Curr Anesthesiol Rep (2016) 6:135–141
DOI 10.1007/s40140-016-0153-x
THORACIC ANESTHESIA (T SCHILLING, SECTION EDITOR)
Oxygenation and Ventilation Strategies for Patients Undergoing
Lung Resection Surgery After Prior Lobectomy
or Pneumonectomy
Chris Durkin1 • Jens Lohser1
Published online: 21 March 2016
 Springer Science + Business Media New York 2016
Abstract Lung resection surgery after a prior lobectomy
or pneumonectomy is becoming more prevalent. Elevated
shunt fractions and reduced functional lung parenchyma
complicate one-lung ventilation in the patient with a prior
contralateral lobectomy. Meanwhile, lung resection after
pneumonectomy requires reliance on the solitary, surgical
lung for adequate oxygenation and ventilation without
impeding surgical progress. These challenges require
appropriate preoperative investigations and planning to
facilitate a technique that balances the need for adequate
gas exchange and lung injury prevention with the desire for
sufficient exposure to allow for a complete surgical
resection and optimal oncologic outcomes.
Keywords Thoracic anesthesia
Secondary lung
resection
Pneumonectomy
Lobectomy
One-lung
ventilation
This article is part of the Topical Collection on Thoracic Anesthesia.
& Jens Lohser
jens.lohser@vch.ca
Chris Durkin
christopher.durkin@vch.ca
1
Department of Anesthesiology, Pharmacology and
Therapeutics, Vancouver General Hospital, University of
British Columbia, JPP2 Room 2449, 899 West 12th Avenue,
Vancouver, BC V5Z 1M9, Canada
Introduction
Secondary primary lung cancers are an increasingly com-
mon occurrence given the improved survival of patients
with stage 1 lung cancer (5-year survival of 60–70 %) and
routine follow-up screening with annual low dose computer
tomography [1]. The incidence of secondary primary lung
cancer has been estimated to be 3–6 % per patient year
after curative lung resection [2]. Secondary lung resection
after prior lobectomy or pneumonectomy presents unique
perioperative challenges to the anesthesiologist.
Lobectomy is the standard of care for stage 1 non-small
cell lung cancer (NSCLC) [3] and is therefore likely to be
the most commonly encountered prior contralateral sur-
gery. One-lung ventilation with operative lung collapse is
routinely employed to enable surgical exposure. While it is
generally well tolerated, hypoxemia continues to occur in
up to 10 % of primary lung resection cases [4]. Oxygena-
tion challenges are likely to be more prevalent in the set-
ting of repeat surgery when relying on a previously
resected lung for gas exchange. Inadequate ventilation is
rare during primary lung resection; however, the lack of
functional parenchyma and altered lung mechanics after
prior lobectomy may result in critical hypercarbia being
encountered during subsequent lung surgery [5].
The options for formal lung resection are limited after
pneumonectomy; however, successful surgical outcomes
have been reported in a number of case series [6••].
Intraoperative management is particularly challenging in
these individuals due to the reliance on the solitary oper-
ative lung for oxygenation and ventilation unless extra-
corporeal cardiopulmonary support is implemented.
In this article, we will review the rationale for secondary
lung resections, the physiologic adaptations after major
lung resection, provide suggestions for preoperative
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evaluation, and discuss intraoperative strategies to facili-
tate surgical exposure, while maintaining adequate oxy-
genation and ventilation in patients with prior contralateral
lobectomy or pneumonectomy presenting for lung
resection.
Rationale for Surgical Resection of Secondary
Tumors
In a patient with a history of lung cancer, a new lung tumor
may represent metastatic disease or a second primary lung
cancer (commonly termed metachronous multiple primary
lung cancer). This distinction is crucial, as surgery for a
second primary lung cancer has a 5-year survival
approaching that of the initial resection [7, 8], while the
resection of metastatic disease is associated with poor
outcomes [9]. Even lung resection after pneumonectomy
has been associated with a 5-year survival as high as 50 %
if done for a second primary lung cancer [6••]. In contrast,
resection of metastatic disease after pneumonectomy is
associated with a 5-year survival of only 14 % [6••]. The
differentiation of metachronous primary lung cancer from
metastatic disease is difficult, particularly when the his-
tology is identical [10]. The American College of Chest
Physicians guidelines suggest that the diagnosis of meta-
chronous multiple primary lung cancer for a new lung
lesion requires a period of at least four cancer-free years
and no evidence of systemic metastases [10]. However,
given the diagnostic uncertainty and the clear benefit of
surgical resection for second primary cancers, many cen-
ters will offer surgery in the absence of extra-thoracic
metastases if the patient is deemed physiologically capable
of tolerating the resection [11].
