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Advanced Principles C > Thoracic Anesthesia I > Flashcards

Thoracic Anesthesia I Flashcards

1
Q

Number of lobes on the right lung?

A

3 lobes

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2
Q

Number of lobes on the left lung?

A

2 lobes

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3
Q

Number of segments on the right lung?

A

22 segments

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4
Q

Number of segments on the left lung?

A

20 segments

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5
Q

Define FEV1

A
  • Forced expiratory volume in 1 second
  • Amount of expired air in the first second after full inspiration
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6
Q

What is FEV1% Predicted?

A

Compares the actual total volume breathed out during the test to an average of the normal total volume for a person of the same gender, height, and age.

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7
Q

What is the normal range of FEV1% Predicted?

A

80-120%

FEV1% Predicted has a strong correlation with post-op outcomes

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8
Q

How is Predicted Postoperative FEV1% (PPO FEV1%) Calculated?

A

Preop FEV1% X (1- % of lung tissue removed/100)

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9
Q

What would be the PPO FEV1% if FEV 1% is 70% and 25% of lung tissue is surgically removed?

A

52%

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10
Q

What PPO FEV1% correlates with an increased risk of pulmonary complication?

What PPO FEV1% is considered high risk?

A
  • <40% → Increased risk
  • <30% → High risk
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11
Q

What PaO2 and PCO2 are associated with poor surgical outcomes?

A
  • PaO2 < 60 mmHg
  • PCO2 > 45 mmHg
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12
Q

What is the most useful pulmonary test for determining gas exchange capacity?

A

Diffusing Lung Capacity for Carbon Monoxide (DLCO)

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13
Q

How is the DLCO PFT performed?

A
  • Carbon Monoxide has a high affinity for Hgb
  • A small amount of CO is inhaled with a tracer gas (helium or methane)
  • After inhalation of the gas, the patient will exhale into an analyzer
  • The analyzer will determine how much CO was picked up by the lungs
  • This will correlate with total functioning surface are of alveolar/capillary interference
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14
Q

What is the absolute minimum value of FEV1 or DLCO for a successful outcome in thoracic surgery?

A

No less than 20%

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15
Q

What is the ideal V/Q ratio?

What is typically the V/Q ratio?

A
  • 1.0 (ideal)
  • 0.8 (typical)
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16
Q

What 3 factors is the V/Q ratio dependent on?

A
  • Position (gravity)
  • Pathology
  • Situation
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17
Q

Blood flow in the lungs is ____________ dependent

A

Gravity

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18
Q

Pulmonary ___________ pressure is always greater than Pulmonary ________pressure

A

Pulmonary artery pressure is always greater than Pulmonary venous pressure

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19
Q

Absolute pressure of Pa and Pv is greater in the dependent portion of the lung due to _____________

A

Hydrostatic gradients

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20
Q

The base of the lung has a ________ mmHg increase in blood flow relative to the apex of the lung in an upright position.

A

20 mmHg

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21
Q

Rank PA, Pa, and Pv in Zone 1

A

PA > Pa > Pv

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22
Q

Rank PA, Pa, and Pv in Zone 2

A

Pa > PA > Pv

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23
Q

Rank PA, Pa, and Pv in Zone 3

A

Pa > Pv > PA

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24
Q

How many cm above the heart is Zone 2?

A

3 cm

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25
Q

Which zone will have the alveoli maximally distended?

A

Zone 1

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26
Q

Which zone will have complete compression of the capillary?

A

Zone 1

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27
Q

Which zone will have the most dead space?

A

Zone 1

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28
Q

In Zone 2, _________ pressure is greater than PA and ________ pressure is less than PA

A

In Zone 2, systolic pressure is greater than PA and diastolic pressure is less than PA

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29
Q

This zone will have less distended alveoli, but greater intrapleural pressure.

A

Zone 3

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30
Q

This zone will have continuous blood flow and is not affected by the cardiac cycle?

A

Zone 3

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31
Q

Which zone is most affected by the cardiac cycle?

A

Zone 2

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32
Q

This zone is absent in healthy patients

A

Zone 1

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33
Q

How is Zone 1 developed?

A
  • Positive Pressure Ventilation (↑ PEEP/ ↑Alveolar Pressure)
  • Decrease Arterial Pressure (Hemorrhage, Shock, Hypovolemia)
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34
Q

For an accurate measurement of PCWP, which zone must the pulmonary artery catheter be placed in?

