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IDC Anes Principles 3 - Respiratory > PRIN 3 - Test 3 Anes Thor Surg YSK > Flashcards

PRIN 3 - Test 3 Anes Thor Surg YSK Flashcards

1
Q

What happens to lung volumes in Restrictive Disease?

A

There is a proportional decrease in all lung volumes.

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2
Q

What happens to FEV1/FVC and FEF25-75% in Restrictive Diseases?

A

Remain “Normal”

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3
Q

Small airway obstruction to expiratory flow or air trapping occur in Obstructive or Restrictive lung disease?

A

Obstructive

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4
Q

What happens to FVC and FEV1 in Restrictive Lung disease?

A

They are both decreased.

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5
Q

What happens to FVC in obstructive lung disease?

A

It can remain normal or be slightly increased

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6
Q

What happens to FEV1 in obstructive lung disease?

A

It can remain normal or be slightly decreased

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7
Q

What happens to FRC and TLC in restrictive lung disease?

A

Both decrease

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8
Q

What happens to FRC and TLC in obstructive lung disease?

A

Remain normal to slightly increase if gas trapping.

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9
Q

Where is the a-line placed for a mediastinoscopy and why?

A

The right; to monitor compression of the innominate artery.

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10
Q

For a mediastinoscopy, if the aline is on the left where must the pulse ox be place and why?

A

Pulse ox on the right to monitor compression of the innominate artery.

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11
Q

For a thoracotomy, where is the aline placed and why?

A

Aline is placed on the side of the dependent lung to monitor axillary artery compression.

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12
Q

In the lateral decubitus position, placement the of the axillary roll in the axilla may cause what to occur?

A

Neurovascular compression

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13
Q

Why is hyperabduction of the arms avoided in the lateral decubitus position?

A

To prevent the brachial plexus from stretching against the humeral head.

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14
Q

In the LD Position, what can happen with lateral flexion of the neck?

A

Can cause compression of the jugular veins or vertebral arteries which can compromise cerebral circulation.

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15
Q

Which nerve in the lower extremity may be injured in the lateral decub position?

A

Common Peroneal Nerve

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16
Q

What are the pressure points on the common peroneal nerve?

A

1) Fibular head of the dependent leg

2) Femoral head of the nondependent leg (with stabilizing strap)

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17
Q

In the lateral position with the patient awake and spontaneously ventilating (Closed) which lung receives more blood flow and ventilation? dependent or nondependent?

A

Dependent Lung - with greater perfusion than NDL

V & Q are high

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18
Q

In the lateral position with the patient awake and spontaneously ventilating (Closed), what is the V/Q relationship in the NDL?

A

Both V and Q are decreased.

V and Q to the DL are significantly greater than to the NDL.

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19
Q

OLV creates an obligatory right-to-left transpulmonary (because the V/Q ratio is zero) shunt through the non-ventilated/non-dependent lung. What is the % shunt thru the NDL?

A

22.5%

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20
Q

What is the total shunt for NDL and DL in % and partial pressure of oxygen?

A

27.5% and a PaO2 of 150 mmHg (at an FIO2 = 100%)

With 5% shunt in the dependent lung, total shunt during OLV is 22.5+5=27.5%

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21
Q

Absolute Indications for OLV

A
  1. Isolation of each lung to prevent contamination of a healthy lung
  2. Control of distribution of ventilation to only one lung
  3. Unilateral lung lavage
  4. Video-Assisted thoracoscopic surgery
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22
Q

Disease processes for OLV that require isolation of the lung to prevent contamination of the healthy lung? (ABSOLUTE)

A
  1. Infection (Abscess, Infected cyst)

2. Massive hemorrhage

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23
Q

Disease states that require OLV to control the distribution of ventilation to only one lung? (ABSOLUTE)

A
  1. Bronchopleural fistula
  2. Bronchopleural cutaneous fistula
  3. Unilateral cyst or bullae
  4. Major bronchial disruption or trauma.
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24
Q

