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AS - N934 Advanced Principles II > Thoracic Anesthesia > Flashcards

Thoracic Anesthesia Flashcards

1
Q

What does V/Q mismatching lead to?

A

HYPOXIA

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2
Q

Awake Patient

A 
Spontaneous respirations, upright position, & closed chest
Lungs apex maximally dilated
1° ventilation occurs at base
Perfusion also prefers the base
V/Q match preserved
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3
Q

Awake Patient in the Lateral Decubitus Position

A

Spontaneous respirations, lateral decubitus position, & closed chest
V/Q matching preserved
Dependent lung receives > ventilation & perfusion than the upper (non-dependent) lung
Diaphragm displacement cephalad

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4
Q

Anesthetized Paralyzed Patient in the Lateral Decubitus Position

A 
Positive-pressure ventilation, lateral decubitus position, & closed chest
Paralysis = PPV
Non-dependent lung ↓resistance
↓FRC
V/Q mismatch
Dependent lung ↑perfusion
Non-dependent lung ↑ventilation
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5
Q

Anesthetized Patient Spontaneous Respirations in the Lateral Decubitus Position w/ Open Chest

A

Spontaneous breathing, lateral decubitus position, & open chest (ex: trauma)
V/Q mismatch ↑shunt
Dependent lung ↑perfusion
Upper long collapse → progressive hypoxemia
- Mediastinal shift
- Paradoxical respirations

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6
Q

Anesthetized Paralyzed Patient in the Lateral Decubitus Position w/ Open Chest

A

Positive pressure ventilation, lateral decubitus position, & open chest (2 lung ventilation)
PPV worsens V/Q mismatch
Non-dependent lung ↑ventilation > perfusion
Dependent lung ↑perfusion > ventilation

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7
Q

HPV

A

Hypoxic pulmonary vasoconstriction
Diverts blood AWAY from hypoxic lung regions
↓blood flow to the non-ventilated lung
Improves arterial oxygen content → improves hypoxemia
↓shunt

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8
Q

Normal Pulmonary Blood Flow

A

Average BOTH lungs being non-dependent (upper)
40%
60%

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9
Q

What factors inhibit HPV?

A

↑pulmonary vascular resistance (↑PAP, volume overload, mitral stenosis)
Hypocapnia (alkalosis or ↓CO2)
↑↓mixed venous PO2
Vasodilators - Nitroglycerin, sodium nitroprusside, β agonists (Dobutamine), Ca2+ channel blockers
Pulmonary infection
Inhalational anesthetics 1 MAC = 4-6% ↑intrapulmonary shunt
Hypothermia

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10
Q

One-Lung Ventilation

Advantages

A

Improved operating conditions & visibility
Facilitates access to the aorta & esophagus
Prevents cross-contamination w/ abscess, secretions, & blood
Press anesthesia gases loss w/ bronchopleural fistula

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11
Q

One-Lung Ventilation

Relative Contraindications

A 
Difficult airway w/ poor larynx visualization
Lesion in the bronchial airway precluding bronchial intubation
Thoracic aortic aneurysm
Pneumonectomy
Lobectomy
Thoracotomy or thoracoscopy
Sub-segmental resections
Esophageal surgery
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12
Q

One-Lung Ventilation

ABSOLUTE Contraindications

A 
Pulmonary infection
Copious bleeding on one side
Bronchopulmonary fistula
Bronchial rupture
Large lung cyst
Bronchopleural lavage
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13
Q

Adult Trachea

A

11-12cm
Begins at cricoid cartilage (C6)
Bifurcates at the sternomanubrial joint (T5)

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14
Q

R Bronchus

A

Wider (more common to R mainstem)
Diverges away from trachea at 20-25° angle (less acute as compared to L)
RUL orifice sits only 1-2cm to carina
R double-lumen ETT has Murphy eye to ventilate RUL