A

Zone 3, where there is a continual column of blood

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35
Q

Which PFT is used to determine whether lungs are obstructive, restrictive, or normal?

A

FEV1/FVC Ratio

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36
Q

What is normal FEV1/FVC?

A

70-85%

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37
Q

FEV1/FVC Ratio of Obstructive Pattern

A

Decreased

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38
Q

FEV1/FVC Ratio of Restrictive Pattern

A

Normal

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39
Q

TLC of Obstructive Pattern

A

Normal or Increased d/t air trapping

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40
Q

TLC of Restrictive Pattern

A

Decreased

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41
Q

Patho of Obstructive Lung Disease

A

Damage to the lung tissue or narrowing of the airways causes air trapping and difficulty expelling air from the lungs

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42
Q

What are the most common Obstructive Lung Diseases

A
  • COPD (chronic bronchitis, emphysema)
  • Asthma
  • Cystic Fibrosis
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43
Q

What is the most common comorbidity in thoracic surgical patients?

A

COPD

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44
Q

Clinical presentation of COPD

A
  • Compromised pulmonary mechanics
  • Hypercapnia
  • Dyspnea
  • Hypoxia
  • O2 therapy commonly required
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45
Q

Patho of Restrictive Lung Disease

A
  • Stiffness in lung tissue, chest wall, or weak muscles.
  • Cannot fully fill lungs with air
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46
Q

What are the most common Restrictive Lung Disease?

A
  • Interstitial Lung Disease
  • Pulmonary Fibrosis
  • Sarcoidosis
  • Obesity (hypoventilation syndrome)
  • Neuromuscular diseases
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47
Q

What is the leading cause of cancer deaths?

A

Lung Cancer

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48
Q

Causes of lung cancer

A
  • Smoking
  • Environmental factors (asbestos, gas, metals)
49
Q

What are the two types of lung cancer?

A
  • Small cell lung cancer
  • Non-small cell cancer
50
Q

Characteristics of Small Cell Lung Cancer

A
  • Fast growing
  • Aggressive
  • Commonly caused by smoking
  • Usually starts in the bronchi
  • Frequently metastasized
51
Q

Characteristics of Non-Small Cell Lung Cancer

A
  • Less aggressive
  • Affects both smokers and non-smokers
  • More common
  • Better prognosis
52
Q

Lung Cancer Signs and Symptoms

A
  • Cough
  • Hemoptysis
  • Wheezing
  • Stridor
  • Dyspnea
  • Airway obstruction
  • Hoarseness
  • Superior vena cava syndrome
  • Pleural effusion
  • Congestive heart failure
53
Q

How are central/endo-bronchial lesions diagnosed?

A

Cytology analysis of sputum using flexible fiberoptic bronchoscopy

54
Q

How are peripheral/pleural lesions diagnosed?

A
  • CT scan
  • Percutaneous fine needle aspiration
  • VATS
55
Q

Lung Cancer Treatment Options

A
  • Radiation
  • Chemo +/- radiation
  • Surgical resection
56
Q

What treatment is effective for small-cell lung cancer?

A

Radiation (small cell very radiosensitive)

57
Q

Procedure where the entire lung is removed

A

Pneumonectomy

58
Q

Procedure where one lobe is removed

59
Q

Procedure where there is partial lobe removal

A

Resection (sleeve, wedge, segment)

60
Q

What is Pleurodesis?

A

A medical procedure that treats fluid or air buildup in the pleural space, the space between the lung and chest wall

61
Q

Indications for a thoracotomy

A
  • Pneumonectomy
  • Lobectomy
  • Advanced malignancy
  • Hemorrhagic complications
62
Q

What are the different approaches to a thoracotomy? Which one will be the most common?

A
  • Sternotomy
  • Anterolateral (Most Common)
  • Posterolateral
63
Q

Indications for Video-Assisted Thoracic Surgery (VATS)

A
  • Pleural surgery
  • Undiagnosed nodules
  • Interstitial disease
  • Lobectomy
64
Q

VATS Benefits

A
  • Reduced hospital stay
  • Less blood loss
  • Less pain
  • Better postop pulmonary function
  • May be done robotically
65
Q

Purpose of One Lung Ventilation

A
  • Immobile Surgical Field
  • Access/ Visibility
  • Prevent fluids/secretions from contaminating non-operative lung
66
Q

What is lung separation

A

ADEQUATE lung deflation

67
Q

What is lung isolation

A

COMPLETE lung deflation

68
Q

What type of tube is typically used for OLV?

