Anesthetic management of a patient with giant emphysematous bullae undergoing total thyroidectomy under spontaneous ventilation: A case report

Patients with longstanding chronic obstructive pulmonary disease are sometimes complicated by emphysematous bullae. These patients pose major challenges during the administration of general anesthesia. Their compromised respiratory reserve due to coexisting restrictive lung pathology puts them at high risk of adverse cardiorespiratory events. Applying positive pressure ventilation (PPV) in these patients may precipitate life-threatening conditions like tension pneumothorax due to barotrauma. We report the anesthetic management of a 48-year-old man with mixed restrictive lung disease and bilateral giant emphysematous bullae scheduled for total thyroidectomy for thyroid carcinoma. Anesthesia was induced and maintained with volatile and intravenous anesthetic agents without neuromuscular blockade, while preserving spontaneous ventilation. Lung-protective strategies were employed to minimize airway pressures and avoid PPV. The intraoperative and postoperative courses were uneventful. With careful planning, avoidance of PPV and lung-protective anesthesia, even high-risk patients with emphysematous bullae can safely undergo major head and neck surgery.