COPD, Stage IV, Laparoscopy, laparoscopic, surgery
Introduction: Laparoscopy is a minimally invasive procedure that associated with decreased morbidity and hospital stays. There are over two million laparoscopic surgeries performed annually in the US. Several studies have shown that patients with mild (Stage I) to moderate (Stage II) Chronic Obstructive Pulmonary Disease (COPD) develop hypercapnia during laparoscopy procedures. However, hypercapnia in this population did not affect the rate of complication or prolonged hospital stay. We report a case of very severe (Stage IV) COPD, who developed an acute respiratory failure with an increase in hospital stay during a laparoscopic procedure. We write this to bring awareness to the use of alternative techniques to more optimally manage patients with severe COPD.
Case Report: A 56-year-old man with past medical history of HIV, TB, and Stage IV COPD, who presented for an outpatient bilateral hernia repair. His symptoms are well controlled as an outpatient with persistent hypercapnia with a PCO2 of 50 mmHg. The patient underwent bilateral laparoscopic hernia repair with mesh placement without any complications. However, he was somnolent and confused after extubation and received 0.8 mg of naloxone with minimal response. An ABG revealed an acute respiratory acidosis with a PH of 7.25 and pCO2 of 80 mmHg. We started him on BiPAP as well as albuterol and Atrovent nebulizers every four hours. The following day he was more oriented, and a repeat ABG showed a pH of 7.36 and pCO2 of 60 mmHg. He was discharged home on budesonide and formoterol nebulizers and albuterol as needed.
Discussion: Laparoscopy has improved outcomes and decreased length of hospital stay as compared to open procedures for most patients. However, this may not be ideal for all patients. During a laparoscopic procedure, carbon dioxide (CO2) is inflated the abdomen to improve visualization of intra-abdominal organ. CO2 is absorbed into the body due to the difference in partial pressure of CO2 in the abdomen and blood. For most patients, the rapid absorption of CO2 can be offset by the adjustment of the anesthetic ventilator. This adjustment is not always possible for patients with severe lung pathology including COPD. The combination of increased CO2 absorption, and decreased ability to efficiently expel CO2, may lead to hypercapnic respiratory failure postoperatively as observed in the case discussed.
Conclusion: Two approaches may be used to combat the accumulation of excess CO2 in patients with severe COPD. Postoperative monitoring and treatment of hypercapnia or prevention of hypercapnia via alternative surgical procedures including an open technique with an aid of local blocks. Further studies should be conducted to assess the effectiveness of alternative surgical approaches in patient with stage III and IV.