Test 1 Flashcards
5 absolute indications for OLV
Isolation of 1 lung r/t infection/hemorrhage
Unilateral bronchopulmonary lavage
Bronchopleural fistula
Large ruptured bullae
Tracheobronchial tree disruption (TEF)
5 surgeries necessitating lung separation
Thoracic procedure (lobectomy, transplant, thoracoscopy)
Mediastinal procedures w/ sternotomy
Descending thoracic aortic aneurysm
Pulmonary embolectomy
Esophagogastrectomy
Anterior thoracic spine sg
3 methods of selective lung ventilation
Single lumen tube with endobronchial intubation
Selective bronchial intubation with MLT
Single lumen tube with endobronchial blocker (Univent, WEB)
Most common method of OLV
Why?
Left sided DLT
More distance to LUL (5 cm)so less likely to isolate upper lobes. With RLT there is only 2 cm from carina to RUL
Insertion depths for left DLT
27.5 to 31.2 cm
Most common used DLT
Robertshaw
Cuffs of Robertshaw tube (DLT)
Color
Inflation amt
Trachea cuff is clear
- 10-20cc
Bronchial cuff is blue
- 2-3 cc
Tracheal cuff ventilates which lung
How
Ventilate both lungs if blue is not clamped
To ventilate only right lung clamp blue (bronchial) lumen
DLT side for large male
41 French (each lumen 6.5mm)
DLT for normal male
39 French (6.0mm ID)
DLT size normal female, small male
37 French (5.5mm ID)
DLT size small female
28 French (5.0mm ID each)
DLT size not usually used, smallest
28French (4.5mm ID each)
Placement of DLT
- blade
- insertion
MAC blade easiest
Insert with tube end facing right.
Pass bronchial cuff through cords.
Remove stylet
Turn exactly 90 degrees forward
Pull up on chin helps
Advance until resistance felt
Where do you tape DLT
Middle of mouth
If bronchial lumen too deep where is tube
Left mainstem bronchus
Not ventilating LUL
Bronchial cuff herniated at carina what occurs
Too much air in cuff
Ventilating both lungs
Bronchial lumen above carina what occurs
Ventilate both lungs
Right main stem bronchial intubation with left DLT
Only ventilate R lung (not including RUL)
4 methods of checking placement of DLT
- check bilateral breath sounds and chest excursion
- selectively clamp lumens one at a time and listen
- open port and listed for air flow through clamped lung
- check placement with fiberoptic bronchoscope
How do you verify placement with fiberoptic bronchoscope
Insert into tracheal lumen and look for bronchial cuff placement
When verifying placement of DLT with FOB what should you see?
- through tracheal lumen
- through bronchial lumen
If not there?
Tracheal lumen
Bronchial cuff should be visualized as crescent shaped
If see too much not in far enough
If don’t see at all, in too far
Bronchial lumen
ID left upper and lower bronchus
3 uses of FOB in OLV
Verify tube placement
Suction
???
6 indications for right side DLT
Left pneumonectomy
Left tracheobronchial disruption or TEF
Mediastinal lesion compressing L mainstem
L bronchial stent
L lung transplant
Descending thoracic aortic aneurysm compressing L main bronchus
4 advantages of inhalation anesthetic on OLV
Bronchodilation
Decreases HPV
Ensures amnesia
Rapidly eliminated, less hemodynamic response
3 advantages of opiod use in OLV anesthetic
No sig. hemodynamic compression
Smooth transition to emergence
Minimal decrease in HPV
Effect of 1 MAC of volatile agent during OLV
Decrease HPV response from 50% to 40%
Increases Qs/Qt (flow to nondependent lung) 4%. Sats on 100% FiO2 96-98%
Proportion of blood flow to each lung during OLV in lateral decubitus position
Without inhalation agent
Dependent- 80%
Non-dependent- 20%
With inhalation agent
Dependent 76%
Non-dependent 24%
5 factors that may increase shunt during OLV and effect on HPV
Atelectasis (increase HPV)
Systemic vasodilators(inhibits HPV)
High PA pressures (inhibits HPV0
Low FiO2 (inhibits HPV)
Surgical interference/compression of operative lung
Management of hypoxia in OLV
Notify surgeon sat < 90% Suction Recheck tube position with FOB Oxygen from sidearm to operative lung via insufflation Change vent mode Change I:E ratio PEEP 5 cmH2O to dependent CPAP 5 cm H2O to non-dependent 150ml Oxygen into non-ventilated lung Intermittent ventilation of non-dependent lung Early clamping of PA if pneumonectomy
Goal of management of hypoxia during OLV
Decrease shunt
Benefit and disadvantages of PEEP and CPAP to lung during OLV
PEEP alone makes sat worse bc Less blood to dependent lung worsening shunt
Add 2.5 CPAP to non depending lung improves sat by providing O2 to blood going to nondependent lung
Add 5 CPAP to non dependent lung improves sat even more
4 contraindications for DLT
- Unable to replace existing ETT
- unable to maintain adequate PO2 w OLV
- technically difficult- anatomy, size
- full stomach
4 complications of DLT
- hypoxemia
- tracheobronchial tree disruption
- traumatic laryngitis
- DLT becomes temporary part of suture line
2 main disadvantages of bronchial blockers
Slow deflation time
Blockage of bronchial blocker by blood/pus
7 indications for wire-guided endobronchial blocker
- ETT or trach in place
- RSI and OLV
- known and unknown difficult airway
- nasotracheal intubation
- small adult pt
- selective lobar ventilation
- trauma
What is the most versatile method for OLV
Left DLT
12 steps of mgmt of hypoxia with OLV
- notifies surgeon of low sat, interventions, exact sat
