title: Thoracic epidural anaesthesia for awake thoracic surgery in severely dyspnoeic patients excluded from general anaesthesia.
abstract: OBJECTIVE
  General anaesthesia (GA) carries high risks of ventilator dependency with increased morbidity and mortality in patients with severe respiratory disease. It also presents an ethical dilemma if surgery remains the only treatment option for patients with advanced terminal chronic respiratory disease. Thoracic epidural anaesthesia for awake thoracic surgery (TEATS) in high-risk patients with dyspnoea at rest could avoid ventilator dependency and speed up recovery even in patients with severe dyspnoea. This retrospective observational study analysed indications, management and outcome of patients contraindicated to GA undergoing awake thoracic surgery with thoracic epidural anaesthesia.
  
  
  METHODS
  From 716 patients requiring thoracic surgery, nine were contraindicated to GA. Eight patients [American Society of Anesthesiologists (ASA) 4] had a maximum grade four of the modified Medical Research Council dyspnea scale (MMRC). Two patients (ASA 3, grade 1 MMRC and ASA 4, grade 4 MMRC) refused GA.
  
  
  RESULTS
  Patients (female : male ratio 1.25 : 1, age 19-76 years) had the following chronic respiratory diseases: pulmonary fibrosis (n = 2), pulmonary metastases (n = 3), chronic obstructive pulmonary disease (n = 1), alveolitis (n = 1) and myopathy (n = 2). Surgical indications were: thoracotomy (n = 6) for pleurectomy to treat recurring pneumothorax (n = 3), pleurostomy (n = 1), emphysema surgery (n = 1), lung biopsy (n = 1) and thoracoscopy (n = 3) for pleural/lung biopsy (n = 2), pneumothorax (n = 1). Lidocaine 20 mg/ml or ropivacaine 7.5 mg/ml was titrated to achieve an anaesthesia level T2-T12. No patient required GA [time of surgery: 46-128 min, mean = 76 min, standard deviation (SD) = 23 min]. Seven patients had light sedation with TCI propofol, remifentanyl or both and remained responsive. Fifty percent of patients received phenylephrine or ephedrine to maintain arterial pressure. Two patients went into hypercapnia, which was reversed with assisted mask ventilation. One patient suffered acute respiratory distress 7 days postoperatively and died of intestinal bleeding on Day 25. There were no postoperative complications in other patients. Excluding Patient 9 always remaining in a medical intensive care unit (ICU), the mean postoperative ICU stay in thoracic surgery was 4.4 days (SD 5.2). Hospital discharge was between 5 and 40 days after surgery.
  
  
  CONCLUSIONS
  TEATS with/without sedation was an alternative to GA for thoracotomy/thoracoscopy in severely dyspnoeic patients (MMRC grade 4, ASA 4) without postoperative sequelae.
authors.affiliation: Department of Anaesthesiology, University Hospital of Lille, Lille, France gaborkiss2001@hotmail.com.
authors.forename: Gabor
authors.initials: G
authors.lastname: Kiss
authors.affiliation: Department of Thoracic Surgery, University Hospital of Lille, Lille, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Claret
authors.affiliation: Department of Anaesthesiology, University Hospital of Lille, Lille, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Desbordes
authors.affiliation: Department of Thoracic Surgery, University Hospital of Lille, Lille, France.
authors.forename: Henri
authors.initials: H
authors.lastname: Porte
mesh_terms: D000328:Adult; D000368:Aged; D000767:Anesthesia, Epidural / Q000379:methods*; D000768:Anesthesia, General; D000075202:Contraindications; D004417:Dyspnea / Q000150:complications* / Q000175:diagnosis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012129:Respiratory Function Tests; D012189:Retrospective Studies; D013896:Thoracic Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D019616:Thoracic Surgical Procedures / Q000379:methods*; D013904:Thoracic Vertebrae; D016896:Treatment Outcome; D014851:Wakefulness / Q000502:physiology*; D055815:Young Adult
keywords: Awake; Dyspnoea; Epidural anaesthesia; Palliative surgery; Thoracic surgery; Thoracoscopy; Thoracotomy