Phrenic nerve infiltration: a good practice to combine pulmonary expansion and pain control in patients with high-risk of prolonged air leak.

Abstract

ObjectiveProlonged air leak (PAL) due to residual air space after lung resection is a main challenge. To date, few surgical options have been described to prevent this complication. The aim of this study is to investigate the safety and the efficacy of intra-operative phrenic nerve infiltration with long-acting anaesthetics in producing transient hemidiaphragm paralysis in patients at high risk for PAL, thus improving pulmonary expansion after surgery, and reducing air leaks, while controlling post-operative pain. MethodsBetween January 2021-2023, 65 consecutive patients at risk for PAL (defined in accordance with “2019 Society of Thoracic Surgery score-criteria of PAL”) who underwent lung resection (lobectomy or anatomical segmentectomy) for malignancy were prospectively included in the study. They have been randomly (1:2 ratio) assigned to receive (group A, 22 patients) intra-operative phrenic nerve infiltration with Ropivacaine 10 mg/ml in the peri-neurotic fat on the pericardium or not to receive intra-operative phrenic nerve infiltration (group B, 43 patients). Five patients of Group B have been excluded because they did not undergo anatomical resection. Data on pulmonary re-expansion, prolonged air leaks, pain at 24- and 72-hours post-surgery, referred shoulder pain, length of hospital stay, length of chest tube permanence, were collected and compared. ResultsHemidiaphragm elevation (p=0.006) and pulmonary expansion (p=0.000) were significantly higher in Group A. Patients in Group A showed lower pain at 24 and 72 hours compared to Group B (p=0.004). Shoulder pain (0.001) and prolonged air leak (0.000) were higher in Group B. Length of chest tube was longer in group B. No difference in hospital stay length was observed. ConclusionThis is the first study to investigate two combined effects of phrenic nerve anaesthetic infiltration (hemidiaphragm elevation and pain control), with potential enhancement of patient’s recovery after surgery. Intraoperative phrenic nerve infiltration in patients with risk for PAL appears a safe and effective clinical practice to improve pulmonary expansion in this set of patients, reducing post-operative air leak. This result is associated with an additional improvement in pain control, especially for shoulder pain.