- ask for help
- decrease volatile agent
- increase FIO2
- change vent to PC
- manipulate PEEP
- manipulates MV
- administer inhaler
- suction ventilated lung
- insufflates with O2
- PEEP down lung, CPAP up lung
8 indications for securing pt airway
Anesthesia Hemodynamic instability Decreased LOC Pain mgmt Severe dyspnea- Acc muscle use Severe hypoxemia/hypercarbia Severe acidosis Inability to protect airway
Normal TMD
> 6cm (more than 3 fingerbreadths)
Normal mouth opening
> 4cm
2-3 fingerbreadths
Neck circumference > ______ predicts difficult airway
60cm
LEMON assessment
Look
- facial trauma, large incisiors, beard, large tongue
Evaluate (3-3-2)
- interincisor gap, hyomental distance, TMD
Mallampati
Obstruction
Neck mobility
7 risk factors for aspiration
Short tasting times Pregnancy Increased abdominal pressure GI disease GERD Bowel obstruction NM disease or nervous system dysfunction
6 complications of airway mgmt
Failed intubation CVCI Airway trauma Aspiration Mainstem intubation Bronchospasm
6 disadvantages of face mask for general
Ties up hands Higher FGF Access difficult More desat than LMA Higher work of breathing Poor correlation of ETCO2 and PCO2
4 complications from using face mask
Pressure necrosis
Nerve injury
Gastric insufflation
Pollution
8 complications of LMA
Aspiration Gastric distention Airway obstruction Trauma (uvula edema) Laryngospasm Dislodgement Nerve injury
5 advantages of LMA
Ease of insertion Smooth emergence Low pollution Avoid complications of face mask and intubation Protect from barotrauma
3 advantages of LMA compared to face mask
Hands free
Better seal in bearded
Lass facial nerve and eye trauma
5 advantages of LMA compared to ETT
Useful for difficult intubation Less coughing on emergence Ability to ventilate until airway reflexes restored Reduced CV response Less laryngospasm and bronchospasm
2 disadvantages of LMA vs ETT
Less safe in prone or jackknife position
Less secure airway
Machine end of ETT has a ______ connector (size)
15mm
6 uses of FOB
Intubation (awake/asleep, nasal, oral) Confirm ETT placement Confirm placement of DLT Clear secretions Bronch with lovage for aspiration or blood in ETT Bronch exam with intervention
3 advantages of FOB
Useful if difficult or impossible to intubate with rigid laryngoscopes
Onstable Cspine
Overcome anatomic variations
7 disadvantages of FOB
- expensive, fragile, difficult to use
- more time and prep required
- difficult or impossible with blood, secretions, hypoxemia
- gastric distension, rupture
- laryngeal trauma
- technical issues (fogging, anatomy, light source)
4 structures at risk of damage from DL
Dental injury
Cspine injury
Lips, tongue, palate, Laryngospasm, esophagus
2 uses of reinforced ETT
- kinking possible (prone, neck sg)
- ETT placed in tracheostomy
3 differences in microlaryngeal tracheal tube and conventional ETT
Larger cuff
Narrow body
Longer body
3 safety features of laser ETT
- cuff filled with blue indicator so see if hit
- saline in cuff helps put out fire
- ???
Type of oral airway used for awake fiberoptic intubation orally
Williams, ovassapian, ROTIG
4 standard monitors for the intubated pt undergoing general anesthetic
ECG
BP
Capnometry
Pulseox
Role of oxygen analyzer in avoiding hypoxic mix of gases
Continuously measure and indicate FIO2 in breathing system. Indicate when inspired O2 deviates from desired limits
Single monitor which provides most clinical information
Pulse oximeter
Which law?
Absorption of a given thickness of a solution of a given concentration is the same as twice the thickness of half the concentration
Beers law
Which law? Each layer of equal thickness absorbs an equal fraction of radiation which passes through it
Lamberts law
Absorption of red and infared light
Oxygenated blood
deoxygenated blood
Oxygenated- 960 mm
Deoxygenated- 660 mm
How do differences in oxygenated and deoxygenated blood absorption generates pulse ox reading?
Change in light absorption when passing through vascular bed during arterial pulsation
5 clinical scenarios which may result in decreased oxygen saturation
VQ mismatch Disconnect Inadequate MV Misplaced ETT Diffusion abnormality
7 location which may be used to monitor oxygen saturation
Finger Nose Earlobe Forehead Lip Tongue Check Forehead
11 Factors affecting pulse ox accuracy
Electrocautery Motion, venous pulsation Ambient light/radiant warmers Nail polish, acrylic nails Low perfusion CO2 methemoglobin Methylene blue/indigo carmine Hypothermia Tourniquet Nonpulsatile flow (CPB) IABP (2 systole)
Accuracy standard of oximeter
Accuracy bw 70-100%
Mandatory sat alarm for oximeter
Sat <85%
4 uses for pulse oximeter other than oxygen saturation
- Estimate systolic BP
- Monitor peripheral circulation (mediastinoscopy, shoulder sg)
- Locating arteries
- Warning of fluid extravasation
Most commonly used technology for gas monitoring
Diverting gas monitoring
How does nondiverting gas monitor works
Diverts some gas to monitor to interpret CO2, volatile anesthetics, N2O
How does infared technology for anesthetic gas concentration works?
Gases with 2 or more dissimilar atoms have specific infared light absorption
Amount of IR light absorbed is proportional to concentration of the absorbing molecules
Compare IT light absorption to known standard