Background:  Some long-term survivors after lung cancer surgery may require additional lung surgery for recurrence. In the second surgery, special precautions are required regarding function and anatomical changes of residual lungs. We experienced repeated episodes of sudden hypotension associated with brief apneic periods during left lung resection in a patient with a non-functioning right lung. Case report:  A 58-year-old woman was scheduled for a left superior segmentectomy for lung cancer. She had undergone a right upper lobectomy and superior segmentectomy 11 years before. Function of the residual right lung was abolished due to radiotherapy-induced pulmonary fibrosis. The mediastinal structures were located completely in the right thoracic cavity. Her major respiratory function were TVC=1.65L (60.5%), FEV1=1.38L, PaCO2=44mmHg, and PaO2=67mmHg. She was free from PH. Anesthesia was maintained with combined general and epidural anesthesia. After failure in an attempt to place an endobronchial tube in the left main bronchus under fiberscopic guidance for protection of the fragile right lung, we placed a wire-reinforced tracheal tube above the carina. Fortunately, the fibrotic right lung did not re-expand nor receive barotrauma due to positive pressure ventilation (PPV). Repeated cycles of apnea for 3-5 min and intermittent PPV were used to facilitate the segmentectomy. While brief apneic periods were repeated, sudden decreases in blood pressure, cardiac output, and SpO2 occurred repeatedly, which resolved with resumption of PPV. The segmentectomy could be completed without extreme hypercapnia or hypoxemia. She was extubated 10 min after surgery. Discussion and Learning point; Repeated hypotension during apneic periods probably resulted from hypoxic pulmonary vasoconstriction, although SpO2 decreased only to 80%-90% . Her right ventricle might not be able to eject a sufficient stroke volume against vasoconstricted pulmonary arterioles probably because of easy collapsibilty of her left lung and also because of remarkable anatomical deformity of the heart system, including the heart encaged in a narrow space in the right thoracic cavity, kinking and stenosis of major systemic veins, and an increased distance from the bifurcation of the pulmonary artery to left pulmonary arterioles. Anesthesiologists should note anatomical changes of not only respiratory but also cardiovascular systems in patients scheduled for lung surgery following previous lung surgery.

Anesthetic management of a patient with a non-functioning right lung who underwent left lung resection