- paradoxical breathing - tympanic chest percussion - rhonchi - wheezing

- ST depression - BBBs - T inversion

Exam II Anesthesia For Thoracic Surgery Flashcards by Linsley Lloyd

Leading cause of cancer deaths in the US

Bronchogenic cancer

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Better prognosis with _____ than with ____ or _____

Resection
Chemo
Radiation

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COPD patients ___ ____ ____ to get lung cancer

4x more likely

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Bronchogenic cancer has ____ ____ d/t aging population and co-morbidities

Increasing morbidity

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___ needing resections are disqualified d/t ____ ____ ____

40%
Poor pulmonary function

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____-_____ ____ ____ has led to a decrease in postop complications such as dysrhythmias, MI, PE, PNA, and emphysema

Video-assisted thoracic surgery (VATS)

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Bronchogenic cancer risk factors: (3)

smoking
air pollution
industrial chemicals

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Smokers need evaluation for ____ or ___ ___ ___

HTN
Ischemic heart disease

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____ history needs stress testing

COPD

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Continue ____ ____ throughout perioperative course

Beta blockers

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Consider ___ ___ ____ if coronary bypass needed

6-week delay

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Radiographic airway evaluation for ______ _____

Mediastinal masses

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Endocrine evaluation - rule out _____ _____ caused by some lung tumors

Paraneoplastic syndromes

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Neuroendocrine tumors can cause ____ _____

Carcinoid syndrome

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_____ occurs in up to 25% of lung cancer pts

Hypercalcemia

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Hypercalcemia symptoms: (6)

polyuria
polydipsia
confusion
vomiting
abdominal cramping
bradycardia

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COPD symptoms: (4)

paradoxical breathing
tympanic chest percussion
rhonchi
wheezing

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cor pulmonale symptoms: (4)

jugular vein distention
peripheral edema
split S2
rales

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Need a CXR in pre-op to test for:
[Pre-op Testing]

airway eval
CHF
PTX
tracheal shift
PA enlargement (sign of increased PVR)
-Eval for airway infringement

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EKG: tall R in V1 =

RVH

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EKG: biphasic P in V1 =

R atrial hypertrophy

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EKG: look for (3)

ST depression
BBBs
T inversion

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EKG: Pathologie Q waves + LVH =

Increased risk of ischemia/infarction

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Best initial tool for pulmonary HTN but higher level studies may need to follow

Echo

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Labs to check for COPD patients: (5)

- room air ABG to check for CO2 retention (>45 = poor function) - SpO2 < 90% = increased risk of complications - albumin < 3.6 g/dL (common) = 2.5x higher risk - BUN > 22 mg/dL = increased risk - renal fxn labs (esp with chemo) - lytes (esp Na, K, Ca)

PFTs: significant improvement = ____ increase in ____ after bronchodilators

12% increase in FEV1

PFTs: ___ ____ test is a good predictor. ___-____ testing is best

No single Multi-modal

PFTs: general cutoffs for increased risk: ____, _____, and _____ < 40%

PPO (predicted post op) FEV1 (forced expiratory volume/1 second) DLCO (diffusion in the lung of carbon monoxide)

PFTs: general cutoffs for increased risk: ____ ____ < 15(10) mL/kg/min

VO2 max (ability to climb 5 flights of stairs = > 20, inability to climb 1 flight = < 10)

Non CV surgeries: ____ of smokers have complications ____ of past smokers have complications ____ non-smokers have complications

22% 13% 5%

Lung cancer patients: ___ are smokers

87%

With lung cancer, smokers have a ____ ____

1.5% mortality

With lung cancer, non-smokers have ____ ____

0.4% mortality

Pack-year index = ____/____x____

Packs / day x years

____ = increased complications over moderate smokers

> 20

Smoking cessation ____ ____ ____ = NO difference in outcomes or possibly worse d/t increased _____ _____

< 4 weeks Mucus production

_____ drops and _____ _____ improves in 1-2 weeks but NO difference in outcomes

Carboxyhemoglobin Mucociliary clearance

Some improvement in ___ ____ but more at ___ ____

4 weeks 8 weeks

Smoking is difficult to successfully intervene d/t ___ ____ of treating ____ ____

Urgent nature Lung cancer

_____ monitoring

Standard

___ ___ best for dysrhythmias

Lead II

____ is best for ischemia

Consistent findings: ____ ____ significantly most effective

Lead combo (lead II and V5)

Arterial line should be placed in the _____ arm

Dependent

____ optional

Foley

PAC evidence: (3)

- NO improvement in outcomes - frequent inaccurate measurements - caution in vessels that could be clamped or ligated

____ for complex cases with large fluid shifts. Caution with ____. Insert _____ on _____ side

CVP EJs (easily kinked in lateral position) Subclavian Operative

Insert subclavian CVP on operative side why?

