VATS left upper lobectomy in a recent smoker with COPD

A 69-year-old man, 175 cm and 80 kg, is scheduled for a video-assisted thoracoscopic left upper lobectomy for a 2.8 cm adenocarcinoma found on screening CT. He has COPD and a 55 pack-year smoking history, and he stopped smoking three weeks ago. He walks a mile with his dog most days but stops to rest on hills. He needed a course of prednisone for an exacerbation last winter and has been well since. He has hypertension and no chest pain or syncope. He asks whether he will "wake up on a breathing machine."

Medications: tiotropium, budesonide-formoterol, albuterol as needed (about once a week), amlodipine, atorvastatin.

Allergies: none known.

• Vitals: BP 148/86, HR 84, RR 16, SpO2 93% on room air, temperature 36.8 °C
• Airway: Mallampati 2, full dentition, thyromental distance 6 cm, full neck extension
• Chest: prolonged expiration, scattered rhonchi that clear with coughing, no wheeze
• Spirometry: post-bronchodilator FEV1 58% predicted, FEV1/FVC 0.58; DLCO 55% predicted
• Predicted postoperative FEV1 43% and DLCO 40%; stair climb 24 m without stopping
• Arterial blood gas on room air: pH 7.41, PaCO2 43 mmHg, PaO2 68 mmHg, HCO3 27 mEq/L
• Hemoglobin 15.9 g/dL, platelets 236,000, creatinine 0.9 mg/dL, potassium 4.1 mEq/L
• ECG: sinus rhythm at 84, no ischemic changes
• Transthoracic echo: LVEF 60%, normal valves, estimated RV systolic pressure 34 mmHg
• CT chest: left upper lobe mass with upper-lobe emphysema, normal-caliber left main bronchus of 14 mm, no endobronchial lesion