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Question 0

WHAT ARE SOME DRUGS YOU COULD GIVE PREOP TO A SMOKER TO DILATE THE AIRWAYS?

Answer 0

B2 AGONIST (ALBUTEROL, TERBUTALINE, AND METAPROTERENOL)

ROBINOL

PERHAPS DECADRON … CORTICOSTEROID (TO DECREASE MUCOSAL EDEMA AND PREVENT RELEASE OF BRONCHO CONSTRICTING SUBSTANCES)

Question 1

WHAT IS THE MOST COMMON PRESENTING COMPLAINT SPECIFIC TO LUNG CANCER?

Answer 1

HEMOPTYSIS IS MOST COMMON PRESENTING SYMPTOM.

ALTHOUGH COUGH IS THE MOST COMMON SYMPTOM…IT COULD BE FROM LOTS OF THINGS AND THUS IS USUALLY IGNORED.

Question 2

WHICH LUNG DO MOST PA CATHETERS FLOAT TO?

Answer 2

RIGHT

Question 3

HOW DOES VENTILATION DIFFER IN A SPONTANEOUS BREATHING VS. POS PRES VENT PT IN TERMS OF LUNG ZONES?

Answer 3

IN UPRIGHT LUNG WITH SPONTANEOUS BREATHING PT BOTH VENTILATION AND PERFUSION ARE GREATEST NEAR THE DIAPHRAM.
BUT POS PRES VENT TENDS TO VENTILATE NON DEPENDENT LUNG REGIONS…..(NOT THE BASES)

Question 4

HOW DOES AIR TRAVEL IN A LATERAL ANESTHETIZED(CONTROLLED VENT) PT WITH A CLOSED CHEST AND WHY?

Answer 4

PERFUSION GOES TO DOWN LUNG. MOST OF TIDAL VOLUME GOES TO THE UP LUNG….TO FOLLOW THE PATH OF LEAST RESISTANCE. THE RESULTING V/Q MISMATCH CAUSES HYPOXEMIA.

Question 5

WHAT ARE 2 PHENOMENON OBSERVED IN A SPONT BREATHING PT WITH OPEN CHEST?

Answer 5

PARADOXICAL RESPIRATION AND MEDIASTINAL SHIFT.

THIS RESULTS IN AN INCREASE OF DEAD SPACE.

Question 6

WHAT POSITION (AND SITUATION) CAUSES THE GREATEST DEGREE OF V/Q MISMATCH?

Answer 6

LATERAL ANESTHETIZED CHEST OPEN.

DEPENDENT LUNG RECEIVES MORE PERFUSION BUT MORE MECHANICAL VENTILATION GOES TO UP LUNG.

Question 7

WHAT ARE THE ABSOLUTE VS RELATIVE INDICATIONS FOR ONE LUNG VENTILATION?

Answer 7

ABSOLUTE: ISOLATION OF ONE LUNG TO AVOID SPILLAGE OR CONTAMINATION (INFECTION, HEMORRHAGE). TO CONTROL THE DISTRIBUTION IN VENTILATION (FISTULA, BULLAE, CYST). UNILATERAL BRONGHOPULMONARY LAVAGE.
RELATIVE: SURGICAL EXPOSURE (LOBECTOMY, ANEURYSM, RESECTION, T SPINE PROC.) POST BYPASS PULM EDEMA/HEMORRHAGE. SEVERE HYPOXEMIA RELATED TO UNILATERAL LUNG DISEASE.

Question 8

WHAT ARE 3 TECHNIQUES OF LUNG SEPERATION?

Answer 8

1. DOUBLE LUMEN ENDOBRONCHIAL TUBES (ROBERTSHAW IS MOST COMMON)
2. BRONCHIAL BLOCKERS
3. UNIVENT TUBE

Question 9

WHICH SIDE TUBE IS USED FOR MOST ONE LUNG VENT?

Answer 9

LEFT SIDED TUBE. SITS IN LEFT BRONCHUS. ACCURACY IN PLACEMENT IS MORE EASILY ACHIEVED.

Question 10

WHY ARE DOUBLE LUMEN ENDOBRONCH TUBES PREFERRED?

Answer 10

LESSER DEGREE OF SKILL TO PLACE, ALLOW CONVERSION BACK AND FORTH FROM 1 TO 2 LUNG VENTILATION, CAN SUCTION BOTH LUNGS (LARGER LUMENS), ALLOW CPAP FOR THE UP LUNG SO ALL THE BLOOD CAN GET OXYGENATED.

Question 11

HOW DO YOU INSERT A DOUBLE LUMEN TUBE? (STEPS)

Answer 11

• PREPARE AND CHECK TUBE
• LUBE
• INSERT DISTAL CONCAVE UP
• ONCE BRONCH CUFF THROUGH CORDS REMOVE STYLET
• ROTATE 90 DEG, IN DIRECTION OF DESIRED LUNG
• STOP ADVANCEMENT WHEN RESISTANCE IS ENCOUNTERED. LIP LINE IS 27-31 CM.

Question 12

HOW DO YOU GUARD AGAINST BRONCHIAL RUPTURE?