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15
Q

L Bronchus

A

Narrower
Diverges away from trachea at 40-45° angle
LUL orifice sits about 5cm distal to the carina

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16
Q

Double-Lumen Tube Sizing

A

Short 4’6”-5’3” → 35-37Fr
Medium 5’3”-5’7” → 37-39Fr (most commonly used size 39Fr)
Tall >5’7” → 41Fr

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17
Q

DLT Insertion Technique

A

Curved bladed provides optimal space
Insert w/ blue bronchial tube upward
Rotate 90° towards side to be intubated after tip enters the larynx
Insertion depth 28-29cm at the teeth

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18
Q

Tracheal Cuff

A

5-10mL air

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19
Q

Bronchial Cuff

A

1-2mL air

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20
Q

When to check DLT placement w/ fiberoptic scope?

A

After initial placement

Re-check after positioning patient for surgery in the lateral decubitus position

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21
Q

Where to clamp the DLT?

A

Clamp on the double-lumen connector piece closer to the circuit
Allows lung deflation via port

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22
Q

DLT Complications

A

Advanced too deep (L DLT → excludes R lung from ventilation)
Not inserted far enough
Bronchial tube advances on wrong side
R DLT Murphy eye does not properly align w/ RUL
Bronchial cuff herniation across carina

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23
Q

R DLT Indications

A

Thoracic aortic aneurysm resection
Tumor in the L mainstem bronchus
L lung transplantation or L pneumonectomy (not absolute indication)
L-sided tracheobronchial disruption

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24
Q

R DLT Placement Confirmation

A

Fiberoptic scope
View down both L tracheal lumen & R bronchial lumen
Ensure the Murphy eye aligns w/ RUL to provide adequate ventilation & prevent atelectasis
Retroflex the fiberoptic scope to visualize the RUL via the Murphy eye

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25
Q

Bronchial Blocker

Advantages

A

Patients who require intubation postop do not have to exchange ETT to single lumen

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26
Q

Bronchial Blocker

Disadvantages

A

Blocked lung collapses slowly & sometimes incompletely d/t small channel size w/in the blocker
Apply suction or syringe to pull back air & help deflate the lung

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27
Q

Univent Bronchial Blocker

A

ETT placed w/ blocker fully retracted
Rotate ETT 90° towards the operative side
Push the bronchial blocker into the mainstem bronchus under direct visualization
High-pressure low-volume cuff → use minimum volume to prevent leak

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28
Q

Lung Resection Indications

A

Diagnose & treat pulmonary tumors
Necrotizing pulmonary infections
Bronchiectasis

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29
Q

Preop Testing

A
  • CXR
  • Chest CT
  • EKG/cardiac clearance
  • ABG
  • PFTs
  • Ventilation-perfusion tests
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30
Q

FEV1

A

Forced expiratory volume in 1 second
> 2L or 80% predicted = low risk
< 2L or 40% predicted = high risk

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31
Q

FEV1/FVC

A

Normal = 75-80%

High risk patients < 50% predicted

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32
Q

High Risk Pneumonectomy Patients

A 
ABG PaCO2 > 45mmHg on RA & PaO2 < 50mmHg
FEV1 < 2L or < 50% predicted
FEV1/FVC < 50% predicted
Maximum O2 uptake (VO2) < 10mL/kg/min
Maximum voluntary ventilation < 50% predicted
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33
Q

Split-Lung Function Tests

A

Uses radio-labeled albumin to calculate predicted pulmonary function, postop outcome, & survival after pneumonectomy
Predicts isolated lung FEV1 after the other lung removed
Postop FEV1 = preop total FEV1 x % blood flow to the remaining lung
Minimal predicted postop FEV1 necessary for long-term survival = 800-1,000mL

34
Q

Small Cell Lung Carcinoma

A

Lambert-Eaton myasthenic syndrome (LEMS) ↑muscle weakness d/t ↓Ca2+ levels at the NMJ
Carcinoid syndrome

