Pneumonectomy

Anatomy and Physiology

The lungs are pyramid-shaped organs within the thoracic cavity and connected to the trachea by the right and left main bronchi. Enclosed by the thoracic cage, the lungs rest above the diaphragm and are separated by the mediastinum. Two layers of pleura cover each lung: the visceral pleura, which adheres to the lung surface, and the parietal pleura, which attaches to the thoracic wall, mediastinum, and diaphragm. The right lung is divided into 3 lobes (superior, middle, and inferior), while the left lung, slightly smaller to accommodate the cardiac notch, consists of only 2 lobes (superior and inferior). Each lobe is further divided into bronchopulmonary segments, each supplied by a tertiary bronchus and its own arterial blood supply, allowing for compartmentalized lung function and targeted surgical intervention.

A pneumonectomy, which involves removing an entire lung, significantly alters the thoracic anatomy and physiology. Unlike other thoracic surgeries, this procedure typically does not require a chest tube postoperatively, as suction may cause a mediastinal or cardiac shift into the pleural space. After pneumonectomy, the space previously occupied by the lung fills with air, gradually absorbed and replaced by fluid. Additional compensatory changes occur, such as hyperinflation of the remaining lung, mediastinal shift, and diaphragmatic elevation.[5] These adjustments are critical for maintaining adequate respiratory function and ensuring thoracic stability, yet they underscore pneumonectomy's physiological challenges and complexity.

Indications

Pneumonectomy, the surgical removal of an entire lung, is primarily indicated for advanced malignant and complex nonmalignant lung conditions.[6] Malignant indications are by far the most common, often reserved for central or extensive tumors that cannot be adequately resected with less invasive surgery. The procedure is frequently necessary in cases of non–non-small-cell lung cancer when the tumor involves the main stem bronchus or extends across major lung fissures. In more advanced cases, such as those involving tumors that reach the carina, a sleeve pneumonectomy may be required. While less common, pneumonectomy may also be considered for aggressive mesotheliomas, extensive thymomas, or certain complex malignancies where parenchymal-sparing resections are insufficient. Metastatic lung disease, however, rarely warrants a pneumonectomy.

For nonmalignant conditions, pneumonectomy is considered in severe inflammatory lung diseases and traumatic lung injuries. Inflammatory lung disease, often marked by chronic infection or destruction, may necessitate pneumonectomy when lung function is compromised or complications, like bronchopleural fistulas, arise. Comprehensive preoperative optimization, including infection control, lung function improvement, and nutritional support, is essential for minimizing complications such as empyema and fistula formation in these patients. Traumatic lung injuries, including severe blunt or penetrating trauma with major tracheobronchial disruptions, represent an urgent indication for pneumonectomy, particularly in hemodynamically unstable patients. However, these cases carry a high risk of mortality, primarily due to pulmonary edema and right heart failure, with blunt trauma associated with worse outcomes than penetrating injuries.

Contraindications

Contraindications to pneumonectomy are essential to identify, as they help ensure patients undergoing this extensive procedure have the best chance for a favorable outcome. Study results have shown that factors like advanced age, reduced pulmonary function, and the need for right-sided pneumonectomy are linked to higher risks of adverse outcomes.[7] Unless it is an emergency, pulmonary function tests should be performed before pneumonectomy to assess if the patient is fit for surgery. Forced expiratory volume in 1 second (FEV₁) and diffusion capacity of the lung for carbon monoxide (DLCO) provide the most accurate risk estimates of postoperative morbidity and mortality.[8] If the estimated postoperative FEV₁ or DLCO is less than 40% of predicted, the risk of morbidity and mortality is relatively high, and other functional assessment modalities should be sought.[9]

Cardiopulmonary exercise testing to measure maximal oxygen consumption (VO₂ max) is the most important functional assessment modality. A VO₂ max of less than 10 to 15 mL/kg/min is associated with an increased risk of postoperative complications.[8][9] Stair climbing, shuttle walk test, and the 6-minute walk test may also be considered, but data on the interpretation of the results of these tests are quite limited.[9] Pneumonectomy is contraindicated in patients deemed not fit based on the above tests, and more conservative treatment modalities should be pursued.

