1: Lightning Bolts & Bullseyes #1 Flashcards
all of the starred/highlighted content for exam 1
considerations for squamous cell caricinoma
central lesions (predominantly)
often with endobronchial tumor
mass effects: obstruction, cavitation
considerations for adenocarcinoma
peripheral lesions
extrapulmonary invasion common
most pancoast tumors
growth hormone, corticotropin
hypertrophic osteoarthropathy
considerations for large cell carcinoma
large, cavitating peripheral tumors
similar to adenocarcinoma
considerations for small cell carcinoma
central lesions (predominantly)
surgery usually not indicated
paraneoplastic syndromes
Lambert-Eaton syndrome*
fast growth rate
early metastases
Lambert-Eaton syndrome
- impaired release of acetylcholine from the terminals; lower limb weakness
- sensitive to non-depolarizers and respond poorly to anticholinesterase reversal agents
- may improve after surgery
considerations for carcinoid tumors
proximal, endobronchial
bronchial obstruction with distal pneumonia
highly vascular
benign (predominantly)
no association with smoking
5 year survival > 90%
carcinoid syndrome (rarely)
carcinoid*
severe hypotension may need to use specific antagonists: octreotide or somatostatin
care of the patient on Bleomycin
low FiO2 d/t pulmonary toxicity (avoid hyperoxia)
care of the patient on Cisplatin
NSAIDs contraindicated d/t increased creatinine
4 M’s of Anesthetic considerations in lung cancer patients
- Mass effects
- Metabolic effects
- Metastases
- Medications
mass effects of lung cancer
obstructive pneumonia, LUNG ABSCESS, SVC syndrome, tracheobronchial distortion, pancoast syndrome, recurrent laryngeal nerve or phrenic nerve paresis, chest wall or mediastinal excision
metabolic effects of lung cancer
Lambert-Eaton syndrome, HYPERCALCEMIA, HYPONATREMIA, cushing’s
metastases effects of lung cancer
particularly to bone, brain, liver, and adrenal
medication considerations for lung cancer patients
Bleomycin, mitomycin: pulmonary toxicity
Doxorubicin: cardiac toxicity
Cisplatin: renal toxicity
of the lung cancer considerations, which are the most detrimental?
mass effects
Preop Lung Function: what is the 80-40-15 rule?
FEV1 > 80% (no testing needed)
PPO FEV1 DLCO < 40% (increased risk, exercise test)
VO2 Max < 15 mL/kg/min (increased risk)
most valid test for respiratory mechanical function
FEV1
most valid test for lung parenchymal function
DLCO
most valid test for caridopulmonary interaction
maximal oxygen consumption (VO2)
ABG CO2 > 45 mm Hg
indicator of poor ventilatory function
SaO2 < 90%
preop hypoxemia
albumin < 3.6 and BUN > 22
important predictor of pulmonary complications
renal function and nephrotoxic drugs
methotrexate & cisplatin
what is a more reliable indicator of poor outcomes with thoracic surgery?
desaturation with exercise
findings consistent with pulmonary disease (echo)
RIGHT ATRIAL CHAMBER ENLARGEMENT i.e. disease, pulmonary hypertension
arterial line in the . . . (mediastinoscopy) ox
Aline = RIGHT to detect compression of innominate artery
BP cuff = left
Pulse ox = right to detect compression of innominate artery
aline position for thoracotomy
in DEPENDENT arm to monitor possible AXILLA artery compression
pros/advantages of DLT
EASY TO PLACE
repositioning rarely needed
bronchoscopy to isolated lung
suction to isolated lung
CPAP EASILY ADDED
can alternate OLV to either lung easily
placement possible without bronchoscopy
best device for absolute lung isolation
pros/advantages of bronchial blockers
size selection rarely an issue
easily added to regular ETT
allows ventilation during placement
easier placement in 1) difficult airways and 2) children
postop two-lung ventilation by withdrawing blocker
selective lobar lung isolation possible
CPAP to isolated lung possible
Cons/disadvantages of DLTs
size selection more difficult
difficult for difficult airways/abnormal tracheas
not optimal for postop ventilation
potential laryngeal trauma
potential bronchial trauma
cons/disadvantages of BBs
more time needed for positioning
repositioning more often
bronchoscope essential for positioning
limited right lung isolation d/t RUL anatomy
bronchoscopy to isolated lung impossible
minimal suction to isolated lung
difficult to alternate OLV to either lung
DLT FM < 160 cm
35
DLT FM > 160 cm
37
DLT M > 170 cm
41
DLT M < 170 cm
39
FM < 152 cm
examine bronchial diameter on CT scan
consider 32-Fr DLT
shorter patients (<155 cm) height is not a good predictor
M < 160 cm
consider 37 Fr DLT
DLT insertion: resistance?
There should be NO resistance with placement but slight resistance when you reach the bifurcation.
indications for DLT
descending thoracic aortic aneurysm
left lung transplant
left-sided tracheobronchial disruption
left-sided pneumonectomy
what can cause malposition of the DLT?
overinflation
surgical manipulation
head extension
how to diagnose malposition?
fiberoptic
s/s of malposition?
hypoxemia
DLT in optimal position but lung deflation is not achieved
suction cath to lung collapse
(make sure to remove)
other problems with DLT
airway trauma
DLT too big
rupture of bronchus or aneurysm
unexpected air leak
subQ emphysema
airway bleed
protrusion of cuff into filed
tension PTX in dependent lung during OLV
benefits of bronchial blockers (again)
challenging airway
previous oral or neck surgery
pediatrics
complications of BBs
lack of seal within bronchus
distal wire stapled into the lobectomy
when is a patient considered high risk
advanced age
poor general health status
COPD
BMI > 30 kg/m2
low FEV1
low predicted postop FEV1
interpleural space
potential space between the parietal pleura of the internal chest wall and the visceral pleura covering the lung
intrapleural pressure
NEGATIVE/SUBATMOSPHERIC
lungs recoil inward and the chest wall recoils outward
inward and outward forces are equal at ?
FUNCTIONAL RESIDUAL CAPACITY
intrapleural during tidal breathing
always negative
intrapleural pressure becomes negative during ____ and positive during _____
inspiration; expiration
vasalva maneuver
intrapleural pressure becomes positive during a forced expiration or during expiratory effort against a closed glottis
zone 1 (west)
dead space
region is ventilated but not perfused
zone 2 (west)
waterfall
arterial pressure exceeds alveolar
flow is solely dependent on arterial flow
zone 3 (west)
swan ganz
pulm arterial and venous pressures exceed alveolar pressure; dependent portion of the lung
zone 4 (west)
pulmonary edema (pahological)
interstitial fluid compresses the vessels and occlude their flow
zone 3 is …
dependent
better ventilation
better perfusion
lower V/Q ratio
less negative intrapleural pressure
west zones describe ______ in the lungs
PERFUSION
which portions of the lung receive greater amount of blood flow?
dependent
due to gravity, vessel recruitment, and distensibility
results in optimal gas exchange
R–>L shunt
Blood pumped by the Rt heart passes to the Lt heart without being oxygenated
Reasons: anatomic defect, blood passing through the lungs does not come in contact with O2 in the alveoli-intrapulmonary ie ARDS
L –> R shunt
Blood is pumped from the Lt heart back to the right usually in neonate
Ductus arteriosus or foramen ovale