Don’t want a double pneumo

Trachea: __-__ cm long Begins at ____ Bifurcates at ____

11-12 cm long C6 (cricoid cartilage) T5 (sternomanubrial joint)

R mainstem bronchus: Wider Angles ____ from trachea at ____ Divides into ____ lobar branches Orifice of right upper lobe __ to ___ cm from carina

Away from trachea at 20 degrees 3 (upper, middle, lower) 1-2 cm from carina

L mainstem bronchus: Narrower Angles ____ from trachea at ____ Divides into ___ lobar branches Orifice of left upper lobe ___ cm from carina

Away from trachea at 45 degrees 2 (upper, lower) 5 cm from carina

Perfusion (Q): increases from ___ to ____ with awake, spontaneous ventilation

Apex to base

Ventilation (V): increases from ____ to ____. More ____ pressure in the apices keeps alveoli _____.

Apex to base Negative Distended

Alveoli in bases less _____, more _____, so most tidal breathing (air movement) distributed to the _____.

Distended Compliant Bases

V/Q not being perfectly correlated net result is…

V/Q matching well enough for efficient gas exchange

More _____ pressure in the apices keeps alveoli _____

Negative Distended

Alveoli in bases less _____, more _____, so most tidal breathing is distributed to ____

Less distended More compliant Distributed to bases

Lateral Awake: _____ displacement of diaphragm on DEPENDENT side

Cephalad

Lateral Awake: So, during inspiration, diaphragm can contract further leading to better ventilation of _____ lung

Dependent

Lateral Awake: Perfusion _____ in _____ lung (gravity)

Higher Dependent

Lateral Awake: Net result of V/Q and gas exchange

Net result of V/Q - no significant change Gas exchange is efficient

Lateral, anesthetized, spont vent, chest closed: induction leads to decreased ____ ____ ____

Functional residual capacity (FRC)

Lateral, anesthetized, spont vent, chest closed: Cephalad diaphragm displacement leads to ____ _____

Decreased FRC

Lateral, anesthetized, spont vent, chest closed: ______ lung is more compliant leading to _____ ventilation

NonDependent Increased

Lateral, anesthetized, spont vent, chest closed: _____ lung is more _____ (gravity)

Dependent Perfused

Lateral, anesthetized, spont vent, chest closed: V/Q net result

Mismatched

Lateral, paralyzed, mech vent, chest closed: with mech vent, diaphragm no longer helps maintain ____ leading to further decrease in ventilation in _____ lung and increased vent in ______ lung and ____ V/Q mismatch

FRC Dependent NonDependent More

Lateral, paralyzed, mech vent, chest closed: PEEP ____ ____ leading to ____ V/Q mismatch

Improves FRC Less

Lateral, anesthetized, chest open: huge reduction in resistance in ______ lung leading to increased ventilation in _____ lung and further decreased vent in ______ lung

NonDependent NonDependent Dependent

Lateral, anesthetized, chest open: Mediastinum shifts _____ d/t loss of _____ _____ pressure

Downward Negative intrathoracic pressure

Lateral, anesthetized, chest open: Vessels can be _____ leading to decreased ____ ____

Compressed Cardiac output

Lateral, anesthetized, chest open: With spontaneous vent (theoretically) leads to _____, _____ exchange. Air from the open-chest _____ lung moves into the ______ lung

Paradoxical, inefficient NonDependent Dependent

Paradoxical Respiration: during inspiration, air from the open-chest ______ lung moves into the ______ lung

NonDependent Dependent

Paradoxical Respiration: During expiration, air moves from ____ lung to the open-chest _____ lung

Dependent NonDependent

Paradoxical Respiration: _____ ventilation helps, but ______ lung is much better ventilated. ______ lung is much better perfused. (Gravity)

Mechanical NonDependent Dependent

Paradoxical Respiration: Net result - major ____ _____ in dependent lung

Physiologic shunt *reminder that this is theoretical and should NOT occur*

With mechanical (positive pressure) ventilation, Paradoxical Respiration and Mediastinal shift are _____. But _____ compliance of the NonDependent lung in open chest leads to ____ _____ _____

Reduced High HUGE V/Q mismatch

What situation has the worst V/Q mismatch? And why do you care?