In addition to pulmonary function assessment, cardiac evaluation is also vital. Pneumonectomy is generally contraindicated in individuals with severe valvular disease, significant pulmonary hypertension, or poor ventricular function.[10] Surgical intervention is further precluded in cases with positron emission tomography or computed tomography evidence demonstrating tumor spread beyond the diaphragm, involving intraabdominal structures, contralateral hemithorax, or ribs. Identifying these contraindications allows for careful patient selection and promotes safer, more effective treatment planning, potentially including alternative, less invasive approaches.

Equipment

A pneumonectomy requires specialized surgical and anesthetic management equipment to ensure safe resection and optimal patient outcomes. From the surgical perspective, thoracotomy instruments are essential. These include rib spreaders to provide adequate access to the thoracic cavity, specialized thoracic instruments tailored to lung tissue handling, tissue forceps, and scissors. These tools facilitate controlled dissection and minimize trauma to surrounding tissues.

From the anesthetic viewpoint, lung isolation techniques are critical for selectively ventilating the remaining lung, maintaining adequate gas exchange, and creating a stable operative field. This isolation can be achieved using a left or right double-lumen endobronchial tube, a bronchial blocker, or the endobronchial placement of a standard endotracheal tube.[11][12] A flexible bronchoscope should be readily available to confirm tube positioning and effective lung isolation.

Personnel

Due to the complexity and risks of the procedure, a pneumonectomy requires a skilled, multidisciplinary team to ensure optimal patient outcomes. The operation is primarily conducted by a cardiothoracic surgeon experienced in pneumonectomies and an anesthesiologist proficient in single-lung ventilation and invasive hemodynamic monitoring.[13] This specialized anesthetic management is critical, as it isolates the lung for resection while maintaining adequate gas exchange and stable hemodynamics. Intraoperative support staff, such as surgical technologists trained in thoracic procedures, are essential for handling thoracotomy instruments and facilitating smooth operative workflow.

Postoperatively, intensive monitoring and management are critical due to potentially life-threatening complications like respiratory distress, bleeding, and pulmonary edema. A dedicated team, including intensive care unit (ICU) nurses trained in caring for patients postthoracotomy, respiratory therapists skilled in ventilator management and pulmonary hygiene, and critical care physicians, is vital. High-volume centers, where specialized personnel and advanced protocols are readily available, generally demonstrate superior short- and long-term patient outcomes due to their proficiency in managing these complex cases compared to centers with lower volumes.[14][15]

Preparation

Preoperative Preparation 

Preparing for pneumonectomy requires thorough patient evaluation, risk stratification, and medical optimization to ensure the best surgical outcomes. The first step is typically pulmonary function testing, which includes spirometry, lung volume measurements, and DLCO. Baseline resting partial pressures of oxygen and carbon dioxide have not been as helpful as measuring FEV₁ and DLCO for preoperative assessment. As mentioned, FEV₁ and DLCO provide the most accurate predictors of postoperative morbidity and mortality and indirectly measure the pulmonary reserve.[8] The predicted postoperative FEV₁ and DLCO calculation considers the preoperative values and lobar or whole lung contribution measurements to function as measured by ventilation-perfusion scanning or computed tomography by subtracting the lung segments to be resected from the total lung function.

Predicted postoperative FEV₁ and DLCO of more than 60% is considered an adequate pulmonary reserve, and patients are at low risk of death and cardiopulmonary complications. Predicted postoperative FEV₁ or DLCO between 30% to 60% usually indicates a moderate risk of morbidity and mortality, and additional low technology exercise testing such as stair climbing or shuttle walk test is usually indicated—values less than 30% mandate a formal cardiopulmonary exercise test with measurement of maximal oxygen consumption. Patients who can achieve a VO₂ max greater than 20 mL/kg/min are likely to have an acceptable rate of postoperative complications. In contrast, those with a value of less than 10 mL/kg/min are best managed by nonsurgical modalities. 

