ultrasound may be used to localize the effusion and guide drainage [8,11]. (See "Imaging of pleural effusions in adults", section on 'Ultrasonography' and "Ultrasound-guided thoracentesis".)

Pleurodesis — Pleurodesis (ie, the fusion of the visceral and parietal pleura) is necessary to obliterate the pleural space for some patients with pleural effusions [8,11]. Examples include patients with recurrent pneumothorax, pneumothorax with persistent air leak, or persistent pleural effusion due to malignant or nonmalignant causes. Management decisions to attempt pleurodesis in such cases are discussed in separate topics:

●(See "Pneumothorax: Definitive management and prevention of recurrence", section on 'Pleurodesis'.)

●(See "Management of malignant pleural effusions", section on 'Pleurodesis (alternative to IPC or failed IPC)'.)

●(See "Management of nonmalignant pleural effusions in adults", section on 'Pleurodesis'.)

Procedural considerations — Anesthetic care is necessary for surgical techniques to accomplish pleurodesis including:

●Instillation of a sclerosing agent such as talc or doxycycline into a chest tube. Although sometimes done at the bedside via an indwelling chest tube, such chemical pleurodesis is a painful procedure. Pain may be somewhat ameliorated by administration of local anesthetics in the pleural space [12]. (See "Chemical pleurodesis for the prevention of recurrent pleural effusion".)

●Mechanical abrasion of the parietal pleura performed via VATS using dry gauze, a Bovie scratch pad, cellulose mesh with fibrin glue, or laser abrasion is also a painful procedure. Thoracoscopy with direct visualization (or minimally invasive thoracic surgery) also allows for inspection of the underlying lung to aid decision-making regarding additional surgical interventions. Examples include lung biopsy to diagnosis the etiology of persistent or recurrent pneumothorax or pleural effusion, or pulmonary wedge resection to treat subpleural blebs. (See "Treatment of primary spontaneous pneumothorax in adults" and "Treatment of primary spontaneous pneumothorax in adults", section on 'Indications for definitive procedure after first event'.)

●Tunnelling an indwelling pleural catheter to drain pleural fluid in selected patients (eg, those with recurrent effusions), which may induce pleurodesis without instillation of a sclerosing agent. (See "Management of malignant pleural effusions", section on 'Indwelling pleural catheter (IPC)'.)

Anesthetic considerations — Anesthetic considerations for mechanical pleurodesis and/or lung biopsy accomplished via VATS are similar to those for other VATS procedures. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

Open drainage or debridement of empyema — Empyema is pus in the pleural space, typically due to local bacterial spread from the lung, postoperative infection due to direct inoculation of bacteria into the pleural space during a thoracic procedure, or infection after penetrating chest wall injury [13]. Acute empyema is typically managed with appropriate antibiotic treatment and tube drainage of the empyema with re-expansion of the lung. Patients who do not improve with antibiotics and tube thoracostomy may require debridement of open drainage of one or more loculated empyemas. Retained clot must also be removed during such procedures to prevent or treat superinfection and/or lung entrapment. (See "Management and prognosis of parapneumonic pleural effusion and empyema in adults".)

Procedural considerations — Elimination of uniloculated or multiloculated empyemas is often accomplished via a VATS procedure [14,15]. However, open thoracotomy is necessary in some cases. (See "Management and prognosis of parapneumonic pleural effusion and empyema in adults", section on 'Treatment failure'.)

Anesthetic considerations

●Preoperative considerations – Usually, the empyema can be eliminated using a VATS technique. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection" and "Anesthesia for open pulmonary resection".)

However, the anesthesia provider should be prepared for possible conversion from a VATS procedure to a thoracotomy (eg, if adequate pleural fluid drainage and lung expansion are not achieved). If preoperative discussion with the surgeon reveals that conversion to open thoracotomy is likely, a thoracic epidural catheter may be inserted before induction of general anesthesia so that thoracic epidural analgesia (TEA) can be provided during the postoperative periods. (See "Anesthesia for open pulmonary resection", section on 'Planning for postoperative analgesia'.)

●Airway management – If the patient has purulent pulmonary secretions, cross-contamination from one lung to the other must be avoided. Thus, we typically select a double-lumen tube (DLT) endotracheal tube rather than a bronchial blocker because a DLT provides a better seal to prevent potential leakage and contamination. DLTs are also more quickly placed and have a lower incidence of malpositioning during patient movement compared with bronchial blockers. (See "Lung isolation techniques", section on 'Unilateral pulmonary infection'.)

●Extubation and postoperative management – Whether the patient will meet extubation criteria after completion of the surgical procedure depends on adequacy of pulmonary reserve and risk of hemodynamic instability (eg, in patients with systemic inflammatory response syndrome or large shifts in intravascular volume).

Empyectomy, pleurectomy, or decortication — Patients with chronic empyema or other inflammatory or traumatic processes may develop pleural fibrosis, with thick pleural fluid and formation of a fibrous peel covering the visceral and parietal pleura (ie, fibrothorax) and causing lung trapping and incomplete lung re-expansion. In some cases, surgical empyectomy, pleurectomy, or complete decortication may be necessary.