Answer 12

SLOWLY INFLATE BRONCH CUFF USING MINIMAL LEAK TECHNIQUE….ONLY REQUIRES 1-3 CC OF GAS.

Question 13

HOW IS POSITION OF DLT MOST RELIABLY DETERMINED?

Answer 13

FIBEROPTIC BRONCH….SO ALWAYS CHECK POSITION THIS WAY!

Question 14

WHEN SHOULD YOU CHECK ABG FOR OLV?

Answer 14

GET PREOP BASELINE ON RA. AND 15-20 MIN AFTER STARTING OLV. ….REMEMBER paO2 CAN CONT TO DECREASE FOR 45 MIN AFTER OLV HAS STARTED.

Question 15

WHAT IS THE MOST EFFECTIVE WAY TO HELP HYPOXEMIA DURING OLV?

Answer 15

UP LUNG CPAP

Question 16

WHAT ARE CONTRAINDICATIONS OF DLT?

Answer 16

CARINA/PROXIMAL BRONCHUS LESION, FULL STOMACH, SMALL PT, DIFFICULT UPPER AIRWAY ANATOMY, CRITICALLY ILL PT THAT CANT BREAK PEEP.

Question 17

WHAT ARE COMPLICATIONS OF DLT?

Answer 17

SORE THROAT (LARNGITIS), TRACHEOBRONCHIAL TREE DISRUPTION FROM OVERINFLATED CUFF. (USE MIN LEAK TECHNIQUE)

Question 18

WHAT IS HPV (HYPOXIC PULM VASOCONSTRICTION) AND WHY IS IT USEFUL?

Answer 18

ITS AN AUTOREGULATORY MECHANISM THAT PROTECTS THE paO2 BY DECREASING THE AMOUNT OF SHUNT FLOW THAT CAN OCCUR THROUGH A HYPOXIC LUNG….REROUTING BLOOD FLOW TO BETTER PERFUSED AREAS. ALL INHALATION AGENTS DECREASE HPV TO SOME EXTENT.

Question 19

DESCRIBE INDUCTION FOR THORACIC SURG. OLV.

Answer 19

• CHECK IF SURGEON WANTS A BRONCH FIRST (MAY WANT A 9ETT)
• PREOXYGENATE
• HIGHER DOSE NARC 200 MCG FENT
• PROPOFOL 1-2MG/KG (ALT ETOMIDATE/KETAMINE)
• MASK WITH VA, GIVE NDMR
• LIDOCAINE 1MG/KG
• LARYNGOSCOPY. CONSIDER MAC 3 FOR BEST EXPOSURE
• MAYBE LTA, INSERT DLT, CONSIDER ALVEOLAR RECRUITMENT MANEUVER, CONSIDER ROBINOL.

Question 20

WHAT IS A MAJOR COMPLICATION AFTER PNEUMONECTOMY (TAKE THE WHOLE LUNG)?

Answer 20

HEART HERNIATION.

SO….AVOID ATTACHING CHEST TUBE TO SUCTION AND AVOID TURNING SO THAT EMPTY HEMITHORAX IS DEPENDENT.

Question 21

WHAT IS THE MOST COMMON SERIOUS COMPLICATION OF THORACOTOMY?

Answer 21

RESPIRATORY INSUFFICIENCY

Question 22

WHEN CAN THE FORAMEN OVALE BECOME PATENT AND SHUNT RIGHT TO LEFT?

Answer 22

WHEN RAP > LAP

Question 23

OXYGENATION DURING OLV IS BETTER IN WHICH SIDE THORACOTOMY AND WHY?

Answer 23

LEFT THORACOTOMY BECAUSE RIGHT LUNG (DOWN LUNG) IS BIGGER THAN LEFT

Question 24

WHAT MAY A LOW FEV1 MEAN FOR THORACOTOMY IN DEPENDENT LUNG?

Answer 24

A LOW FEV1 INDICATING OBSTRUCTIVE DISEASE MAY CREATE AUTO PEEP IN DEPENDENT LUNG AND SLOW DEVELOPMENT OF ATELECTASIS.

Question 25

WHICH POSITION HAS LESS HYPOXEMIA….LATERAL, SEMI-LATERAL, OR SUPINE?

Answer 25

LATERAL

Question 26

WHY IS ATELECTASIS DETRIMENTAL IN DEPENDENT LUNG?

Answer 26

IT ACTIVATES HPV THEREBY LIMITING DOWNSIDE PERFUSION/INCREASING UP LUNG PERFUSION ….WHICH CAUSES MORE SHUNTING.

Question 27

WHAT ARE 2 STRATEGIES TO LIMIT ATELECTASIS AND HYPOXEMIA DURING OLV?

Answer 27

HIGH TV (10-12 ML/KG) WITHOUT PEEP.

USE CAUTION IN THIS STRATEGY IN PTS WITH PRE EXISTING LUNG DISEASE AND LONG SURGERY TIME (4-6HRS)

-MODERATE TITAL VOL (6-8ML/KG) WITH PEEP (5) AND PCV