Management of chronic conditions like chronic obstructive pulmonary disease, hypertension, and diabetes is essential for optimizing preoperative health. Smoking cessation weeks before surgery is strongly encouraged to improve pulmonary and wound healing, and pulmonary rehabilitation may enhance lung function and reduce complications. Comprehensive informed consent and patient counseling are also critical, with discussions on risks like respiratory complications, pulmonary hypertension, and quality-of-life changes.

Routine laboratory evaluations, including complete blood count, renal function panel, and coagulation profile, are conducted to evaluate overall health, and type and crossmatch are performed in anticipation of blood loss. Renal function is carefully reviewed, as chronic kidney disease can increase the risk of postoperative complications.[16][17] Functional capacity should always be adequately assessed, and cardiac risk assessment with an electrocardiogram, echocardiography, or a stress test should be performed when necessary. Other treatment modalities should be sought in patients with active or high-risk cardiac conditions.

Additionally, recent lung imaging—typically computed tomography or positron emission tomography within 6 to 8 weeks of surgery—helps map out the anatomical landscape and surgical field. In some cases, preoperative medications, such as antibiotics or bronchodilators, may be prescribed, while anticoagulants are generally withheld to minimize intraoperative bleeding risks. This comprehensive, multidisciplinary approach to preoperative preparation aims to enhance surgical outcomes and minimize perioperative risks associated with pneumonectomy.

Intraoperative Preparation and Management 

To manage postoperative pain for pneumonectomy, a thoracic epidural catheter is often placed preoperatively. Alternative regional techniques, such as paravertebral or intercostal nerve blocks, may also be used and are generally considered low-risk, even in patients with mild hemostatic abnormalities. The standard American Society of Anesthesiologists monitors and invasive hemodynamic monitoring devices are used during surgery. General anesthesia is typically induced in the supine position. Single-lung ventilation is almost always necessary, usually achieved via a double-lumen endotracheal tube (DLT), a single-lumen tube with a bronchial blocker, or by advancing a single-lumen tube into a mainstem bronchus.

DLTs consist of separate tracheal and bronchial lumens, with size selection generally based on the patient’s height.[11] DLTs come in left- or right-sided options depending on which bronchus the tube’s bronchial lumen is designed for. Left-sided DLTs are typically preferred unless the procedure involves the left mainstem bronchus due to the proximity of the right upper lobe bronchus to the carina. Since the right upper lobe bronchus branches close to the carina, there is a risk of insufficient ventilation and upper lobe collapse during right lung ventilation. Right-sided DLTs have an additional sidewall orifice to ventilate the right upper lobe, but this configuration still carries a risk of inadequate ventilation. In about 3% of patients, the right upper lobe bronchus originates at or even from the trachea, adding further complexity to DLT placement.[11]

DLTs are advanced under direct laryngoscopy with the endobronchial lumen directed anteriorly for placement. Once the tube passes the vocal cords, the stylet is removed, and the DLT is rotated 90 degrees toward the intended lung (left or right). The DLT is advanced until resistance is felt, and a flexible bronchoscope is used to verify proper placement. The flexible bronchoscope is initially inserted into the tracheal lumen, confirming that the bronchial balloon is visible beyond the carina without herniation. Next, the flexible bronchoscope is passed through the bronchial lumen to confirm the correct positioning. Reconfirmation with a flexible bronchoscope should occur whenever there is a change in the patient’s position.