In selected patients with malignant pleural mesothelioma (MPM), pleurectomy/decortication (ie, removal of both the parietal and visceral pleura with preservation of the lung parenchyma) may be attempted. (See "Initial management of malignant pleural mesothelioma", section on 'Outcomes with EPP and P/D'.)

Procedural considerations — Empyectomy procedures involve complete removal of the empyema in the pleural space to allow lung re-expansion. Additional surgical interventions may be necessary to treat complications of empyema at previous surgical sites. Complete decortication (ie, surgical removal of a fibrotic peel from the lung with preservation of the visceral pleura) is the selected treatment for some patients. (See "Diagnosis and management of pleural causes of nonexpandable lung", section on 'Management of trapped lung'.)

Surgical management requires VATS or open thoracotomy. Anesthetic considerations for these procedures are discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection" and "Anesthesia for open pulmonary resection".)

Anesthetic considerations — If open thoracotomy is planned, a thoracic epidural catheter may be inserted before anesthetic induction to provide supplemental intraoperative and postoperative analgesia [16]. (See "Anesthesia for open pulmonary resection", section on 'Planning for postoperative analgesia' and "Anesthesia for open pulmonary resection", section on 'Use of neuraxial agents'.)

Significant bleeding may occur during decortication or empyectomy procedures. For example, lung tissue may be injured during entry into the chest or dissection of the empyema peel from visceral pleura if it is strongly adherent to the lung. Transfusion of red blood cells (RBCs) may be necessary. Persistent oozing from lung surfaces after decortication may necessitate transfusion of fresh frozen plasma and/or platelets. We employ standard laboratory tests and point-of-care (POC) viscoelastic tests of hemostasis (eg, thromboelastography [TEG] or rotational thromboelastometry [ROTEM]) to guide decision-making regarding transfusion of these products. (See "Intraoperative transfusion and administration of clotting factors", section on 'Intraoperative diagnostic testing' and "Intraoperative transfusion and administration of clotting factors", section on 'Indications and risks for specific blood components'.)

Although lung resection procedures are typically managed with restrictive fluid management (see "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'), volume resuscitation should be provided as appropriate in a patient with persistent bleeding.

At the end of the procedure, full re-expansion of the lung is important to fill the pleural space and prevent development of postoperative fibrosis within this space. (See "Management and prognosis of parapneumonic pleural effusion and empyema in adults".)

Postoperative management

●Postoperative transport – Many patients are transported to the intensive care unit (ICU), intubated, and sedated. Early extubation (in the operating room or shortly after transport to the ICU) may be possible in patients with full re-expansion of the lungs. (See "Transport of surgical patients".)

●Pain management – If an epidural catheter was placed, TEA provides optimal analgesia in the postoperative period, and may reduce the incidence of complications. In one observational study in 99 consecutive patients undergoing pleurectomy/decortication, the incidence of major postoperative complications (defined as need for an additional postoperative surgical, endoscopic or radiological intervention, development of organ dysfunction including renal failure requiring dialysis, or death) was lower in patients who had TEA compared with those with no epidural (32.3 versus 63.1 percent) [16]. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia'.)

Repair of bronchopleural or alveolopleural fistula — A bronchopleural fistula is an abnormal connection between the pleural space and a bronchus, while an alveolopleural fistula is a pathologic communication between the pleural space and the pulmonary parenchyma distal to a segmental bronchus (alveoli). The air leak and pneumothorax resulting from such fistulas is considered to be prolonged if it persists beyond five days. This type of pneumothorax occurs most commonly after pulmonary resection. (See "Alveolopleural fistula and prolonged air leak in adults" and "Bronchopleural fistula in adults".)

Procedural considerations — Repair of an alveolopleural fistula is usually achieved with tube thoracostomy and prolonged drainage. In some cases, surgical obliteration involving revision of a bronchial stump with debridement of necrotic tissue and suture reclosure of the stump is necessary. Primary closure of a bronchopleural fistula may not be possible, and creation of a muscle (eg, thoracic skeletal muscle, rectus abdominis muscle) or omental flap for reinforcement at the site of the leak may be necessary to obliterate the leak [17,18]. (See "Bronchopleural fistula in adults", section on 'Surgical repair (curative)' and "Alveolopleural fistula and prolonged air leak in adults", section on 'Surgical repair'.)

Closure of a bronchopleural fistula is accomplished via VATS or open thoracotomy. Anesthetic considerations for these procedures are discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection" and "Anesthesia for open pulmonary resection".)

Anesthetic considerations

●Airway management – Lung isolation is necessary to decrease pressure and air flow on the side of the pathology. Precise placement of an endobronchial blocker under direct bronchoscopic guidance can provide temporary occlusion of the fistula to stabilize a patient who is unstable due to air leakage until a more permanent endobronchial intervention (eg, surgical repair) is performed [19]. (See "Lung isolation techniques" and "Lung isolation techniques", section on 'Bronchial blockers'.)

