Airway / Thoracic Viva Phrases Flashcards
Describe your ventilation strategy for ARDS
My ventilation strategy would be based on ARDS network guideline.
- Controlled ventilation
- Low TV 6ml/kg
- Incremental increase in PEEP based on FiO2
- Aim plateau pressure <30 cmH2O
- Target SpO2 >90%, PaO2 >60
- Aim for normocarbia.
36yo for glottic papilloma excision, on background of amphetamine use and appears agitated.
How will you manage the airway?
Although this is an elective case, his agitation will limit my standard airway surgery set up. Instead, I’d opt for my airway management technique for emergency cases, which includes:
- Trial of sedation with remifentanil 0.1mcg/kg/min to allow for awake techniques.
- If not cooperative, then proceed to RSI with video laryngoscope + ENT surgeon scrubbed in case front of neck access is required.
How would you perform a emergency chest drain insertion for tension pneumothorax
I would confirm the diagnosis on CXR or lung ultrasound, consent the patient is able, then proceed to a sterile set up for this procedure.
I will identify the triangle of safety, as marked by pec major anteriorly, lat dorsi posteriorly, at the fifth intercostal space just anterior to the mid axillary line.
I will then make a horizontal incision just above the 5th rib, blunt dissect to enter the pleural space, perform finger thoracotomy.
At this point I should hear a hiss. Then I will insert the chest tube with forceps guidance posteriorly and superiorly, secure with suture, connect to underwater seal drain, and confirm with chest XR
What investigations would you order for a patient with lung adenocarcinoma for lobectomy?
In addition to my usual investigations for major thoracic surgery, which includes bloods, ECG, CXR, I would focus on specific tests related to the three-legged stool.
1) Spirometry for both lung mechanics and parenchyma
2) Functional assessment for cardiopulmonary reserve
Consider V/Q scan to determine to overall contribution to ventilation of tissue being resected
What are the important parameters for investigations in thoracic surgery?
Predicted Post-Op FEV1 >40%, DLCO > 40%
CPET VO2 max of >15ml/kg/min
6MWT of >400m
Describe your ventilation strategy for one lung ventilation
My goal is to maintain oxygenation while prevent volume or barotrauma.
I will achieve this by having
- Low TV of 4ml/kg
- RR of 15-20 / min
- Plateau pressure <30, peak pressure <35
- Driving pressure ≤15
- Adequate PEEP, up to 10
- Permissive hypercapnia
Describe your technique of inserting a DLT for a 75F of height 163cm
I will use a 37Fr, left sided double lumen tube.
Perform a standard induction with 100mg rocuronium, then insert the DLT with the tip angled anteriorly.
Once past the glottic opening, I will remove the stylet, then advance while turning the tube anti-clockwise for 90-180 degrees until snug.
Inflate the tracheal balloon and check for rise and fall of both lungs and confirm EtCO2.
I will then further confirm the position using a bronchoscope, and inflate the bronchial lumen under direct vision.
what’s your airway plan for a patient with angioedema?
This is a difficult intubation due to anatomical distortion and risk of complete airway obstruction.
My plan A is to maintain spontaneous ventilation and perform an awake fiberoptic intubation, with ENT scrubbed and ready for surgical airway should I fail.
Plan B is an asleep airway management with THRIVE for apnoeic oxygenation, videolaryngoscopy-assisted fiberoptic intubation. Alternatively, a D-blade with smaller than usual ETT.
Plan C is rescue oxygenation with LMA or BMV, acknowledging this may be ineffective due to pharyngeal swelling.
Plan D is a FONA by surgeons.
Describe your FONA technique
I will use a scalpel boogie tube technique, by positioning myself on the left side of the patient.
I will identify the cricothyroid membrane with laryngeal handshake, make a horizontal incision to puncture the membrane then rotate the blade 90 degrees.
Then place the bougie and railroad the tube, inflate cuff, gentle test ventilation to confirm end-tidal CO2.
How will you perform an AFOI.
I will start by rapidly explaining the procedure and gaining the consent, have IV access, and have relevant equipment including the difficult airway trolley ready.
I will administer 200 micrograms of glycopyrulate and topicalise with lignocaine with max dose of x mg (9mg/kg).
Then I will use a mix of co-pheynylcaine and 5% gel for the nasopharynx, followed by atomiser spray using syringes of 5ml, 2% lignocaine, with each syringe containing 100mg. I will aim to use 3-4 syringes.
My end points will be loss of gag reflex and change in voice. At this point I will commence remifentanil at 0.1microg/kg/min, then coach the patient through the intubation process.
Once ETT is railroaded through the scope, I will inflate cuff, confirm EtCO2, then induce anaesthesia.
