Reduction of airspace after lung resection through controlled paralysis of the diaphragm.
OBJECTIVE
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 24h 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.


CONCLUSIONS
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.
Carboni
Giovanni L
GL
Division of General Thoracic Surgery, University Hospital Bern, Switzerland.
Vogt
Andreas
A
Küster
Jan R
JR
Berg
Peter
P
Wagnetz
Dirk
D
Schmid
Ralph A
RA
Dutly
André E
AE
D000368:Aged; D000388:Air; D000779:Anesthetics, Local / Q000627:therapeutic use*; D003964:Diaphragm / Q000187:drug effects*; D004322:Drainage; D005240:Feasibility Studies; D005260:Female; D005541:Forced Expiratory Volume / Q000502:physiology; D006801:Humans; D008012:Lidocaine / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control*; D013510:Pulmonary Surgical Procedures; D012133:Respiratory Paralysis / Q000139:chemically induced; D014797:Vital Capacity / Q000502:physiology
D000779:Anesthetics, Local; D008012:Lidocaine