Physiologic Adaptations After Lung Resection
Pneumonectomy and lobectomy procedures have been
performed well over 60 years [12, 13], providing a large
body of knowledge on the physiologic adaptations after
major anatomic lung resection.
Years after major lung resection lung volumes tend to
exceed the postoperative predicted values at the time of
surgery [14]. Early studies in children after pneumonectomy
suggested that new alveoli compensate for resected lung
parenchyma [15], in fact, Laros and Westermann demon-
strated near normal lung function in patients who underwent
pneumonectomy at the age of 5 or less [16]. In adult patients,
however, lung capacities are only 10–15 % greater than
predicted five or more years after pneumonectomy. This
increase is reflected in an increased residual volume and
therefore felt to represent lung distention as the primary
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Curr Anesthesiol Rep (2016) 6:135–141
compensatory mechanism [14]. While lung regeneration
may not be exclusive to children based on computer
tomography and magnetic resonance imaging studies eval-
uating tissue volume and lung microstructure [17], it seems
likely that alveolar growth predominates in infants, whereas
lung distention predominates in adults. The hyperexpansion
of residual lung tissue was initially feared after pneu-
monectomy and was termed vicarious emphysema [18].
However, more recent evidence suggests that the degree of
hyperinflation on imaging correlates with improved post-
operative forced expiratory volume in 1 s (FEV1) [14].
It is well documented that the long-term reduction in
FEV1 and diffusing capacity for carbon monoxide (DLCO)
after major lung resection is less than what is predicted
based on standard equations [19–24]. The average decline
in FEV1 is only 30 % after pneumonectomy [14] and 15 %
after lobectomy [25]. Larger anatomic resections tend to
result in a greater decline in FEV1 [14, 25]; however, there
is some variability as upper lobectomies result in relatively
larger reductions [26, 27], and FEV1 values may actually
improve in a subgroup of emphysema patients after formal
lobectomy [28]. Interestingly, lung expansion has been
shown to occur not only in the ipsilateral lung but also in
the contralateral lung after lung volume reduction surgery
in emphysema patients [29]. After lung resection, the
decline in lung function reaches its nadir 1 month post-
operatively and subsequently improves toward a new pla-
teau at 3 months after lobectomy and 6 months after
pneumonectomy [30]. Spirometric recovery likely repre-
sents decreased pain and improved chest wall mechanics
[30, 31] as well as a degree of pulmonary hyperinflation
[14]. Taken together, the above factors make the prediction
of pulmonary function values all but impossible and point
to repeat spirometry being essential prior to a second major
lung resection (Table 1).
Exercise tolerance may be affected after major pul-
monary resection secondary to impaired pulmonary or
cardiac function, or more commonly the interaction of
these systems. However, the correlation between reduc-
tions in pulmonary function indices such as FEV1 and
DLCO and reductions in exercise capacity is poor. In fact,
maximal oxygen consumption (VO2max) is not reduced
after lobectomy [32], and even after pneumonectomy, the
decline in FEV1 and DLCO is disproportionate to the
actual loss in exercise capacity [30]. Maximal oxygen
consumption is reduced by 28 % in the first 6 months after
pneumonectomy [32], however, has normalized in 79 % of
patients by the 5-year mark after surgery [14]. Conse-
quences of lung resection on the cardiac system largely
relate to the cardiac output moving through a reduced
pulmonary vascular bed, leading to elevated pulmonary
vascular resistance and an increased workload on the right
ventricle [33]. Pulmonary hypertension is a known
Curr Anesthesiol Rep (2016) 6:135–141 137

Table 1 Recommended workup for lung resection after previous lobectomy or pneumonectomy
Post-ipsilateral lobectomy Post-contralateral lobectomy Post-pneumonectomy

PFT Recommended for prognostication Recommended for prognostication Mandatory to assess suitability for
surgery
V/Q Consider Strongly recommended to assess feasibility N/A
scan of OLV
ETT Consider 6MWD or VO2max Consider 6MWD or VO2max Mandatory VO2max for prognostication
TTE Recommended for baseline assessment of Recommended for baseline assessment of Mandatory to rule out significant PHTN
RV function and PASP RV function and PASP or RV dysfunction
ETT exercise tolerance testing, PASP pulmonary artery systolic pressure, PFT pulmonary function testing, PHTN pulmonary hypertension, RV
right ventricle, 6MWD 6 min walk distance, TTE transthoracic echocardiography, VO2max maximal oxygen uptake in 1 min, V/Q ventilation/
perfusion

independent predictor of mortality in patients with COPD
[34] and may be present after major lung resection. Venuta
and colleagues evaluated right ventricle free wall thickness
and pulmonary artery systolic pressure (PASP) 4 years
after major lung resection. While no significant changes
were observed after lobectomy, patients after pneumonec-
tomy exhibited an average 8 mmHg rise in PASP with
significant right ventricular remodeling (dilation not
hypertrophy) [35]. Deslauriers et al. recently demonstrated
the presence of pulmonary hypertension in 32 % of
patients five or more years after pneumonectomy [36].