35
Q

Lung Oat Cell Carcinoma

A

Small cell lung carcinoma
SIADH ↓UOP, hypervolemia, hyponatremia
CHF
Pulmonary edema

36
Q

Non-Small Cell Lung Carcinoma

A

Ectopic parathyroid hormone → Ca2+ problems

37
Q

Patients w/ Lung Cancer

ASSESSMENT

A

Mass effects - obstructive pneumonia, SVC syndrome, tracheo-bronchial distortion, RLN or phrenic nerve paralysis
Metabolic effects - LEMS, hypercalcemia, hyponatremia, Cushing syndrome
Metastases → brain, liver, bone, & adrenals
Medications - chemotherapy-induced lung/cardiac changes

38
Q

Thoracotomy

Preop Medications

A

Bronchodilators

Anticholinergics ↓secretions ↑HR to counteract Vagus nerve stimulation when pleura opened

39
Q

Thoracotomy

Monitoring & Equipment

A

Multiple size ETTs
Difficult airway cart w/ pediatric fiberoptic

A-line (place on dependent limb to monitor extremity perfusion)
CVP or PA catheter less common
PIV x2
Blood warmer & rapid infuser available
Type & cross PRBCs
40
Q

Lateral Decubitus Positioning

A

Axillary roll to protect brachial plexus

Ensure proper placement

41
Q

Thoracotomy

Postop Pain Management

A

Thoracic epidural

42
Q

One-Lung Ventilation

Anesthesia Management

A

Baseline ABG prior to one-lung ventilation
Maintain two-lung ventilation until pleura opened
Maximum anesthesia depth w/ chest opening & rib splitting
Operative lung deflated (clamp & open port; apply suction to help deflate as needed)
- 100% FiO2 to dependent lung
- Obtain ABG 15min after one-lung ventilation initiated
- Continue ABG Q30min-1hr
- Volume or pressure controlled
- Vt 5-6mL/kg
- RR 12-15bpm to maintain PaCO2 35-45mmHg
- PEEP 0-5mmHg

43
Q

What is the greatest risk associated w/ one-lung ventilation?

A

Hypoxemia

44
Q

One-Lung Ventilation

↑PIP

A

Check ETT position
Reduce Vt & ↑RR to maintain minute ventilation

Maintain peak airway pressures < 35cmH2O
Plateau airway pressures < 25cmH2O

45
Q

What patients should not receive PEEP?

A

COPD

46
Q

After deflating the lung, expect to see what vital sign change?

A

ETCO2 ↑1-3mmHg during one-lung ventilation

47
Q

Response to hypoxemia during one-lung ventilation:

ASSESSMENT & INTERVENTIONS

A

Confirm ETT placement
↑FiO2 100%
Check hemodynamic status → HoTN ↓SpO2 ↓ETCO2
+ 2-10cmH2O CPAP to the collapsed lung
Periodically inflate the collapsed lung w/ 100% oxygen (inform the surgeon)
+ 5-10cmgH2O PEEP to the dependent lung
Continuous insufflation to the collapse lung w/ 100% FiO2
Early ligation/clamping to the ipsilateral pulmonary artery (when performing pneumonectomy) ↑blood flow to one-lung & improves V/Q match

48
Q

One-Lung Ventilation Alternatives

A

Stop ventilation for short period & used 100% FiO2 insufflated at rate > O2 consumption
Apneic oxygenation 10-20min → progressive respiratory acidosis ↑PaCO2 6mmHg 1st min & 3-4mmHg each additional min
High frequency jet ventilation - low volumes w/ high pressure

49
Q

Emergence

A

Inflate lung to 30cmH2O
Valsalva requested per surgeon to check for leaks or microbleeding (watch monitor bradycardia)
Thoracostomy tubes places
Exchange DLT to single lumen prior to transporting to ICU when patient remains intubated after surgery (consider tube exchanger w/ DVL)

50
Q

Thoracic Anesthesia Complications

A 
Hypoxemia or respiratory acidosis
Postop hemorrhage
Arrhythmias (Afib most common)
Bronchial rupture
Acute R ventricle failure
Positioning injuries
51
Q

What contributes to the 1° complication postop thoracic surgery developing?

