Thoracic

Question 1

[21B10] A 60yo patient is scheduled for stenting of a tracheobronchial mass. Outline your perioperative management.

59.1%

tracheobronchial mass

vs.
PERIOP MED (Resp/thoracics) – Mediastinal mass
[18B15] A 45-year-old woman with a large mediastinal mass is scheduled for mediastinoscopy and biopsy. Discuss your preoperative assessment of this patient. (also 13B08)

Answer 1

Background
Pre/intra/post

BG:
1. comm teamwork
2. rigid bronch for critical AW obs
3. Next GA with stent in situ - avoid intubation OR fibreoptic guidance

Preop -
Hx/Ex/Ix

Hx: local vs systemic

Ix: flow volume loop

*Intraop
rigid vs flexi bronch

Postop:
RAW

Complications
1) central Aw syndrome
2) severe venous oozing
3) RLN injury

It is recognised that candidates are unlikely to have had first-hand experience of this procedure. An application of theoretical knowledge and a sensible safe approach to the problem was required. This was achieved by many candidates.
Candidates who didn’t reach the required standard were those who weren’t able to demonstrate they understood what the procedure entails, or how they would anaesthetise a patient safely while providing access for a surgeon to place a stent using a bronchoscope. Sensible, safe, systematic, and resourceful options for oxygenation and airway management was required. Ensuring appropriate skill mix, location and equipment was also essential.

Question 2

[17B01] A patient is anaesthetised for video-assisted thoracoscopic resection of the left upper lobe. At the completion of surgery, the double lumen tube is in situ and the patient has persistent hypoxia. a) List the potential causes of hypoxia in this situation. (30%)
b) How will you manage this? (70%)

Double lumen tube / hypoxia

Answer 2

Causes:
1) ETT issues

2) physiological
a) V/Q mismatch

b) atelectasis

Mx
a) correct reading
b) A
B) B
c) C

This question was reasonably well answered. A borderline answer needed to mention ETT issues, V/Q mismatch as well as atelectasis. The 2nd part required examination of the patient, equipment checks, use of fibreoptic bronchoscope & +ve pressure/recruitment manoeuvres.

Question 3

[03B15] Evaluate the methods available to confirm correct placement of a double lumen endobronchial tube.

22%

Answer 3

1. Clinical Assessment
2. Bronch
3. CXR

Clinical ax
Pros:
1) quick
2) cheap
3) repeated
Cons:
1) trauma
2) malposition

Bronch
1) accurate
2) aspirate
3) correct malpos
Cons
1) slower vs clinical
2) anatomy confusion

CXR
time and cost and radiation

Question 4

PERIOP MED (Resp/thoracics) - PFTs

[17B12] This table displays the pulmonary function tests results for a 67yo M. a) Define the following: FEV1, FVC, VC and DLCO. (50%)
b) Interpret these results and discuss the patient’s possible diagnoses. (50%)
(also 10B15)

Answer 4

FEV1 = max vol air exh in 1sec of FVC maneover

FVC - max exp from max inh

VC - greatest vol exp after taking deepest breath

DLCO - conductance of CO molecle from Alv to Hb
*~25mL/min/mmHg

> 75, 60-75, 40-60, <40

Low FEV1, High FVC = obstructive

Low FEV1, low FVC = restrictive

DLCO - parenchymal vs intraparenchymal in RESTRICTIVE

Obstructive ddx:
Asthma
Bronchiectasis
COPD
a-1
brochiolitis
CF

Restrictive
PF
NMD
CCF
sarcoidosis
obesity

Question 5

PERIOP MED (Resp/thoracics) - OSA

[08B15] What symptoms and signs suggest the presence of sleep apnoea in a patient presenting for pre-operative assessment. How does the presence of sleep apnoea alter your anaesthetic plan?

Answer 5

SDB
1. OSA
2. central SA

OSA Dx
- STOPBANG

Sleep study
PSG + AHI > 5
>5, >15, 30+
AHI = sum of apnoea and hypopnoea / sleep duration (hrs)

or overnight oximetry
ODI = 5 episodes of SpO2 desat

SX:

Intraop
- minimise opioids
- AW
- NMJ
- extubate awake, sit up with PEEP
Post op
R
- CPAP in PACU
A

W
- consider HDU
- overnight pulse ox

Question 6

PERIOP MED (Resp/thoracics) - OSA 2.