PASP elevations were in the mild to moderate range
(36 ± 9 mmHg) and not associated with altered exercise
capacity in their study. A more recent study confirmed a
similar degree of pulmonary hypertension in a similar
proportion of post-pneumonectomy patients and impor-
tantly was associated with a decrease in exercise tolerance
and worse clinical (non-operative) outcomes [37•]. Inter-
estingly, a small study previously demonstrated worse
surgical outcomes in patients with exercise induced right
ventricular dysfunction prior to surgery [38]. The presence
of elevated PASP may therefore be a marker of significant
deterioration in cardiopulmonary function. While the
presence of pulmonary hypertension was not shown to
affect outcomes of primary lobectomy surgery [39], the
same may not hold true for repeat lung resection surgery. It
thus appears advisable to estimate PASP and rule out right
ventricular dysfunction by transthoracic echocardiography
prior to repeat anatomic lung resection, particularly after
prior pneumonectomy (Table 1).
Preoperative Evaluation for Secondary Lung
Resection
A formal assessment of the cardiorespiratory reserve will
enable risk stratification and guide the surgical approach (in
addition to oncologic criteria). It is generally agreed that a
predicted postoperative FEV1 (ppoFEV1) \40 % and/or a
predicted postoperative DLCO (ppoDLCO) \40 % identi-
fies high-risk lung resection candidates [3]. Exercise testing
(VO2max, stair climbing, 6 min walk test, exercise
oximetry) is required in this group of patients to aid in risk
stratification [40]. Individuals with a VO2max \10 ml/kg/
min and either a ppoFEV1 \30 % and/or a ppoDLCO
\30 % have a high risk of mortality and long-term dis-
ability after major anatomic resection [41]. Patients with a
prior ipsilateral or contralateral lobectomy are unlikely to
have concerning ppoFEV1 or ppoDLCO values in the
absence of significant underlying lung disease. Standard
assessment guidelines [41] therefore appear sufficient to
assess this type of patient prior to repeat lung resection. The
amount of resection that a patient will tolerate post-pneu-
monectomy is more difficult to determine. Expert opinion
suggests that lobectomy after pneumonectomy is absolutely
contraindicated, with the possible exception of the right
middle lobe [42]. In a review of the published data on 102
anatomic lung resections after pneumonectomy, lobectomy
was associated with a pooled perioperative mortality of
33.3 % (N = 6), whereas sublobar resections had a 6.2 %
mortality [6••]. The American College of Chest Physicians
recommends segmentectomy or extended wedge resection
(margins [1 cm) with hilar and mediastinal lymph node
evaluation as a safe and effective alternative in high-risk
patients with stage 1 NSCLC [3]. Importantly, these non-
anatomic resections have been shown to produce similar
survival rates to anatomic resections in patients with limited
pulmonary reserve [43].
When considering repeat lung resection surgery, it is
important to realize that there is a significant disconnect
between suitability for surgery and the complexity of
anesthetic management. A patient after prior left-sided
lobectomy may present with relatively normal pulmonary
function values for right-sided lobectomy, yet present a
major perioperative challenge to the anesthesiologist given
the need for operative lung collapse.

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Oxygenation and Ventilation Strategies
for Secondary Lung Resections
Post-ipsilateral Lobectomy
The intraoperative management of a repeat lung resection
on the side of a prior lobectomy is similar in complexity
and management to the initial resection, as the ventilated
lung is in its native state. In fact, one-lung oxygenation
should be improved given that the collapsed lung, i.e.,
shunt fraction, has been surgically reduced by the prior
lobectomy. Ventilation would be unaffected by the prior
lung resection and mainly determined by any underlying
lung pathology. Preoperative lung function studies would
still be advisable unless prior testing readily qualified the
patient for pneumonectomy, and the likelihood of interval
deterioration is negligible. Similarly, exercise tolerance
testing should be considered, given that patients are
essentially presenting for a completion pneumonectomy.
