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Advanced Principles III > Thoracic Anesthesia > Flashcards

Thoracic Anesthesia Flashcards

1
Q

When are thoracic surgeries indicated?

A
  • Malignancy
    • pulmonary
    • esophageal
    • mediastinal
  • Infections
    • empyema
    • lung absess
  • End stage lung disease
    • lung volume reduction
    • lung transplantation
  • ***An operable person is someone who can tolerate the proposed resection with acceptable risk
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2
Q

What are the common complications?

What are the risk factors for complications?

A
  • Complications
    • 3-4%mortality
    • atelectasis
    • pneumonia
    • respiratory failure
    • cardiac (arrhythmia and ischemia
  • Risk factors
    • advanced age
    • poor general health
    • COPD
    • BMI > 30
    • low FEV1
    • low PPO (predictive post-op function
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3
Q

Small cell carcinoma:

prognosis?

treatment?

How does it originate?

A
  • Poor prognosis, usually not resectable and metastatic on presentation
    • survival is about 3 months after diagnosis
  • Usually not candidates for surgery
    • chemo/radiation
  • Neuroendocrine origin
    • Lambert-Eaton Myasthenic syndrome
    • SIADH- hyponatremia
    • Hypercortisolism
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4
Q

What is Lambert-Eaton Myasthenic Syndrome?

A
  • paraneoplastic syndrome caused by impaired release of acetylcholine from nerve terminals
  • presents as proximallower limb weakness and fatigability that may temporarily improve with exercise
  • Pts are extremely sensitive to nondepolarizing muscle relaxants
    • Respond poorly to acetylcholinesterase inhibitors such as neotigmine
    • diaphragm and muscles of respiration may be involved.
  • **Thoracic epidural can be used in these pts without complication
  • Neuromuscular fxn may improve after resection of lung cancer
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5
Q

Non-Small cell lung cancer

types?

prognosis?

A
  • Types:
    • squamous cell
    • adenocarcinoma
    • **Can have big masses->SVC syndrome
  • Prognosis is variable; cancer is slow growing
    • surgery usually considered
    • <50% survive 5 years
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6
Q

What are the anesthetic considerations for different types of lung cancer? (table)

Squamous cell

Adenocarcinoma

Large cell

Small cell

Carcinoid

A
  • **of note, SCLC carcinoid tumors are the most malignant form of carcinoid tumors
    • be prepared to deal with severe hypotension that will not respond to usual drugs
    • be prepared to treat with octreotide or somatostatin
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7
Q

What should be included in your pre-op assessment for all thoracic surgery patients?

A
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8
Q

What are your anesthetic considerations for pts with lung cancer?

A
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9
Q

What are the problems with pts how took these medications?

Bleomycin?

doxorubicin?

cisplatin?

A
  • Bleomycin- can have oxygen toxicity, keep O2 low
  • Doxorubicin- can have cardiac toxicity
  • Cisplatin- can have renal toxicity
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10
Q

What types of symptoms might a pt with a lung tumor have?

A
  • Bronchopulmonary
    • involvement of the lung: cough, dyspnea
  • Extrapulmonary intrathoracic- tumor growth beyond the confines of the lung
    • pleural effusion, chest wall pain, dysphagia
  • Extrathoracic Metastatic- tumor spread outside the thorax
    • brain, skeletal, kidney, lymph, skin
  • Extrathoracic Non-metastatic- paraneoplastic syndrome
    • endocrine or endocrine -like syndrome, Cushings disease, hypercalcemia, SIADH, Lambert-Eaton
  • Non-specific
    • weight loss, anemia, anorexia, malaise, vague cold-like symptoms
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11
Q

What should be included on the pre-op physical assessment?

A
  • Physical exam: inspection, palpation, auscultation, percussion
  • Exercise tolerance: primary determinant of outcome in older pts
  • Laboratory tests:
    • routine labs
    • sputum gram stain
    • culture and cytology
    • LFTs
    • ABGs
  • Chest radiograph
  • PFTs
  • pre-op bronchoscope
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12
Q

Which CXR findings have specific anesthesia implications?

(6)

A
  • Tracheal deviation and obstuction-
    • difficulty with intubation or ventilation
  • Mediastinal mass-
    • difficulty with intubation and ventilation
    • SVC syndrome compression of PA
  • Pleural effusions
    • decreased VC and FRC
  • Cardiac enlargement
    • susceptible to depressant effects of the heart
  • Bullous cyst
    • prone to rupture
  • Parenchymal reticulation consolidation
    • prone to atelectasis edema
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13
Q

Wha is the three legged stool of pre-thoracotomy respiratory assessment? (chart)

A
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14
Q

Who needs PFTs?

A
  • Pts with evidence of COPD
  • smokers with hx of persistant cough
  • Pts with hx of wheezing or DOE
  • Restrictive lung dx: chest wall or spinal deformities
  • morbidly obese
  • upper abdominal surgery candidates
  • thoracic surgery candidates
  • pts >70 yrs
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15
Q

What are the different lung volumes and capacities?

