Thoracic Epidural Anesthesia for Emergent Laparotomy in a Patient with Advanced Chronic Obstructive Pulmonary Disease (COPD) and Recent Pneumothorax

Patients with advanced chronic obstructive pulmonary disease (COPD) undergoing major abdominal surgery are at particularly high risk of perioperative respiratory complications, especially when general anesthesia and positive-pressure ventilation are required.We report the anesthetic management of a 64-year-old man with advanced COPD and extensive emphysematous lung disease complicated by recurrent bilateral pneumothoraces, including a large right-sided pneumothorax two months before surgery.The patient presented with an acute right-sided colonic volvulus associated with radiological signs of bowel ischemia and underwent emergent ileocolic resection through laparotomy.Given his extremely limited respiratory reserve, extensive bullous disease, and recent pneumothorax, thoracic epidural anesthesia combined with dexmedetomidine and ketamine sedation was selected to avoid tracheal intubation and positive-pressure ventilation.Postoperative recovery was uneventful, with stable respiratory status on his baseline oxygen requirement, effective epidural analgesia, and no relevant postoperative complications or organ dysfunction.He was discharged on postoperative day seven to a respiratory rehabilitation facility.This case illustrates that, in carefully selected patients, neuraxial anesthesia combined with titrated sedation may provide an alternative to general anesthesia when avoidance of positive-pressure ventilation is considered particularly important.