Reduction of airspace after lung resection through controlled paralysis of the diaphragm☆

Abstract

Objectives: Residual airspace following thoracic resections is a common clinical problem. Persistent air leak, prolonged drainage time, and reduced hemostasis extend hospital stay and morbidity. We report a trial of pharmacologic-induced diaphragmatic paralysis through continuous paraphrenic injection of lidocaine to reduced residual airspace. The objectives were confirmation of diaphragmatic paralysis and possible procedure related complications. Methods: Six eligible patients undergoing resectional surgery (lobectomy or bilobectomy) were included. Inclusion criteria consisted of: postoperative predicted FEV1 greater than 1300 ml, right-sided resection, absence of parenchymal lung disease, no class III antiarrhythmic therapy, absence of hypersensitivity reactions to lidocaine, no signs of infection, and informed consent. Upon completion of resection an epidural catheter was attached in the periphrenic tissue on the proximal pericardial surface, externalized through a separate parasternal incision, and connected to a perfusing system injecting lidocaine 1% at a rate of 3 ml/h (30 mg/h). Postoperative ICU surveillance for 24 h and daily measurement of vital signs, drainage output, and bedside spirometry were performed. Within 48 h fluoroscopic confirmation of diaphragmatic paralysis was obtained. The catheter removal coincided with the chest tube removal when no procedural related complications occurred. Results: None of the patients reported respiratory impairment. Diaphragmatic paralysis was documented in all patients. Upon removal of catheter or discontinuation of lidocaine prompt return of diaphragmatic motility was noticed. Two patients showed postoperative hemodynamic irrelevant atrial fibrillation. Conclusion: Postoperative paraphrenic catheter administration of lidocaine to ensure reversible diaphragmatic paralysis is safe and reproducible. Further studies have to assess a benefit in terms of reduction in morbidity, drainage time, and hospital stay, and determine the patients who will profit. #

Effect of Phrenic Nerve Palsy on Early Postoperative Lung Function After Pneumonectomy: A Prospective Study

“…Additionally, it should be noted, that our investigational approach has never been used before to examine the intraindividual effect of phrenic nerve palsy in patients after pneumonectomy, and that our method has proven to be safe and reproducible [5]. Nevertheless, further studies are needed to validate the results and obtain more evidence in this field of research.…”

“…Our group has previously demonstrated the feasibility and reproducibility of a controlled induction of paralysis of the diaphragm after lung resection by paraphrenic lidocaine application [5]. The same technique was used for this study: upon completion of lung resection a standard epidural catheter (Braun Perifix; B. Braun Medical Ltd, Melsungen, Germany) was placed in the paraphrenic tissue on the pericardial surface and fixed with an absorbable suture (4-0) and externalized through a separate parasternal incision where the catheter was fixed to the skin with a nonabsorbable suture (3-0).…”

Clinical outcomes of polymeric sealant use in pulmonary resection: a systematic review and meta-analysis of randomized controlled trials

“…Thoracic surgeons have also endeavored decrease PAL with intra-operative technical modifications. Blood patch, pleural tenting, pneumoperitoneum and phrenic nerve paralysis have reported mixed efficiency (15)(16)(17)(18). When approaching an incomplete lobar fissure, the "fissureless" approach employing surgical stapling has shown to result in greater pneumostasis compared to precision dissection with electrocautery (16,19).…”

A retrospective study of diaphragmatic motion, pulmonary function, and quality-of-life following video-assisted thoracoscopic lobectomy in patients with nonsmall cell lung cancer

“…[6,7] This will lead to a paralysis of the diaphragm, consecutively to an elevation and reduction of intrapleural space. Although reducing residual air space could theoretically be useful in preventing several complications such as prolonged air leak, bronchopleural fistula and empyema, persistent diaphragm paralysis may also cause other respiratory problem.…”