Lateral, anesthetized, paralyzed, open-chest patient We care bc we have to deal with this exact situation for the duration of the surgery

Lateral, open-chest, one-lung ventilation (OLV): ____ resistance, _____ compliance of NonDependent lung which leads to ____ ventilation

Low High High

Lateral, open-chest, one-lung ventilation (OLV): _____ in dependent lung leads to ____ perfusion

Gravity High

Lateral, open-chest, one-lung ventilation (OLV): When vent stops in NonDependent lung, all _____ is diverted to _____ lung

Ventilation Dependent

Lateral, open-chest, one-lung ventilation (OLV): Perfusion to ______ lung now creates a ______

NonDependent Shunt

Lateral, open-chest, one-lung ventilation (OLV): BUT HPV in ______ lung diverts perfusion to ______ lung and decreases the ______ effect

NonDependent Dependent Shunt

Lateral, open-chest, one-lung ventilation (OLV): Net result - ____ V/Q mismatch (clinical picture ____ when _____ lung is clamped)

Less Improves NonDependent

Patient Related (isolation) indications for Lateral, open-chest, one-lung ventilation (OLV): (6)

- lung abscess - copious bleeding on one side - bronchopulmonary fistula - bronchial rupture - large lung cyst - bronchopleural lavage

Procedure Related (exposure) Indications for Lateral, open-chest, one-lung ventilation (OLV): (7)

- thoracic aortic aneurysm - pneumonectomy - upper lobectomy - thoracostomy/thoracoscopy - lower/middle lobectomies - sub-segmental resections - esophageal surgery

Double-Lumen EBTs: ____ tube, _____ lumen

Single Double

Double-Lumen EBTs: __ or __ available

L or R

Double-Lumen EBTs: Right DLTs designed to ventilate ____

RUL

Double-Lumen EBTs: ____ almost never used d/t missed ____ if not positioned perfectly

R DLT RUL

Double-Lumen EBTs: External French sizes - Internal sizes -

External - 26, 28, 35, 37, 39, 41 Internal - 3.4 - 6.6 mm

Double-Lumen EBTs: Sizing based on ____

Height

Double-Lumen EBTs: Usual sizing ___, ___ in females, and ___, ___ in males

35, 37 39, 41

Double-Lumen EBTs: 35 French DLT = ____ mm (ID) 41 French DLT = ____ mm (ID)

5.5 6.5

Double-Lumen EBTs: Have ____ outer diameters. Ex 37 Fr DLT has outer diameter equivalent to ____ mm ID standard ETT

Larger 11

Contraindications for L DLT (indications for R DLT): (5)

- distorted L main bronchus d/t mass - compression of L main bronchus d/t aortic aneurysm - left-sided pneumonectomy - left-sided single lung transplantation - left-sided sleeve resection

Most common DLT complication:

Malposition

Other common DLT complications: (5)

- thoracic aneurysm rupture with L DLT - vocal cord damage from carinal hook, or hook breaking off - bronchial cuff rupture d/t over-inflation - barotrauma if DLT inserted too deeply - inadvertent suturing of DLT to bronchus

Insertion of DLT: stylet through the _____ lumen, _____ blade, _____ DLT

Bronchial Mac Lube

Insertion of DLT: Insert with _____ curve, through ____ ____, remove _____

Anterior curve (over and under shotgun) Vocal cords Stylet

Insertion of DLT: Turn ___ ____ toward R (or L) bronchus and advance until _____. (Male approx. ____ cm, female approx. ____ cm)

90 degrees Resistance 29 27

Insertion of DLT: Inflate ____ cuff, verify ____, inflate ____ cuff

Tracheal BBS Bronchial

Insertion of DLT: Auscultate per _____

Protocol

Insertion of DLT: _____ ____ to verify. (Up to ____ of DLTs are malpositioned when verified by _____ ____)