Post-contralateral Lobectomy
Lung resection on the opposite side of a prior lobectomy
presents a significantly greater anesthetic challenge despite
the fact the pulmonary function testing may indicate that
the patient easily qualifies for a repeat lobectomy. One of
the known risk factors for OLV hypoxemia is when pul-
monary blood flow to the operative lung exceeds flow to
the ventilated lung, as in right sided surgery, which results
in shunt fractions in excess of 50 % [prior to redistribution
by gravity and hypoxic pulmonary vasoconstriction
(HPV)]. Significantly larger shunt fractions, however, may
be encountered after prior contralateral surgery when the
vascular territory in the now ventilated side has been sur-
gically reduced. Preoperative ventilation/perfusion scan-
ning may be able to predict intraoperative challenges with
oxygenation and ventilation. Any perfusion ratio with more
than 60 % of perfusion toward the operative lung may
present significant oxygenation challenges during periods
of lung collapse as it will produce shunt fractions of 30 %
or more once HPV is established [44••]. Oxygenation may
not be sufficient at this level of shunt unless supported by
operative lung CPAP, intermittent positive airway pressure
(IPAP), or partial ventilation with lobar isolation [45].
Ventilation is similarly affected by a prior contralateral
lobectomy, as it is in most cases restricted to a single lobe
(except for a prior right upper or lower lobectomy with
persistence of the right middle lobe). Protective ventilation
settings are crucial given the minimal amount of remaining
lung parenchyma. While compensatory overdistention has
increased the size of the remaining lung, volumes remain
smaller than prior to lung resection [46]. Tidal volume
restriction to 4–5 ml/kg or less is therefore an essential
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Curr Anesthesiol Rep (2016) 6:135–141
component of management. CO2 elimination is unaffected
by the increased shunt fraction but significantly impaired
by the reduced amount of alveolar tissue and the low tidal
volume ventilation. Respiratory rate compensation will be
unable to fully compensate for the reduction in alveolar
minute ventilation and will create high ventilating pres-
sures, exposing to lung to a high risk of alveolar stress
injury [44••]. Mild to moderate permissive hypercapnia
(arterial CO2 45–70 mmHg) is therefore mandatory for
lung protection [44••].
Post-pneumonectomy
Lung resection after pneumonectomy presents an unusual
and high-risk scenario with only a limited number of
published cases identified in a recent surgical review by
Tuofektzian [6••]. Based on this cohort, the mortality risk
for a post-pneumonectomy lobectomy appears prohibitive
at 33 % [6••]. However, even subsegmental resections and
wedge resection are associated with a substantial mortality
risk (*6 %) and a morbidity rate of 37 % [47, 48].
Hypoxemic and/or hypercapnic respiratory failures are the
root causes of poor post-pneumonectomy lung resection
outcomes. The intraoperative management of these patients
is similarly limited by the difficulty to oxygenate or ven-
tilate given the fact that the solitary operative lung is
manipulated and needs to be partially deflated or
hypoventilated to allow for surgical exposure. A variety of
techniques have been described to enable surgical access to
the lung; however, it is important to note that reports
consist primarily of level 4 evidence.
Intermittent apnea through a single lumen tube is fea-
sible and technically simple but limits surgery to short
intervals and may be injurious to the lung due to repeated
collapse and re-expansion of the solitary lung [44••].
Selective lobar isolation or high frequency jet ventilation
(HFJV) allow continuous surgical progress and likely result
in fewer precipitants of pulmonary injury but might
encounter hypoxemia more frequently. Unfortunately,
otherwise standard maneuvers to improve oxygenation
such as PEEP escalation or the equivalent increase in
driving pressure during HFJV are likely detrimental to
surgical access. Ventilation of a single lobe as in lobar
isolation, or ‘gentle’ HFJV of a partially collapsed lung,
will significantly affect CO2 elimination and may result in
progressive hypercapnia. Lobar isolation has been descri-
bed in a case of right upper lobectomy after pneumonec-
tomy [49]. HFJV has been shown to be an effective
alternative to conventional OLV, both in terms of oxy-
genation and ventilation [50, 51], and can provide equiv-
alent surgical exposure during pulmonary resection [50, 52,
53]. Extracorporeal support has been described as an
alternative approach [54–56]; however, the associated
Curr Anesthesiol Rep (2016) 6:135–141
invasiveness and resources required suggest that it should
be limited to highly selected cases. In our opinion, selective
lobar isolation or whole lung HFJV provides the most
controlled anesthetic environment for these patients. We
reserve intermittent apnea as a secondary approach when
inadequate surgical conditions are encountered and limit its
use to brief intervals.