[17A04] How do you determine if a patient with known obstructive sleep apnoea is suitable for day surgery?

Answer 6

PS15 - suitability for day surg

OSA - post op resp dep

P
- severity OSA
- discharge plan

A
- type - LA/RA/sed - OK
- post op analgesia - more opioid BAD

S
- type

no CPAP/AW - bad

Question 7

PERIOP MED (Resp/thoracics) – Pulmonary HTN

[16A10] A patient with known primary pulmonary hypertension is scheduled to undergo elective umbilical hernia repair. a) How will you assess the severity of this patient’s pulmonary hypertension? (50%)
b) How does this diagnosis affect your perioperative management of this patient? (50%)

Answer 7

Severity
1. fx status (Hx)
- NYHA/METS

2. Signs (Ex)
3. Ix
   - TTE
   - RHC - mPAP
   - 6MWT - 600m = 15mL/kg/min VO2 –>
   - <300m - elevate M&M+++

Periop Mx
Preop
- Facility -

M - IAL/CVC/5 lead ECG

• Avoid inc PVR
• Avoid dec SVR

Open > Lap

Post
- HDU - continuous monitoring

Question 8

PERIOP MED (Resp/thoracics) – MR & PHTN

[10B11] A 78-year-old female presents for fixation of a displaced femoral fracture. She has longstanding mitral regurgitation and is known to have a mean pulmonary artery pressure of 60mmHg. She reports orthopnoea but is not short of breath at rest.

(a) What are the issues of concern in your preoperative assessment? (50%)

(b) How would you manage pulmonary vascular resistance perioperatively? (50%)

Answer 8

1. MR
   - risk of MI CCF

2.
mPAP 60 = severe PHTN

3. NOF
   - cause of fall
   - consent - delirium/demention/pain

Fixation technique:
Cannulated hip screws are quick, largely non-invasive procedures with a small incision and little blood loss.

DHS/ Richards screw and plate are intermediate procedures.

Cemented/uncemented hemiarthroplasty is a longer procedure, similar to the femoral part of a 1° hip replacement.

PRE

INTRA
PVR measure
1. normal O2/pH/CO2
2. Avoid SNS/N2O/ket

IAL/ CVP +/- PAC +/- TOE

dec PVR vs dec SVR

BCIS -
Sx: hypoxia/hypotension/CVS collapse
Mx:
vasopressor - aramine/adrenaline
fluids

See AAGBI 2020 / ortho

Question 9

PERIOP MED (Resp/thoracics) – Mediastinal mass

[18B15] A 45-year-old woman with a large mediastinal mass is scheduled for mediastinoscopy and biopsy. Discuss your preoperative assessment of this patient. (also 13B08)

PR 73%

Answer 9

loss of cardiac output or loss of airway secondary to the mass effect were required to pass.

Complications
1. Catastrophic blood loss

2. Compression of CVS?Resp structure

Question 10

PERIOP MED (Resp/thoracics) – Pulmonary fibrosis

[11A02] A patient with known idiopathic pulmonary fibrosis presents for an open right hemicolectomy.
a) What are the respiratory issues facing this patient with regard to their general anaesthetic? (70%) b) Explain your intraoperative ventilation strategy. (30%)

Answer 10

Issues
1. Disease severity
2. Sequelae
3. Rx SE
4. Abdo surgery
5. Resp phys
6. Postop implications

Vent strategies (ARDS)
1. PCV
2. Paw min
3. High RR
4. Low Vt
5. PEEP <10
6. Paw < 30
7. I/E 1:1

Question 11

THORACICS – Right pneumonectomy pre-op assessment

[07A07] A 65 year old man with a 40 pack a year history of smoking is scheduled for right pneumonectomy for carcinoma. Describe your preoperative evaluation of his respiratory system to decide his capacity to undergo this operation.

Answer 11

3 legged stool
1. Resp mech
- FEV1>40% post op
2. Lung parenchymal fx
- DLCO post op >40%
3. Cardiopulm reserve
- VO2max > 15mL/kg/min

Preop FEV1
Pneumonectomy >2L
Lobectomy >1.5L

Fx
1. 6MWT
- 450m = 15ml/kg/min = 4 MET = 2FOS
* >660m = low risk

2. CPEx / CPET
   VO2 > 15mL/kg/min = low risk
   * <10mL/kg/min = high risk

CONSULT resp
1. COPD
2. Smoking cessation

3. Post op HDU/ICU