Fiberoptic scope 80% Auscultation only

Insertion of DLT: Position patient into _____ position and then then _____ with _____

Lateral Re-verify FOB

Insertion of L DLT: (7 steps)

1. Inflate tracheal cuff (5-10 mL) 2. Check for BBS (unilateral = too deep) 3. Inflate bronchial cuff (1-2 mL) 4. Clamp tracheal lumen 5. Check for unilateral L BS 6. Unclamp tracheal lumen, clamp bronchial lumen 7. Check for unilateral R BS. If absent or weak R BS, DLT is too shallow, occluding the distal trachea

Insertion of L DLT: after clamping tracheal lumen, you check for unilateral L BS. However, if you hear - R BS also - Unilateral R BS - No R BS, no LUL BS It means:

- R BS also means: bronchial lumen is in trachea, Advance the DLT into L side. - Unilateral R BS means: DLT in R bronchus - No R BS, no LUL BS means: DLT too deep into L side

Bronchial Blockers: catheter with ______ ______ to block _____ lung bronchus

Inflatable balloon Operative

Bronchial Blockers: Types (2)

- side-channel (Univent) - separate devices through or outside of regular ETT

Bronchial Blockers: Place with ____ guidance

F/O

Bronchial Blockers: May be better with _____ airways than _____

Difficult DLTs

Bronchial Blockers: Use when ____ _____ is risky

ETT change

Bronchial Blockers: Can be used in _____

Children

Bronchial Blockers: Higher incidence than DLT of _____

Malposition

Bronchial Blockers: Lung deflation ____ _____ than DLT

Less effective

Bronchial Blockers: No ability to _____ below balloon

Suction

Bronchial Blockers: Caution with removal on _____ lung cases

“Dirty”

Bronchial Blockers: Same problem as DLT with missing ____. Usually only used for ___ ___ surgery

RUL Left side surgery

During OLV, NonDependent (deflated) lung becomes ___ ___ leading to decreased ____

Shunt flow PaO2

Hypoxia pulm vasoconstriction: lungs compensate by increasing _____ _____ in _____ areas which diverts perfusion to areas with better ______. (_____ phenomenon from general circulation)

Vascular resistance Hypoxic Ventilation Reverse

HPV is caused by ____ hypoxia, NOT ____ hypoxemia

Alveolar Arterial

HPV and OLV net result

Pulm blood flow matched to better oxygenated areas of the lung (improved VQ matching)

W/O HPV, approx ___ ___ would result

40% shunt

HPV occurs within seconds of _____, max effect in a few mins, can be maintained for ____ ____

Hypoxia Long periods

HPV improves SaO2 during __-__ lung hypoxia which is the ____ ____ present with OLV

20-80% Usual condition

We can facilitate the effectiveness of HPV by AVOIDING: (7)

AVOIDING - alkalosis/hypocapnea - excessive PIP, TV, or PEEP - hemodilution/hypervolemia (L atrial pressure > 25 mmHg) - prostacyclins - hypothermia - vasodilators, PDE inhibitors, CCBs - > 1.5 MAC of volatiles

Anesthetic agents: ____ are a good choice because they are ______, allow for high FiO2, ____ elimination for emergence

Volatiles Bronchodilators Rapid

Anesthetic agents: ____ ____ does NOT inhibit HPV

<1.5 MAC volatile

Anesthetic agents: ____ do not inhibit HPV. But ___ ____ in outcomes when compared to volatiles

TIVAs No difference

Anesthetic agents: Use ___/___ mix

Air/O2

Anesthetic agents: Avoid ____. It increases ____ and moves into ____ and _____

N2O PVR Bullae and cysts

Anesthetic agents: Avoid potential ____ ____. Can be deadly.

Residual blockade

Anesthetic agents: Use _____ relaxants, _____, antagonize.