Relative Indications for OLV

A
  1. Surgical exposure-High priority

2. Surgical exposure - Low Priority

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25
Relative Indications for OLV: What are the conditions associated with a surgical exposure that is HIGH priority?
1. Thoracic Aortic Aneurysm 2. Pneumonectomy 3. Lung Volume reduction 4. Min Invasive Cardiac Surg 5. Upper lobectomy
26
For Relative OLV Indications: What are the conditions associated with a surgical exposure that are LOW priority?
1. Esophageal surgery 2. Middle and lower Lobectomies 3. Mediastinal mass resection, thymectomy 4. Bilateral sympathectomies
27
BASIC (3) steps for placement of a DLT
1) Lubricate DLT 2) Use a Mac 4 to insert distal curve anteriorly until passed the cords 3) Rotate the tube 90 degrees
28
DLT Depth for Female
27 cm
29
DLT Depth for Male
29 cm
30
The amount of air used to inflate the tracheal cuff of a DLT
5-10 ml
31
The amount of air used to inflate the Bronchial cuff of a DLT
1-2 ml
32
9 Steps for Auscultating Breath sounds after DLT placement
1) Inflate tracheal cuff 2) Verify BIL equal BS (withdraw 1-2 cm PRN) 3) Inflate bronchial cuff 4) Clamp Y-piece for bronchial lumen and open lumen to atmosphere. 5) Verify BS in correct lung (tracheal side); Absent on Bronchial side 6) Verify the absence of air leakage thru bronchial (AND tracheal) lumen 7) Unclamp and reconnect the bronchial lumen and verify BIL BS 8) Clamp Y-piece to tracheal lumen and open the lumen to atmosphere. 9) Verify BS in the correct lung (bronchial side) &; absent on tracheal side.
33
What instrument is used to confirm placement of a DLT? It is considered the gold standard for verifying placement.
Fiberoptic Scope
34
Checking Position of LT-DLT - | 4 Step Checklist for tracheal placement (nothing is clamped)
1) Inflate tracheal cuff 2) Ventilate rapidly by hand 3) Check that both lungs are being ventilated. 4) With draw 2-3cm if PRN
35
Checking Position of LT-DLT - | 4 Step Checklist for bronchial (Left Side) placement
1) Inflate bronch (Lt) cuff 2) Ventilate and check BIL BS 3) Clamp Tracheal Tub. 4) Check for Unilateral BS (only on Left)
36
Checking Position of LT-DLT - | 2 Step Checklist for Rt Side/Tracheal placement
1) Clamp bronchial tube | 2) Check for Unilateral BS (only on Right)
37
Verifying DLT Placement with Bronchoscopy - Tracheal Lumen View
Visualize the carina distally. | Not in a bronchus or cuff is in the trachea
38
Verifying DLT Placement with Bronchoscopy - Tracheal Lumen View checking bronchial cuff placement
Cuff 1-2 mm beyond the carina. | Ensure cuff is not too proximal or overinflated causing obstruction.
39
Verifying DLT Placement with Bronchoscopy - Bronchial Lumen View
Insert bronchscope thru bronchial lumen. confirm tip of lumen is unobstructed. For Lt DLT - visualize bronchial carina distal to tip. For Rt DLT - visualize the RUL bronchus is aligned with the ventilation port.
40
Possible complications of DLT include (6 things):
#1 = Malposition 2) Rupture of a thoracic aneurysm 3) Damage to the cords or arytenoid cartilages 4) Carinal hook break off 5) Bronchial rupture 6) Barotrauma
41
With DLT complications, what is the location of the thoracic aneurysm (TA)?
The TA is compressing the left mainstem bronchus.
42
With DLT complications, what part of the DLT can damage the vocal cords and arytenoid cartilages?
The carinal hook of the DLT
43
With DLT complications, if the bronchial hook breaks off, how is it retrieved?
Using a bronchoscope
44
With DLT complications, what is the cause of bronchial rupture?
Overinflation of the cuff
45
With DLT complications, what can cause barotrauma?
DLT inserted too deeply so that the entire tidal volume is delivered to one lung.
46
What are the 4 Cons to using a Bronchial blocker?
1) Greater incidence of becoming malpositioned 2) Lung deflation is less effective 3) Blockers do not allow suctioning esp with unilateral infection or bleeding 4) Used mainly for left sided surgery
47
What are the 3 major indications for using a bronchial blocker?
1) Difficult airway 2) Management 3) Surgical Procedures not involving the lung.
48
``` Avoids the need for tube exchange. After laryngeal surgery Patient with a trach Distorted bronchial anatomy due to compression. Requiring Nasotracheal intubation. ```
Difficult airway indications for endobronchial blockers
49
If a patient requires segmental blockage but cannot tolerate OLV, what is the best option for surgical exposure?
Use a bronchial blocker
50
What are 3 management indications for the use of bronchial blockers?
Morbid obesity pediatric or small-sized patients. Tracheally intubated patients.
51
Types of surgical procedures, NOT involving the lung, requiring the use of a bronchial blocker?
Esophageal surgery Spine surgery - Transthoracic approach Minimally invasive cardiac surgery
52
Left DLT placement checking, In the absence of pulmonary lesions and pleural effusions, bilateral peak airway pressures are: Greater on the left, greater on the right or the same?
Same
53
Blood Flow Distribution: in two lung ventilation - When LEFT Lung is NDL What is the distribution of BF between the NDL:DL?
35%:65% NDL:DL
54