A

Hypoxemia & respiratory acidosis

Atelectasis & shallow breathing d/t incisional pain
Gravity dependent fluid transudation into the dependent lung

52
Q

Postop Hemorrhage S/S

A

Occurs in 3% thoracic surgery
Associated w/ 20% mortality

CT drainage > 200mL/min
Hypotension
Tachycardia
↓Hct

53
Q

What causes bronchial rupture?

A

Excessive bronchial tube cuff inflation

54
Q

Acute RV Failure S/S

A

Low CO
↑CVP
Oliguria

55
Q

VATS

A

Video-assisted thoracoscopic surgery
Uses video camera & surgical instruments inserted via port in the thoracic wall
Typically 3-5 ports
Staplers used to resect lung tissue & divide large blood vessels

56
Q

VATS

Indications

A 
Lung biopsy
Wedge resection
Hilar & mediastinal mass biopsy
Esophageal & pleural biopsy
Pericardiectomy
Pneumonectomy
57
Q

VATS

Advantages

A 
Smaller incision
No intraop rib spreading
Less postop pain
↓risk postop hypoxemia
Faster recovery & discharge from hospital
58
Q

VATS

Anesthetic Approaches

A

Local, regional (epidural), or general anesthesia
Two or one-lung ventilation

*General anesthesia most common approach

59
Q

VATS

Preop Evaluation & Planning

A

Discuss pain management options w/ patient

Consider conversion to open thoracotomy & consult surgeon Same preop evaluation as thoracotomy

60
Q

VATS

Intraop Anesthetic Management

A 
GA one-lung ventilation w/ DLT or bronchial blocker
Surgeon injects LA prior to placing ports
Lateral decubitus position
PIV x2
A-line 
ABG Q30min-1hr
Suction lung & gently re-inflate
Exchange DLT → single lumen
CT placed prior to closing
61
Q

VATS

Intraop Complications

A 
CO2 insufflation to improve surgical visualization → hemodynamic compromise or gas embolism enters venous circulation (VAE) 
Tension pneumothorax
Hemorrhage
Diaphragm or other organ perforation
Positioning & DLT complications
62
Q

Mediastinoscopy

A

Lymph node or tissue biopsy to diagnose lung carcinoma, thymoma, or lymphoma or to determine intrathoracic tumor resectability
Performed via small transverse incision above the suprasternal notch
Scope similar appearance to laryngoscope inserted anterior to the trachea to biopsy lymph nodes

63
Q

Mediastinoscopy

Anesthetic Considerations

A

Chest roll behind back to help facilitate head/neck extension
GETA
Innominate artery supplies R arm & R common carotid
Place A-line and/or Pox on R arm
Absent waveform indicates innominate artery compression → ask surgeon to reposition the scope
BP cuff on L arm
Central airway obstruction d/t trachea compression during induction or mediastinoscope manipulation near the trachea

64
Q

Mediastinal Tumors S/S

A

Often asymptomatic & discovered incidentally on CXR
Symptomatic masses are usually malignant w/ extensive involvement → airway obstruction, impaired cerebral circulation, anatomy distortion
Frequently associated w/ systemic syndromes
Cough, dyspnea, stridor, jugular distention, exaggerated BP changes associated w/ positioning
SVC syndrome

65
Q

SVC Syndrome

A

Progressive mediastinal tumor growth results in SVC compression → obstructs venous drainage into the upper thorax