Intermediate MONITOR

Regional Anesthesia: ____ required for open lung case but ____ good choice for post-op pain control

GA Regional

Regional Anesthesia: ______ from epidural, ______ does not appear to affect local HPV

Vasodilation Sympathectomy

Regional Anesthesia: ____ can cause same response as heavy opioids: decreased _____ ____, ____, _____

Pain Respiratory effort, hypoxemia, acidosis

Regional Anesthesia: Good choices (5)

- IV PCA - thoracic epidural (T6-T8) - paravertebral nerve block - ketamine - NSAIDs

____ of thoracotomy patients have pain ___ ___ out. 1/3 have pain at ____ ____ out.

50% 1 year 4 years

Primary goals of anesthetic management: maintain adequate ____, protect ____, provide favorable ____ ____

Oxygenation Lungs Surgical field

Protective ventilation strategies: physiologic VT of ____ (____ needed on the left)

6-8 mL/kg Less

Protective ventilation strategies: PEEP as low as possible to _____ lung

Dependent

Protective ventilation strategies: Limit PiPs to ___-___

20-25 cm H2O

Protective ventilation strategies: Permissive ______ (____) to support HPV

Hypercapnia (< 60 mmHg)

Protective ventilation strategies: ___/___ mix at lowest level that maintains _____. (But ____ ____ frequently needed)

Air/O2 PaO2 100% O2

Protective ventilation strategies: ____ limiting ventilation modes

Pressure

___ lung is larger than ___ lung so hypoxemia will be worse in ___ ____ procedures

Right Left R-side

____ can be predictive of intraoperative shunting

EtCO2

the degree of drop in EtCO2 when shifting to OLV is proportionate to _____ of the ______ lung

Perfusion NonDependent

The greater the initial drop in EtCO2, the ____ chance of ____ during OLV

Greater Hypoxia

Causes of OLV hypoxia: (6)

- tube Malposition (check first) - bronchospasm - drop in cardiac output - hypoventilation - low FiO2 - PTX of dependent lung (the only good lung)

If still hypoxic, ____ to NonDependent lung. Start at ___ ____ and use the lowest possible ____

CPAP 2 cmH2O Pressure

Too much CPAP inflates the lung causing a ____ ____ ____

Surgical exposure problem

For CPAP, can use _____ system or CPAP _____

Breathing Valve

Can use ___ ___ O2 via catheter insufflated through ______ circuit limb

Low flow NonDependent

Can ____ ventilate _____ lung with very small TV

Hand NonDependent

PEEP can be delivered to _____ lung

Dependent

PEEP produces alveolar _____, increases ____ ____ and _____

Recruitment Lung compliance and FRC

High PEEP leads to decreased ____ ____

Cardiac output

____ + ____ = auto PEEP effect with CO2 retention and lung ____

PEEP + fast rate Trauma

____ _____ of NonDependent lung, this is where communication with surgeon is vital

Intermittent reinflation

______ to NonDependent lung (can cause movement and ____ ____)

HFJV CO2 retention

Selective oxygenation of non-operative lobes of ______ lung with _____ _____ or _____

NonDependent Bronchial blocker FOB

Early _____ of pulm artery for ______

Ligation Pneumonectomies

After procedure, ____ NonDependent (operative side)

Unclamp

After procedure, use PiP of ___-___ cm H2O to _____ NonDependent lung

30-40 cm H2O Reinflate

After procedure, ____ bronchial cuff

Deflate

Inhaled selective pulm vasodilators such as ____ ____ and _____ can help with perfusion

Nitric oxide (NO) Prostacyclin

New research: _____ to NonDependent lung with ____ to dependent lung (100% increases PaO2)

Almitrine NO

Almitrine promotes ____ in NonDependent lung. (____ ____ ____ agonist)

HPV Carotid body chemoreceptor

NO is _____, _____, requires complex ____-___ independent of anesthesia machine with dedicated RT.

Expensive, toxic, requires complex set-up

Most mediastinal masses are _____

Asymptomatic

Symptomatic masses are usually ____ (larger with extensive involvement)

Malignant

Mediastinal tumors are frequently associated with systemic syndromes which include: (6)

- MG (thymoma) - cushing’s syndrome (thymoma, carcinoid) - hypercalcemia (parathyroid adenoma) - HTN - myasthenic syndrome (lung cancer) - cough, dyspnea, stridor, jugular distention, exaggerated postural changes in BP

Mediastinal mass: Problematic with _____ position; VERY problematic with _____/_____

Supine Induction/anesthesia

Mediastinal mass: Loss of _____ vent leads to potential airway collapse

Spontaneous

Mediastinal mass: If distal to ETT, ventilation can be _____. Have ___/___ _____ available before induction.

