Abstract
BACKGROUND: Pneumoconiosis is a chronic occupational lung disease characterized by progressive diffuse pulmonary fibrosis and irreversible impairment of pulmonary function. The coexistence of bilateral giant bullous emphysema (GBE), end-stage chronic obstructive pulmonary disease (COPD), chronic hypercapnia, and cor pulmonale in pneumoconiosis patients is exceedingly rare and poses extraordinary anesthetic challenges. CASE DESCRIPTION: We report the anesthetic management of a 67-year-old man with stage III pneumoconiosis complicated by bilateral GBE, stage IV COPD, chronic hypercapnia, and cor pulmonale. Preoperative pulmonary function testing revealed profoundly impaired lung function, with a predicted forced expiratory volume in one second (FEV(1)) was 19.22%. The patient underwent staged video-assisted thoracoscopic bullectomy. Anesthetic management included individualized one-lung ventilation (OLV) using pressure-controlled ventilation-volume guaranteed (PCV-VG) mode, acceptance of permissive hypercapnia, and a stepwise contingency strategy involving continuous positive airway pressure (CPAP) and pulmonary vein clamping for refractory hypoxemia. Both procedures were completed successfully without the need for extracorporeal membrane oxygenation (ECMO). Postoperatively, the patient demonstrated significant symptomatic improvement, and FEV(1)% increased to 28.62% at follow-up. CONCLUSIONS: This case demonstrates that a meticulously tailored anesthetic strategy, incorporating staged surgery, advanced OLV strategies with CPAP and pulmonary vein clamping, can enable the safe performance of bullectomy and yield meaningful functional improvement in this patient with pneumoconiosis and profoundly compromised pulmonary function.