(chart)

A
  • TV- volume inhaled and exhaled with normal breath
  • IRV- volume that can be maximally inhaled beyond nml TV
  • ERV- maximal volume of air that can be exhaled beyond nml TV
  • RV- volume of air that remains in the lung after maximal expiration
  • TLC- sum or IRV, TV, ERV, and RV
  • VC- sum of IRV, TV, and ERV
  • IC- sum of IRV and TV
  • FRC- volume of air in the lung at the end of a normal expiration and is the sum of RV and ERV
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16
Q

What are the different phases of PFT testing?

A
  • Phase I- Whole lung test
    • detect abnormalities of gas exchange
    • detect abnormalities of lung size, chest wall, mechanical aspects of ventilation
  • Phase II- Split lung testing
    • details the fxn of each lung separately
  • Phase III- Post0op condition of pt is simulated via temporary balloon occlusion of the majory pulmonary artery on that side
17
Q

Vital capacity:

What is it?

What is normal?

What decreases VC?

A
  • Vital capacity is deep maximal inspiration followed by maximal exhalation “slow and relaxed”
    • VC = IRV + TV + ERV or VC = TLC - RV
  • Normal is >/= 80% of predicted value (based on height, age, and gender)
  • VC is decreased:
    • going from sitting to supine position
    • restrictive lung disease
    • loss of distensible lung tissue
    • whenever maximal inspiration or axhalation is not achieved
18
Q

Forced Vital Capacity:

What is it?

How is it interpreted?

A
  • Maximal inspiration followed by rapid forceful exhalation
    • reflects flow resistance in the airway
    • measured as volume/time
  • Interpretation of % predicted:
    • 80-120% normal
    • 70-79% mild
    • 50-69% moderate
    • <50% severe
  • ** little to no difference btwn VC and FVC in nml pts
    • low FVC signifies airtrapping or small airway collapse
19
Q

FEV1

What is it?

Normal?

A
  • FEV1 is the forced expiratory volume in the first second of the FVC measurement
    • Normal is 75-80% of FVC (declines with age)
  • Most valid test for postop respiratory complications is ppoFEV1
    • ppoFEV1 %= preop FEV1 x (1-% functional lung tissue removed/100)
20
Q

What are the lung lobe segments used to calculate ppoFEV1?

(pic)

A
21
Q

How is the FEV1/FVC ratio interpreted?

How does this test differ between restrictive and obstructive disease?

A
  • >75% = normal
  • 60-70% = mild
  • 50-59% = moderate
  • <49% = severe obstruction
  • ***FEV1/FVC ratio is normal in restrictive disease because both the FEV1 and FVC decrease, whereas in obstructive disease the ratio is usually low because the FEV1 is markedly decreased
22
Q

What is FEF25-5%?

How is it interpreted?

A
  • Forced expiratory flow 25-75%
    • mean forced expiratory flow during middle of FVC
    • may reflect effort independent expiration and the status of the small airways
    • sensitive in early stages of obstructive disease
    • more reliable than FEV1/FVC ratio
  • Interpretation of % precicted:
    • >60% normal
    • 40-60% mild
    • 20-40% moderate
    • <10% severe obstruction
23
Q

What would you expect to see for your FEV1, FVC, and FEV1/FVC values in:

Obstructive disease

restrive disease

muscle weakness

A
24
Q

What is MVV?

A
  • Maximum voluntary ventilation is the largest volume that can be breathed per minute by voluntary effort
  • requires high rate of air flow, changes in aw resistance alter MVV
  • MVV is ​reduced in obstructive disease, normal in restrictive disease
  • MVV correlates to FEV1
    • FEV1 x 35 ≈ MVV
  • Normal is >50% of predicted values
25
Q

What factors affect MVV?

A
  • Patient effort (motivation, coordination)
  • Elastic properties of the lung
  • chest wall abnormalities
  • Respiratory muscle strength
26
Q

What is closing volume?

When do you see it elevated?

A
  • Closing volume is the lung volume at which airways begin to close or stop contributing to the expired gas
  • In the sitting position CV for health ppl is about 15-20% of VC
  • CV is elevated in smokers!
    • reflects the loss of elastic recoil and/or small airway pathology
27
Q

PFTs in restrictive and obstructive lung disease: (table)

definition

FVC

FEV1

FEV1/FVC

FEF25-75%

FRC

TLC

A
28
Q

What is a significant result regarding the maximum oxygen consumption (VO2max) during exercise testing?

What is DCLO?

A
  • Decrease of 4% during exercise is considered high risk
  • Pre-op VO2max < 15 ml/kg/min is high risk
  • DLCO (diffusing capacity) is the ability of the lung to perform gas exchange (pt inhales CO)
    • <40% of postop predicted value is high risk
    • **DLCO is a better predictor of complications than FEV1 in pts who have received chemotherapy
29
Q

How can we estimate the VO2max?

A
  • 6 minute walk test in meters / 30
    • ex. 6 minute walk of 450 meters/30 = 15 ml/kg/min
  • Pts with decrease in Spo2 > 4% during exercise are also at increased risk
30
Q
A

Advanced Principles III (3 decks)

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