An alternative to DLTs for single-lung ventilation is the bronchial blocker, typically placed under flexible bronchoscopic guidance through a single-lumen endotracheal tube. While bronchial blockers take longer and may require intraoperative repositioning, they are easier to place in patients with difficult airways and allow for selective lung segment isolation.[12][18] A third single-lung ventilation method involves advancing a single-lumen endotracheal tube to a mainstem bronchus under flexible bronchoscope guidance. When using this technique, a specially designed long endotracheal tube is preferred to avoid obstructing the upper lobe bronchus with the endotracheal tube cuff, which can occur with standard endotracheal tubes.[19] 

An arterial line is often placed for hemodynamic monitoring to facilitate frequent blood sampling and real-time blood pressure monitoring. In patients with compromised hemodynamic stability, the arterial line may be placed before anesthesia induction to maintain adequate perfusion pressure. Depending on comorbidities, a central venous line might also be needed, and selected cases may warrant transesophageal echocardiography or pulmonary artery catheters, especially in patients with severe right ventricular dysfunction, pulmonary hypertension or significant valvular disease.[20] The patient is positioned in the lateral decubitus position with the operative side up. Positioning is carefully checked to avoid nerve injuries, and the DLT or bronchial blocker positioning is reconfirmed with a flexible bronchoscope. With ongoing vigilance, single-lung ventilation is then initiated to maintain optimal tube placement and patient safety throughout the procedure.

Technique or Treatment

Pneumonectomy is usually performed through a posterolateral thoracotomy incision, as it provides the best exposure. The incision is generally made at the fourth or fifth intercostal space level. Other approaches commonly employed are the axillary and anterior thoracotomy, providing poor access to the posterior thorax. Hemiclamshell and clamshell approaches are usually used for large tumors involving the apex of the upper lobe or the anterosuperior mediastinum. 

The surgical technique for pneumonectomy involves several key steps and requires careful adherence to anatomical planes to ensure complete resection while minimizing complications. The technique includes:

• Thoracotomy incision
  • The surgeon typically makes a posterolateral thoracotomy incision along the fourth or fifth intercostal space to access the pleural cavity. A rib spreader is placed to increase exposure, allowing visualization of the lung and surrounding structures.
• Mobilization of the lung
  • The surgeon mobilizes the lung by dissecting and releasing any adhesions between the lung and the pleura. Careful dissection along the pleural surfaces ensures the lung is fully freed for mobilization without injuring adjacent structures.
• Isolation and division of the pulmonary vessels
  • The pulmonary artery and veins are dissected and individually ligated to control blood flow. Each vessel is divided using a vascular stapler or ligatures while ensuring hemostasis. Attention is given to avoiding tearing the vessel walls, particularly in cases with friable vessels due to prior treatments like chemotherapy or radiation.
• Isolation and division of the mainstem bronchus
  • After securing the vessels, the bronchus is dissected and stapled close to the carina. Ensuring an adequate margin is critical to prevent recurrence in malignant cases. Ventilation or underwater tests can be performed to confirm that the stapled bronchial stump is sealed, observing for any air leaks.
• Specimen removal
  • The resected lung is removed en bloc. For larger specimens, the incision may need to be extended, or in some cases, the specimen may be delivered in a protective bag to prevent contamination.
• Hemostasis and closure
  • Meticulous hemostasis is achieved within the chest cavity. A chest drain may be placed to evacuate residual air or fluid, although pneumonectomy cavities are often managed without a drain. The thoracotomy incision is then closed layer-by-layer, with attention to securing the chest wall muscles and skin.

The interest in minimally invasive lung surgery has significantly grown in the past few years. This includes video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). Surgery is usually performed through 1 or more small incisions in the chest wall. This approach typically translates into lower morbidity and more favorable pain control when compared to open surgical approaches. In VATS, the surgeon holds the surgical instruments, while in RATS, the surgeon does not handle the instruments but can control all movements from the console. Compared to RATS, VATS is associated with a lower cost, less blood loss, and shorter operative time.[21] 

