Emphysema

Give the lungs time to empty - Loss of elastic recoil means slow exhalation. Long expiratory time, slow rates, and a watchful eye on the capnograph and the reservoir bag; stacked breaths hyperinflate the lung, drop venous return, and cost you cardiac output before they cost you oxygenation.

Skip nitrous oxide - N2O diffuses into closed gas spaces and expands them, and a bulla is a closed gas space. Nitrous is contraindicated with pneumothorax for the same reason — don't give a bulla the chance to become one.

Barotrauma and pneumothorax - Hyperinflation from air trapping is a barotrauma setup, and bullous bleb rupture releases air straight into the chest cavity. Know where the chest tube tray is before induction on a bullous patient.

Grade the obstruction preoperatively - PFTs give the picture: FEV1/FVC under 0.7, obstruction graded off the FEV1, increased residual volume and TLC from air trapping, and a reduced DLCO. A bronchodilator response over 200 mL or 12% flags bronchial hyperreactivity and tells you to premedicate.

Read the chest film and the gas - Chest x-ray shows hyperinflation with flattened diaphragms; ABG shows chronic respiratory acidosis with hypoxia. That ABG is their baseline — target their usual PaCO2 on emergence rather than a textbook 40.

Look for the right heart - Cor pulmonale complicates long-standing disease. A loud P2 and peripheral edema on exam, a dilated pulmonary artery on chest x-ray, and an echocardiogram to confirm secondary pulmonary hypertension.

Know their oxygen baseline - Long-term oxygen therapy is prescribed at a resting or exertional SpO2 under 88% or PaO2 under 55 mm Hg (under 59 mm Hg with cor pulmonale). A patient on home O2 is telling you their reserve is gone.

Young patient with emphysema - Send an alpha-1 antitrypsin level. AAT deficiency causes panacinar, lower-lobe disease at a younger age, and these patients may be on augmentation therapy.

Don't anesthetize through an exacerbation - Copious phlegm, extensive wheezing, and progression to hypercarbic and hypoxic respiratory failure define a decompensation. Elective cases wait for bronchodilators, steroids, and antibiotics to do their work; oral prednisone works as well as IV.

Bullectomy and lung volume reduction surgery - Sort out the double-lumen tube, arterial line, and the analgesia plan — epidural, block, or PCA — before the patient is in the room. These are general anesthesia with endotracheal intubation cases, and the whole point of the operation is that the lung they are giving you back works better than the one you started with.

Emphysema is permanent dilatation of the airways distal to the terminal bronchiole — respiratory bronchioles, alveolar ducts, and alveolar sacs — from destruction of the airway walls without fibrosis. Cigarette smoke or alpha-1 antitrypsin (AAT) deficiency tips the proteinase–antiproteinase balance, and released proteinases chew through the parenchymal connective tissue.

The loss of elastic recoil is what matters at the board. Airways collapse on exhalation, air traps, and residual volume, FRC, and total lung capacity climb while vital capacity falls. Alveolar-capillary surface area is gone, so DLCO drops and hypoxia with hypercarbia follows. Eighty percent of patients with bullae — air spaces larger than 1 cm — have underlying emphysema, and those bullae rupture into pneumothorax. Long-standing disease brings pulmonary hypertension and cor pulmonale.