Lung Cancer

Pulmonary reserve before resection - FEV1 and DLCO are the two numbers that matter, and both at or above 80% predicted marks a low-risk patient. With FEV1 under 60% predicted, a V/Q scan gives the predicted postoperative FEV1. A ppo-FEV1 and ppo-DLCO above 60% means adequate reserve; 30% to 60% earns a stair-climb or shuttle-walk test; under 30% means formal cardiopulmonary exercise testing. VO2 max above 20 mL/kg/min tolerates resection, under 10 mL/kg/min argues against it.

Lambert-Eaton myasthenic syndrome (LEMS) - IgG antibodies against presynaptic voltage-gated calcium channels, with more than half of cases tied to SCLC. These patients are sensitive to both succinylcholine and nondepolarizers — cut the dose, titrate to TOF, and expect a prolonged recovery. Proximal weakness that improves with repeated effort separates it from myasthenia gravis, and anticholinesterases help far less. Autonomic features travel with it: gastroparesis, orthostatic hypotension, urinary retention.

SVC syndrome recognition - Up to 97% of superior vena cava syndrome cases come from bronchogenic carcinoma or non-Hodgkin lymphoma compressing the thin-walled SVC. Look for swelling of the face, neck, upper trunk and arms, distended jugular veins, collateralized chest wall veins, hoarseness, stridor, dysphagia, and hemoptysis; chest radiograph or CT shows the thoracic collaterals. Cyanosis, cerebral edema, and laryngeal edema signal a bad trajectory.

SVC syndrome setup - Put the IV in a lower extremity. Drugs given above the obstruction circulate slowly and IV fluid into the blocked upper venous system worsens the congestion. Keep the head up in sitting or semi-Fowler position, and consider dexamethasone plus a racemic epinephrine nebulizer for airway edema.

SVC syndrome airway decision - The literature favors avoiding airway manipulation, but weigh that against losing an unsecured, edematous, possibly anticoagulated airway partway through a long case — securing it electively in a controlled environment beats an emergency later. Blind oral airway insertion can cause heavy oropharyngeal bleeding that makes everything worse.

Mediastinal mass - Anterior mediastinal masses compress the trachea, bronchi, and great vessels; size and anatomic location drive the plan. When thoracotomy is planned, lung isolation devices are recommended.

Hypercalcemia - Lung cancer is among the tumors that produce malignancy-related hypercalcemia, typically with a low or normal PTH and an elevated PTHrP. Check the calcium and PTH/PTHrP preoperatively; management is volume resuscitation first, then a loop diuretic once rehydrated, with bisphosphonates for the resistant range.

Use the staging workup - The CT of chest, abdomen and pelvis, brain MRI, and PET-CT done for staging also tell you about airway compression, effusions, and brain metastases before you induce. Bronchoscopy and EBUS reports describe the airway you are about to instrument.

Document the deficit first - A superior sulcus tumor brings shoulder pain, brachial plexopathy, and Horner syndrome (ptosis, miosis, ipsilateral anhidrosis). Record the pre-existing neurologic exam before positioning or any regional technique.

Post-obstructive disease - Central tumors obstruct and seed post-obstructive pneumonia; malignant pleural effusion cuts breath sounds and reserve. Both show up on the preop chest imaging and both shrink the margin you have during one-lung ventilation.

Lung cancer (bronchogenic carcinoma) arises in the lung parenchyma or within the bronchi. Non-small cell disease — adenocarcinoma, squamous cell, large cell — is roughly 80% to 90% of cases; small cell lung cancer (SCLC) makes up the rest. Smoking accounts for about 90%, so the same patient usually carries COPD and coronary disease alongside the tumor. What changes the anesthetic is mass effect and paraneoplastic physiology more than histology: airway and mediastinal compression, superior vena cava obstruction, hoarseness from recurrent laryngeal nerve involvement, malignant pleural or pericardial effusion, post-obstructive pneumonia, and shoulder pain with brachial plexopathy and Horner syndrome from a superior sulcus tumor. SCLC is the most common solid tumor to cause paraneoplastic syndromes.