A restrictive intravenous (IV) fluid strategy is usually employed in the absence of severe hemodynamic instability and ongoing blood loss. This is associated with a lower incidence of acute lung injury and enhanced postoperative recovery.[22] Vasopressors are usually preferred over IV fluid boluses to correct hypotension related to general anesthesia. Notably, it has been shown that using colloids like albumin is not superior to crystalloids for volume expansion.[23] A lung-protective ventilation strategy is usually employed to decrease the risk of acute lung injury. This includes using low tidal volumes of around 5 mL/kg of ideal body weight, low airway driving pressure maintenance, and positive end-expiratory pressure. The fraction of inspired oxygen should be kept at the lowest possible to maintain arterial oxygen saturation above 90%. Unless contraindicated, permissive hypercapnia is usually allowed to achieve these goals.[24] 

After surgery, the standard endotracheal tube is placed, and the patient is returned to the supine position. Bronchoscopy is performed if needed. An arterial blood gas is usually obtained to ensure adequate oxygenation and ventilation, and the patient is extubated if deemed appropriate. Some patients may require continuous positive airway pressure or a high-flow nasal cannula after extubation. Such noninvasive ventilatory strategies improve oxygenation without increasing the incidence of complications.[25] If the patient is to remain intubated, DLT must be changed to a single-lumen tube using a tube exchanger catheter. 

Postoperative care is critical for minimizing complications, ideally in an intensive care setting with invasive monitoring and controlled oxygen supplementation. Fluid management remains conservative to prevent pulmonary edema, and the chest tube, if present, is kept off suction. Pain management is handled through a multimodal approach, and gradual dietary progression is recommended to avoid complications related to esophageal dysmotility. Through meticulous surgical and anesthetic techniques and attentive postoperative care, pneumonectomy can be performed more safely, with efforts focused on improving patient outcomes and minimizing risks.

Complications

Following pneumonectomy, pulmonary functions decrease but are usually less than anticipated for the removal of 50% of the lung, especially for residual volume, and this may be explained by overexpansion of the remaining lung tissue. FEV₁, DLCO, forced vital capacity, and lung compliance decrease. Airway resistance increases. Patients with no disease in the remaining lung usually have normal oxygen saturation and partial oxygen and carbon dioxide pressures at rest. 

A chest radiograph following pneumonectomy usually reveals a midline trachea and air-filled postpneumonectomy space. Later, that space gradually fills with fluid at a rate of 1 to 2 intercostal spaces/day. The ipsilateral diaphragm becomes elevated, and the mediastinum gradually shifts towards the operative side.[5] Resting heart rate typically increases, and stroke volume decreases following pneumonectomy. Pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure usually do not change. Cardiac function in long-term survivors is usually compromised, and the altered position of the heart may explain this.[26] 

Common complications following pneumonectomy include:

• Cardiac arrhythmias
  • These are some of the most common complications after pneumonectomy. Atrial fibrillation/flutter is the most commonly encountered dysrhythmia and usually occurs in the first 3 days following surgery.[27][28][29]
• Postpneumonectomy cardiac herniation
  • This usually occurs within the first 24 hours after surgery, but it has been reported up to 6 months following pneumonectomy.
  • The condition presents with an abrupt drop in blood pressure and hemodynamic collapse and requires immediate reoperation.
• Bronchopleural fistula
  • About 1.5% to 4.5% of patients undergoing pneumonectomy will have a bronchopleural fistula. This complication is associated with a mortality of 29% to 79%.
  • Risk factors include right-sided procedures, a large diameter bronchial stump, residual tumor, concurrent radiation or chemotherapy, age older than 60, and prolonged postoperative mechanical ventilation.[30] 
  • Symptoms include fever, cough, hemoptysis, and subcutaneous emphysema. A persistent air leak is usually detected if a chest tube is still in place. A chest radiograph usually demonstrates a new air-fluid level or worsening of a preexisting air-fluid level.
  • If the patient is still intubated and mechanically ventilated, measures should be taken to reduce airway pressure to limit the leak. Some patients may require lung isolation using a DLT for proper oxygenation and ventilation. Management includes drainage of pleural space and systemic antibiotics. Surgical repair will be necessary for severe cases.
• Postpneumonectomy pulmonary edema
  • This occurs in 2% to 5% of cases, typically presents on postoperative days 2 to 3, and is associated with a significant increase in mortality by up to 50%.
  • Patients usually present with dyspnea and poor oxygenation with an increased alveolar-arterial gradient. These findings are more common after right-sided pneumonectomy. 
  • Liberal IV fluid administration has been implicated; pulmonary edema may still occur in patients with restrictive fluid management. Proposed mechanisms include increased capillary permeability, lymphatic damage, and ventilator-induced lung injury.
  • After pneumonectomy, a single intraoperative dose of methylprednisolone just before pulmonary artery ligation may decrease the risk of pulmonary edema and acute respiratory distress syndrome (ARDS).[31] Treatment is generally supportive, with ventilatory support as required, restrictive fluid management, and diuretics.
• Pulmonary complications
  • These include pneumonia, atelectasis, and respiratory failure, which are also common. The incidence and severity of such complications increase with age and may require reintubation and mechanical ventilation.[32]
• Injuries to the surrounding structures
  • These occur mainly in the diaphragm, liver, spleen, or a major vessel.
• Other potential complications include multiorgan dysfunction, acute lung injury, ARDS, and postoperative acute kidney injury. 