66
Q

SVC Syndrome S/S

A

Venous distension in the neck, thorax, & upper extremities
Facial, conjunctiva, neck & upper chest edema
Mouth & larynx edema associated w/ severe airway obstruction
Mucosal edema & direct compression → cyanosis d/t compromise trachea airflow
Depressed CO d/t impeded upper body VR or direct mechanical heart compression from the tumor
Venous backflow into the upper extremity IV lines
↑ICP

67
Q

Mediastinoscopy

Relative Contraindications

A 
SVC syndrome
Previous medistinoscopy (scar tissue)
Airway obstruction & distortion
Impaired cerebral circulation
Myasthenic syndrome
68
Q

Mediastinoscopy

ABSOLUTE Contraindications

A

Inoperable
Coagulopathy (hemorrhage risk)
Thoracic aortic aneurysm

69
Q

Mediastinoscopy

Preop Considerations

A

Assess airway compromise S/S including dyspnea, tachypnea, tracheal deviation
CXR & CT scan
Assess tumor size & location
Evaluate tracheal distortion or compression
PFTs obtained in upright & supine position
Flow-volume loops detect airway obstruction
Patient able to lay flat?
SVC obstruction or impaired cerebral circulation
Muscle relaxants, coughing & breath holding, and/or position changes potential to worsen symptoms

70
Q

Mediastinoscopy

Monitoring & Equipment

A

PIV x2
Consider placing in lower extremities d/t SVC syndrome
Monitor R radial pulse (doppler, A-line, Pox)
BP cuff on L arm
PNS

71
Q

Mediastinoscopy

Anesthetic Management

A

Deep anesthesia to blunt autonomic reflexes
Avoid N2O & monitor for pneumothorax
Innominate, R subclavian, or R carotid artery compression → distal pulse loss & postop neuro deficits
RLN or phrenic nerve injury
Vagal-mediated reflex bradycardia d/t trachea or vessels compression

72
Q

Mediastinoscopy

Emergence

A

4/4 twitches
Airway reflexes present
SVC syndrome patients awake to prevent obstruction
Postop CXR on ALL patients to r/o pneumothorax

73
Q

Mediastinoscopy

COMPLICATIONS

A 
Mediastinal hemorrhage 
Pneumothorax
RLN injury
Phrenic nerve injury or L hemiparesis
Esophageal injury
Air embolism → HOB elevated 30°
Dysrhythmias
Acute airway obstruction
74
Q

Mediastinal Hemorrhage

A

Most common complication
Prevention → limit IVF especially in SVC syndrome patients
↑CVP ↑risk

75
Q

Pneumothorax

A

2nd most common mediastinoscopy complication

76
Q

RLN Injury

A 
3rd most common mediastinoscopy complication
NIMS tube provides nerve monitoring
- Place w/ video laryngoscope
Monitor postop respiratory status
Hoarseness or vocal cord paralysis
77
Q

Acute Airway Obstruction

A

Prolonged tumor cause tracheal malasia leading to tracheal collapse → GA w/ reinforced ETT
Place patient in lateral, reverse Trendelenburg, prone, or high Fowlers position to help shift mass away from the trachea or SVC & relieve the obstruction

78
Q

Difficult Intubation and/or Ventilation

A

Various ETT sizes, establish ability to ventilate BEFORE muscle relaxation, & provide intraop muscle relaxation to prevent coughing/straining

79
Q

Interventions to implement that ↓respiratory complications incidence in high risk patients undergoing thoracic surgery:

A

Smoking cessation
Physiotherapy
Thoracic epidural analgesia

80
Q

Patients undergoing pulmonary resection preop evaluation:

A

3 parts

  • Lung mechanical function
  • Pulmonary parenchymal function
  • Cardiopulmonary reserve
81
Q

What patient population is at an increased risk for cardiac complications, particularly arrhythmias, after pulmonary resections?

A

Geriatric patients

Best predictor post-thoracotomy outcome in the elderly = preop exercise capacity

AS - N934 Advanced Principles II (18 decks)

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