Anaesthetic management of a patient with a descending thoracic aortic aneurysm and severe bilateral bullous pulmonary parenchymal disease.

The anaesthetic management of the surgical repair of a descending aortic aneurysm in a patient with large, bilateral, pulmonary bullae is described. Anaesthesia for descending aortic surgery normally involves unilateral, positive-pressure ventilation, an option which poses some risk of barotrauma in the presence of bilateral bullae. Patients with bullous disease commonly have severe lung disease and thorough preoperative assessment and preparation are necessary. Intraoperatively, bilateral rupture of the bullae could be catastrophic and preparations should be made for this possibility. In order to diminish this risk, a surgical technique including preemptive collapse of the bulla by minithoracotomy and tube drainage, with use of a bronchial blocker to the affected part of the lung may be used. If rupture occurs, then high frequency jet ventilation may be effective. Use of a double lumen endobronchial tube may be advantageous for patients with either unilateral and bilateral bullae. Anaesthesia for patients with bullae should avoid positive-pressure ventilation and nitrous oxide in order to limit the risk of barotrauma from a ball valve mechanism. In this case, the risk of barotrauma was reduced by performing an inhalational induction of anaesthesia and limiting peak inflation pressures during thoracotomy. It was elected to use positive-pressure ventilation through a double lumen endobronchial tube following chest incision. A high frequency jet ventilator was available but not employed. Anaesthetic management was complicated by the presence of pleural adhesions, surgical approach directly through a bulla, and the requirement for one lung ventilation.