Blood Flow Distribution: in two lung ventilation - When RIGHT Lung is NDL What is the distribution of BF between the NDL:DL?
45%:55% - NDL:DL
55
Blood Flow Distribution: in two lung ventilation - The average of both lungs being NDL is equal to?
40%:60% - NDL:DL
56
What should you observe with DLT when both Tracheal and Bronchial Lumens open
BIL chest rise, condensation and bilateral auscultation
57
Left DLT Tracheal Lumen Clamped and breath sounds heard on the right indicates
The tube is in the right bronchus.
58
Left DLT Tracheal Lumen Clamped
Bronchial lumen open breath sounds heard over the left.
59
Left DLT Tracheal Lumen Clamped, both cuffs are inflated and BS can heard on both sides. What is happening?
Tube is not deep enough into the left bronchus or not enough air in the bronchial tube cuff
60
Left DLT Bronchial (Left) Lumen Closed/Clamped. What should happen during ventilation?
Ventilation thru the tracheal lumen with BS heard only over the right.
61
Left DLT Bronchial (Left) Lumen Closed/Clamped. If the tube is not in the right position with both cuffs inflated, it will be difficult to ventilate on the right due to_______?
High resistance
62
Left DLT Bronchial (Left) Lumen Closed/Clamped and the tracheal lumen is obstructed by the cuff above and the bronch tube below, what is the Tx?
Deflate the bronchial tube.
63
Pulmonary compensatory mechanism that increases vascular resistance in hypoxic areas, diverting blood flow to the areas with better ventilation and oxygenation.
Hypoxic Pulmonary vasoconstriction
64
What is the purpose of the HPV reflex?
Improve gas exchange and arterial oxygenation.
65
HPV is triggered by?
Alveolar hypoxia (NOT arterial hypoxemia).
66
Three agents that may inhibit HPV
1) vasodilators (PDE inhibitors and CCBs) 2) chemoreceptor agonists (eg. almitrine) 3) prostacyclin
67
What are the 4 H's that prevent HPV
1) HemoDILution 2) HyperVOLemia (Left Atrial Pressure >25mmHg) 3) HypoCAPnia 4) HypoTHERMIA
68
What shunt fractions cause a reduced HPV effect?
<20% and >80%
69
Which causes a decrease in effectiveness of HPV Alkalosis or Acidosis?
Alkalosis (thus the permissive hypercapnia)
70
Which ventilator parameters can cause HPV ineffectiveness?
High tidal volumes | High PEEP
71
When managing OLV to avoid Hypoxemia, where do we keep the FIO2 and why?
Less than 100%; 40-80% w/ O2 sat >90% | FIO2 at 100% can facilitate atelectasis, induce trauma and hypoxaemia.
72
When managing OLV to avoid Hypoxemia, what is the target range for the TV and what do we do with the pressures?
TV at 6-8ml/kg or use lower pressures, to avoid trauma
73
When managing OLV to avoid Hypoxemia why is PEEP used.
It is beneficial for oxygenation and lung protection.
74
When managing OLV to avoid Hypoxemia why do we use recruitment maneuvers?
Improves oxygenation and achieves a better distribution of aeration
75
What are the ventilation parameters for OLV?
``` TV: 6-8ml/kg Rate: 12-15 bpm FiO2: 0.4-0.8; maintain SpO2 >90% PEEP: 5-10 cmH2O (2.5-5 if COPD) I:E: 1 : 2 (or 1 :3 if COPD or intrinsic (auto) PEEP) ```
76
Prior to OLV what should you consider doing? How often should you assess ABGs What is the desired MAC for Volatile Anes (VA)? A good alternative to VA?
Recruitment Maneuvers Q 15 mins MAC <1-1.5 IV agents
77
For OLV Management, what is the stepwise response to worsening hypoxemia?
1) INC FiO2 2) Confirm Tube Position with scope 3) Ensure adequacy of CO 4) Remedy detrimental effects caused by anemia or vasodilators 5) Perform alveolar recruitment maneuver to DL 6) Titrate PEEP in DL 7) CPAP 5-10 cmH2O to NDL 8) Intermittent or continuous two-lung ventilation 9) Low or No pressure Oxygen insufflation to NDL or selected lobe of NDL 10) Reposition to LD if Supine 11) Alter perfusion with almitrine to NDL; Nitric Oxide to DL.
78
Why is N2O avoided in Thoracic surgery?
to prevent hypoxia and any significant increase in PVR
79
Complications associated with mediastinoscopy include:
1) hemorrhage resulting from disruption of major vessels; 2) pneumothorax; 3) dysrhythmias; 4) bronchospasm; 5) LEFT recurrent laryngeal nerve palsy; 6) laceration of the trachea or esophagus; 7) chylothorax secondary to laceration of the thoracic duct
80
For complications of mediastinoscopy, what types of dysrhythmias are most common and why?
Bradycardia d/t manipulation of the aorta or trachea during blunt dissection.
81
A common complication of using the mediastinoscope is that it can place pressure on the innominate artery prior to dividing into the right common carotid artery and right subclavian. What are the implications of this occurring?
DECrease cerebral BF can cause acute ischemic stroke and DECrease BF to the Right Arm.
82
Where does the mediastinoscope pass?
In front of the trachea and behind the thoracic aorta.
83
The mediastinoscope can compress or damage which structures?
``` Aorta Innominate artery trachea SVC Left RLN ```
84
Common nerve injuries can occur during thoracic surgery include:
``` phrenic nerve (passes thru the mediastinum) L RLN (vulnerable during dissection of the aortopulmonary lymph nodes and mediastinal procedures) ```

IDC Anes Principles 3 - Respiratory (6 decks)

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