Rethinking Radical Mastectomy Anesthesia: Combined Erector Spinae Plane and Pectoral Nerve Block Type II Blocks in Bullous Chronic Obstructive Pulmonary Disease Without Positive-Pressure Ventilation.

Breast surgery with axillary dissection is traditionally performed under general anesthesia with positive-pressure ventilation. However, in patients with bullous chronic obstructive pulmonary disease (COPD), mechanical ventilation may increase the risk of barotrauma and pneumothorax. We report the case of a 75-year-old male with moderate COPD and a large pulmonary bulla who underwent modified radical mastectomy with axillary dissection using combined erector spinae plane and pectoral nerve block type II, associated with sedation and preservation of spontaneous ventilation. The procedure was completed without conversion to general anesthesia, opioid administration, or respiratory complications. Intraoperative oxygen saturation remained between 96% and 99%, and capnography demonstrated preserved spontaneous ventilation without clinically significant carbon dioxide retention. Postoperative pain scores remained low, without opioid requirement during the first 24 hours. This case illustrates a possible physiology-guided anesthetic alternative in carefully selected high-risk patients when avoidance of positive-pressure ventilation is clinically desirable. However, limitations related to anatomical coverage variability and the possible need for significant sedation should be recognized.