Impossible ENT/rigid bronchoscope

Mediastinal mass: Mass encroaching on ___, ____, or ____ ____ can cause potential CV collapse. ____ would need to be initiated immediately.

Heart, aorta, or vena cava CP bypass

Mediastinal mass: Pre-op eval - ___, ___, ____, ____, ____, to determine size, location, compression effects

CXR, CT, MRI, TEE, PFTs

Mediastinal mass: ____ to shrink mass before surgery

Radiate

Mediastinal mass: ____ ____ ____ ____ - venous distention of thorax and neck, redness/edema of face, neck, torso, airway, conjunctiva, SOB, HA, confusion. Place PIVs in ____ _____

Superior vena cava syndrome Lower extremities

Mediastinal mass: Major goal

Maintain spontaneous ventilation

Mediastinal mass: Biopsy with LA in ____ position if possible

Sitting

Mediastinal mass: Biphasic positive airway pressure (BiPAP) supports airway during _____ _____ with _____

Spontaneous ventilation with sedation

Mediastinal mass: _____ to shrink mass before surgery

Radiate

Mediastinal mass: ____ ____ is good choice for intubation

Awake FOB

Mediastinal mass: Avoid ____ ____ until ability to ventilate confirmed

Muscle relaxants

Mediastinal mass: ____/____ mixture (____) to minimize turbulence

Helium/O2 Heliox

Mediastinoscopy: incision above ____ ____, scope passed between ____ and ____ ____, near L common carotid, L subclavian, and innominate arteries, innominate veins, L ____ ____ nerve, thoracic duct, superior vena cava and aortic arch

Sternal notch Trachea and thoracic aorta Recurrent laryngeal nerve

Complications with mediastinoscopy: (9)

- hemorrhage - PTX - dysrhythmias - bronchospasm - laryngeal nerve damage - tracheal or esophageal rupture - chylothorax - air embolus - DEATH

Mediastinoscopy: monitor ___ arm (d/t pressure on _____ artery)

Right Innominate

Mediastinoscopy must haves: (2)

- good IV access - cross matched blood available

VATS replaces ____ ____

Open thoracotomy

VATS most common technique

GA with DLT

VATS usual monitoring

Arterial line

VATS can be done with ____, ____, ____ _____ for patients with poor pulmonary function

Epidural, sedation, spontaneous ventilation (although not commonly done)

Bullectomy: For ____ patients with bullae. (Prone to ____ leading to ____ PTX)

COPD Rupture Tension

Bullectomy: ____ approach

VATS

Bullectomy: Spont vent until chest ____ to decrease risk of ____

Open Rupture

Bullectomy: Vent settings (4)

- low TV - high RR - 100% O2 - PiP < 20 cmH2O

Bullectomy: Epidural?

Try your very best to do GA unless you think it’s going to kill them. Then maybe epidural

Bullectomy: AVOID ____

N2O

Complications Post-Thoracotomy: Highest risk factors- (5)

- > 80 years old - PPO FEV1 or DLCO < 40% - ASA status > or equal to 3 - > 80 mins surgery time - hemorrhage

Most Common Complications Post-Thoracotomy: (4)

- resp failure - dysrhythmias - cardiac failure - acute lung injury (ALI)

Highest risk factors for ALI: (4)

- R pneumonectomy - overhydration - high PiPs during OLV - pre-op ETOH abuse

Complications Post-Thoracotomy: Chest tube drainage should not exceed ____ mL/day. ____ mL/hr calls for ____ _____

500 mL/day 200 mL/hr Surgical exploration

Complications Post-Thoracotomy: Lung resection leads to increased ____ leading to ___ failure. Increased risk with _____, hyper____, _____

PVR RV Pneumonia Hypercarbia Acidosis

Complications Post-Thoracotomy: _____ dysrhythmias common.

Supraventricular

Complications Post-Thoracotomy: Morbidity ___, ___ death in 1st 30 post-op days. Treat aggressively with ____ _____.

High 25% Beta blockers

Complications Post-Thoracotomy: ___ or ___ nerve damage

Phrenic or laryngeal

Complications Post-Thoracotomy: SCI if ____ artery damaged, _____ hematoma, positioning injury (____ ____)

Radicular Epidural Lateral decubitus