The critical outcomes measured should be 90-day mortality, 1-year mortality, and overall survival. Recent studies indicate that 90-day mortality is a more accurate indicator of perioperative mortality, as it is nearly double that of 30-day mortality following lung resection. Consequently, 90-day mortality is considered more reliable, surpassing in-hospital mortality, 30-day mortality, or composite endpoints.[33]

Clinical Significance

Pneumonectomy is a major surgical procedure typically performed as a treatment for advanced central lung tumors, extensive malignancies, or other severe pulmonary conditions that are unresectable with lung-sparing techniques. This procedure's clinical significance lies in its potential to offer a curative option when less extensive surgeries, like lobectomy, are inadequate. In the context of non small cell lung cancer, pneumonectomy may be the only viable intervention for the complete resection of tumors in central or complex anatomical locations. Additionally, pneumonectomy has been applied in managing severe infections, trauma, and benign diseases, though these indications are less common.

Despite its life-saving potential, pneumonectomy carries substantial clinical risks and is associated with higher perioperative morbidity and mortality than less extensive lung resections due to the loss of significant respiratory capacity and the physiologic impacts on cardiovascular function. Postoperative complications may include pulmonary edema, infection, bronchopleural fistula, and cardiac complications such as right heart failure. Consequently, the procedure requires meticulous preoperative planning, close interprofessional coordination, and appropriate patient selection to optimize outcomes. For appropriately selected patients, pneumonectomy can yield a significant survival benefit and improve quality of life by eliminating diseased lung tissue while providing an opportunity for prolonged survival in malignant cases.

Enhancing Healthcare Team Outcomes

Pneumonectomy is a complex procedure that requires advanced surgical skills, precise anesthetic management, and a collaborative approach from the entire healthcare team to ensure optimal outcomes. Surgeons must be proficient in thoracic anatomy and highly skilled in techniques to control bleeding and protect critical structures. Preoperative planning involves risk assessment, often with input from pulmonologists and cardiologists, to evaluate the patient's ability to tolerate the procedure. Anesthesiologists must be skilled in lung isolation techniques and vigilant monitoring, especially given the increased risk of hemodynamic instability after lung resection. Nurses and advanced clinicians provide essential intraoperative and postoperative monitoring, patient education, and support for pain management.

Effective interprofessional communication is essential in coordinating care for pneumonectomy patients, particularly in managing perioperative risks. Regular team briefings and debriefings improve safety, allowing all members to anticipate potential complications and communicate updates. Pharmacists contribute by managing complex medication needs, including anticoagulants and pain management, and minimizing drug interactions. Precise discharge planning and follow-up care with rehabilitation specialists further support the patient’s recovery. This coordinated approach enhances patient-centered care, reduces the likelihood of adverse events, and promotes positive long-term outcomes, with each team member playing a role in ensuring the procedure’s success.