After confirming proper placement of the lung isolation device, the bronchial cuff should be inflated to isolate the contralateral lung before repositioning the patient for surgical repair. Typically, a lateral decubitus position is selected, with the operative lung or pleural space up. Notably, contamination of the nonoperative lung is most likely to happen during repositioning; thus, it is important to ensure lung isolation before repositioning, and to carefully avoid accidental displacement of the lung isolation device during repositioning. Furthermore, the nonoperative lung may be flooded as saline is instilled into the chest of a patient in the lateral decubitus position if the contralateral lung has not already been isolated. It is also important to ensure lung isolation during later repositioning from left or right lateral decubitus to a supine position if harvesting of the omentum or rectus abdominis muscle for muscle transposition is necessary. (See "Lung isolation techniques", section on 'Abnormal tracheobronchial anatomy'.)

●Ventilation management – Similar to all procedures employing one lung ventilation (OLV), a lung protective ventilation strategy should be employed. However, the tidal volume actually delivered may be difficult to measure due to volume loss from the fistula site. (See "One lung ventilation: General principles", section on 'Lung-protective ventilation strategies'.)

Vigilance for development of tension pneumothorax with sudden hemodynamic compromise and desaturation is necessary.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pleural effusion".)

SUMMARY AND RECOMMENDATIONS

●Preanesthetic assessment – Preanesthetic assessment includes the etiology of pleural disease (eg, malignant or nonmalignant fluid [pleural effusion], air [pneumothorax], chyle [chylothorax], blood [hemothorax] or purulent material [empyema], fibrosis of the pleural space [fibrothorax], formation of an alveolopleural or bronchopleural fistula). (See 'Preanesthetic assessment' above.)

•Elective procedures – Chronic comorbid conditions are managed (eg, underlying pulmonary disease, anemia, frailty). Antibiotic therapy is continued during the perioperative period to treat infectious empyema. Hypovolemia, electrolyte abnormalities, and malnutrition may require management in patients who have had continuous drainage of chylous pleural fluid.

•Emergency procedures – Patients with acute pleural effusions or pneumothorax presenting in respiratory distress may require immediate endotracheal intubation. If one lung ventilation (OLV) will be necessary during the surgical procedure, then a lung isolation device such as a double-lumen endotracheal tube (DLT) or a bronchial blocker is inserted. (See "Lung isolation techniques".)

Patients with hemothorax, pneumothorax, or empyema with septic shock may be hemodynamically unstable. (See "Intraoperative management of shock in adults", section on 'Tension pneumothorax or hemothorax' and "Intraoperative management of shock in adults", section on 'Septic shock'.)

●Monitoring and intravascular access – For limited surgical interventions when conversion to open thoracotomy is highly unlikely, one large-bore peripheral intravenous (IV) catheter is typically adequate, and invasive hemodynamic monitoring (eg, intra-arterial catheter or central venous catheter placement) is not usually necessary. For major procedures that may involve significant blood loss, additional IV access for rapid volume resuscitation is necessary. If hemodynamic instability is anticipated, invasive circulatory system monitoring (eg, an intra-arterial catheter) is established. (See 'Monitoring and intravascular access' above.)

●Intraoperative management

•General anesthesia – General anesthesia is necessary for most surgical interventions for pleural diseases. (See 'General anesthesia' above.)

-Airway and ventilation management – If OLV is necessary, a DLT is usually preferred to prevent soiling of the airway and the contralateral lung in the lateral decubitus position (figure 2 and figure 3). A lung protective ventilation strategy is employed during ventilation with one or two lungs. Details are discussed in separate topics. (See "Lung isolation techniques" and "One lung ventilation: General principles".)

-Maintenance of anesthesia – Anesthesia is maintained with a potent volatile inhalation anesthetic agent such as sevoflurane, supplemented with a short-acting intravenous IV opioid, and a neuromuscular blocking agent (NMBA). Nitrous oxide should be avoided to prevent excessive expansion of gas-filled spaces.

•Local anesthesia – Selected video-assisted thoracoscopic surgery (VATS) procedures may be performed with a local anesthetic technique and monitored anesthesia care (MAC) with sedation as needed. Details are discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Nonintubated thoracoscopic surgery'.)

●Postoperative management – Decisions to extubate after surgical repair depend on patient-specific and procedure-specific factors (eg, severe preoperative respiratory failure, postoperative need for continuous pulmonary toilet). (See 'Postoperative management' above.)

Pain management techniques after thoracotomy or VATS procedures are discussed in separate topics:

•(See "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management'.)

•(See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Postoperative pain management'.)

●Anesthetic management for specific procedures – Specific anesthetic considerations for the following procedures are discussed above:

•(See 'Catheter drainage of pleural effusions' above.)

•(See 'Pleurodesis' above.)

•(See 'Open drainage or debridement of empyema' above.)

•(See 'Empyectomy, pleurectomy, or decortication' above.)

•(See 'Repair of bronchopleural or alveolopleural fistula' above.)