Pulmonary resection

Question 1

What is the three legged stool method for preop assessment for pulmonary resection?

Answer 1

Respiratory mechanics, lung parenchymal function, and cardiopulmonary interaction (exercise testing)

Question 2

What is the single most valid test for postthoracotomy respiratory complications:
How is that calculated?

Answer 2

Is the predicted postoperative FEV% (ppoFEV1%)

Calculated as: preop FEV1% (predicted FEV1%) x (1-the %functional lung tissue removed/100)

Question 3

How do you estimate the amount of tissue removed?

Answer 3

RUL: 6 segments
RML: 4 segments
RLL: 12 segments

LUL and LLL are 10 segments each

Question 4

Which ppoFEV is associated with respiratory complications and need for mechanical ventilation postoperatively?

Answer 4

<30-40% (this is under respiratory mechanics)

Question 5

Lung parenchymal fxn (ppoDLCO)-what value is associated with increased risk of both cardiac and respiratory complications. What is it independent of ?

Answer 5

ppoDLCO <40% predicted is associated wiht an increased risk of both cardiac and respiratory complications (and is independent of the FEV1)

Question 6

What is the DLCO?

What increases it? What decreases it? Briefly explain DLCO and area and thickness.

Answer 6

It is a measurement of the diffusion of the lungs.
DLCO-diffusion is worsened by decreased area (emphysema), increased thickness (fibrosis). Decreased also by:cigarette smoking, emphysema, interstitial lung disease, anemia, decreased lung volume, heart failure, pulmonary vascular disease (pulmonary emboli and pulmonary hypertension)

Increased by:
asthma, obesity, high altitude, lying supine, exercise, left-to-right cardiac shunt, polycythemia, pulmonary hemorrhage

Question 7

What about the cardiopulmonary interaction (exercise testing) ?

Answer 7

VO2 max can correlate with risk of morbidity and mortality-can be impractical
stair climbing: <2 flights is high risk
6 minute walk test: patients walk as far as they can for 6 minutes. <2,000 feet correlates with an increase in morbidity and mortality

Question 8

Lets talk extubation: what if ppoFEV1 is:
>40%
Between 30-40%
Between 20-30%

Answer 8

> 40%: possible to extubate provided that the patient is awake, comfortable, and warm
30-40%: extubation should be possible provided minimal co-existing disease (CAD, dysrhythmias, COPD)
20-30%: if parenchymal fxn/testing and exercise testing is favorable-extuabtion can be considered if thoracic epidural or paravertebral analgesia is used. Otherwise-they need to go to ICU for staged weaning.

Question 9

Who would have to get a pulmonary resection?

Answer 9

lung cancer, mass effect, airway narrowing, postobstructive pneumonia, mets, chemo, Eaton lambert syndrome, hypercalcemia

Question 10

What is Eaton Lambert syndrome?

Answer 10

When the body makes antibodies against the presynaptic calcium channels at the NMJ-decreased ACh secretion

Question 11

What are complications related to removal of bronchopulmonary segments and vasculature?

Answer 11

pul HTN, and right heart failure, dysrhythmias, pulmonary edema

Question 12

Issues with being in the lateral position in pulmoary resection:

Answer 12

potential nerve/eye/brachial plexus injuries

Question 13

Anticipating what intraop and post op?

Answer 13

Intraop: anticipation of arterial hypoxemia with OLV, mod-severe pain that intrfers with recovery

Question 14

What would you want to get from a history and physical?

Answer 14

History: coexisting diseases-smoking, COPD, dyspnea, orthopnea, exercise tolerance. Chemo-affectedwith bleomycin
Physical exam: RR, wheezing, rales, cyanosis, clubbing SVC syndrome, room air SpO2

Question 15

What is SVC syndrome

Answer 15

Obstruction of blood returning to SVC-Swelling of the face, neck, upper body, and arms.
Trouble breathing or shortness of breath.
Coughing

Question 16

What lab tests/imaging would you want to get?

Answer 16

CBC, electrolytes, Calcium, ABG if COPD
Review CXR and CT scan (difficult placement of DLT due to tracheobonchial distortion?
PFTs, V/Q scan if ppoFEV1 <40% ?

Question 17

Conflicts that can occur in this case:

Answer 17

Difficult airway versus need for large DLT

Hypoxemia and need to inflate operative lung versus interference with surgical exposure

Question 18

How can you optimize these patients?

Answer 18

I can perform a risk assessment (ppoFEV1, ppoDLCO, exercise testing)
Incentive spirometry prior to Sx
Smoking cessation
prescribe/continue bronchodilator (albuterol B2 agonist, anticholinergics (ipratropium)

Question 19

Goals of surgery:

Answer 19

maintain lung separation and oxygenation, prevent post-op pulm comlciations

Question 20

Options for anesthesia:

Answer 20

GA + thoracic epidural or paravertebral block (not as confident with this one)

Question 21

Pre-op-pre med, blood, ICU?

Answer 21

pre-oop antisialogogue for FOB
2 units PRBC
ICU/Stepdown bed-yes

Question 22

Room set up:

Answer 22

Arterial line, difficult airway cart with FOB

Question 23

What kind of tube are you using?

Answer 23

DLT (37-39 Fr for males, 35-37 Fr for females)

Question 24

How are you going to maintain anesthesia?

Answer 24

balanced anesthetic with volatile gas and IV narcotics,
May require CPAP on operative lung +/- PEEP to nonoperative lung for hypoxiemia
Adjust TV to keep PIP <35 cm H20

Question 25

Disposition/Pain: what helps with decreasing post op respiratory complications? What about NSAIDs?

Answer 25

Regional anesthesia can decrease postop respiratory complications, and no NSAIDs if on cis-platin (causesrenal toxicity)