Due to the need for operative lung ventilation in the
post-pneumonectomy surgery setting, thoracoscopic
approaches initially appeared contraindicated [57]. Video-
assisted thoracoscopic surgery (VATS) however has sig-
nificant potential benefits on postoperative pain and respi-
ratory function [58], particularly in patients with borderline
respiratory function [59]. Successful VATS has been
described for peripheral [53] and anatomic lung resections
after pneumonectomy [60], suggesting appropriate opera-
tive conditions can be achieved with a minimally invasive
approach. It is however important to be cognizant of the
fact that a VATS approach may increase perioperative risk
if it leads to increased operating times [58] and marginal
ventilation with subsequent increased right heart strain.
Given these concerns and the difficulty of resecting, all but
small peripheral lesions in a ventilated lung is favoring the
open approach in many cases [61]. It therefore appears
reasonable to attempt a thoracoscopic approach in favor-
able lesions, with a low threshold to convert to thoraco-
tomy if surgical progress is hampered or oxygenation and
ventilation are tenuous. Non-intubated thoracoscopic lung
resection in the sedated, spontaneously ventilating patient
has been described for a variety of procedures, including
peripheral wedge resection, segmentectomy, and lobec-
tomy [62–64]. Outcomes appear to be equivalent if not
better than traditional management under general anes-
thesia [65]. This approach might be of interest in the post-
pneumonectomy patient and is comparable in theory to
maintaining HFJV on the operated lung with minimal
collapse. Due to a lack of familiarity with this approach, we
cannot comment further on the merits of this technique.
Inadequate oxygenation and ventilation worsen pul-
monary vascular resistance and thereby aggravate any pre-
existing pulmonary hypertension. Caution is therefore
advised in managing the patient with pre-existing pul-
monary hypertension or, more concerning, right ventricular
dysfunction on preoperative echocardiography. Preopera-
tive exercise induced right ventricular dysfunction, sug-
gestive of impaired cardiopulmonary reserve, predicts
morbidity and mortality after major lung resection [38].
Surgical manipulation and resection in addition to partial
lung collapse may exhaust this reserve. Perioperative
monitoring of PASP with a pulmonary arterial catheter or,
preferably, right ventricular function with transesophageal
echocardiography is advisable.
139
Postoperative Disposition
Given the high morbidity and mortality, patients should
routinely be cared for in a critically care setting. The
management of patients after repeat lung resection is
heavily influenced by the ppoFEV1, ppoDLCO, and VO2
max values. It has previously been suggested that short-
term ventilation is mandatory in patients with ppoFEV1
values \30 % and should be considered in those with
ppoFEV1 30–40 %, particularly if ppoDLCO values are
significantly reduced [40]. Patients with marginal values
may benefit from extubation to non-invasive ventilation,
particularly if there is a high likelihood of lung derecruit-
ment or lung injury. Non-invasive ventilation has not been
formally assessed in this setting but has been shown to
improve oxygenation and lung function recovery after lung
resection surgery [66] and reduce mortality in patients with
acute respiratory failure after lung resection [67].
Conclusion
The number of patients presenting for resection of sec-
ondary primary lung cancers is on the rise. Preoperatively,
a thorough patient assessment is required to establish the
suitability for surgery and formulate an intraoperative
strategy for oxygenation and ventilation based on prior
resection size and location, current lung function, and
proposed resection. Lung resection on the contralateral side
of a prior lobectomy is amenable to traditional OLV but
more likely to require advanced interventions (CPAP/
IPAP/segmental blockade) to improve oxygenation. Pro-
tective ventilation is crucial to limit lung injury in the
remaining lung. Post-pneumonectomy patients can be
managed with selective lobar isolation or whole lung
HFJV, with intermittent apnea reserved as the alternative if
inadequate gas exchange or surgical exposure is encoun-
tered. Minimally invasive approaches can be achieved in
some patients, particularly for peripheral lesions amenable
to wedge resection. Given the high perioperative risks,
patients will benefit from postoperative care in a high-
acuity setting. Staged extubation with the use of non-in-
vasive ventilation may proof useful in this population.
Compliance with Ethics Guidelines
Conflict of Interest Chris Durkin and Jens Lohser declare that they
have no conflict of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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