A

A Double Lumen Endotracheal Tube (DLT), usually left-sided to avoid obstructing the right main bronchus.

69
Q

When is a right-sided DLT preferred?

A

When a left pneumonectomy or left upper lobe surgery is planned or if the left bronchus has structural issues like a tumor or aneurysm.

70
Q

Typical DLT size for women

A

35 or 37 Fr

71
Q

Typical DLT size for men

72
Q

What are the key steps in placing a DLT?

A

Lubricate the tube, insert under direct vision or with a scope, rotate 90° as needed, advance into the trachea, inflate cuffs, and verify placement.

73
Q

How much air is inflated into the tracheal cuff?

74
Q

How much air is inflated into the bronchial cuff?

75
Q

How is DLT placement confirmed?

A

Placement is confirmed with fiberoptic bronchoscopy to ensure the bronchial cuff is below (5-10 mm) the carina in the target bronchus.

76
Q

What is a bronchial blocker, and when is it used?

A

A catheter with an inflatable balloon that occludes a bronchus, used for selective lung isolation, especially if DLT placement is challenging.

77
Q

Name a specific case where a bronchial blocker would be used.

A

In patients with difficult airways or when nasotracheal intubation with OLV is necessary.

78
Q

When should you confirm the placement of DLT?

A
  • Immediately after placement
  • Immediately after positioning
79
Q

What should be clamped when deflating one side of the DLT?

80
Q

What can be used to deflate the lung completely?

A

Suction catheter

81
Q

What should be the tidal volume of the non-operative lung during OLV?

82
Q

How should FiO2 be administered during OLV?

A

Judiciously, aiming to avoid hyperoxemia, with a target oxygenation of 88-95% to minimize absorption atelectasis.

83
Q

If the patient is on this medication, do not administer 100% FiO2 because of O2 toxicity.

84
Q

What are ways to increase O2 saturation during OLV?

A
  • CPAP to non-dependent lung
  • PEEP to dependent lung (5cm H2O)
  • Recruitment manuevers
85
Q

What physiological change occurs during OLV?

A

A right-to-left shunt occurs, potentially causing relative hypoxemia due to blood bypassing the deflated lung.

86
Q

How is the right-to-left shunt lessened during thoracic surgery?

A
  • Surgical manipulation, obstruct flow to operative lung
  • Lateral positioning, increase perfusion to ventilated lung
  • Hypoxic pulmonary vasoconstriction in the operative lung
87
Q

What is Hypoxic Pulmonary Vasoconstriction (HPV)?

A

A response where hypoxic alveoli trigger vasoconstriction, directing blood to better-ventilated areas, enhancing V/Q matching.

88
Q

What factor increases perfusion in the dependent lung?

89
Q

What factors decrease ventilation in the dependent lung?

A
  • Expansion of dependent lung limited by weight of mediastinum
  • Expansion limited by non-compliance of thoracic wall pressed on OR bed

increase risk of atelectasis

90
Q

Do you want to decrease HPV in the operative lung?

A
  • No
  • Decrease HPV to the operative lung will increase shunt and worsen oxygenation
91
Q

What factors can decrease HPV during anesthesia?

A
  • Volatile anesthetics >1 MAC
  • Hypocapnia
  • Alkalosis
  • Hypothermia
  • Vasodilators
92
Q

What are common OLV complications?

A
  • Hypoxemia
  • Bronchospasm
  • Hypoventilation
  • Malpositioning
  • Airway trauma from the large DLT
93
Q

How is hypoxemia managed intraoperatively during OLV?

A
  • Increase FiO2
  • Perform alveolar recruitment maneuvers
  • Resume two-lung ventilation if necessary.
94
Q

What steps are taken if hypoxemia persists during OLV?

A
  • Communicate with the surgical team
  • Resume two-lung ventilation
  • Manage hemodynamics
  • Possible pulmonary artery ligation
95
Q

What is the best predictor of difficult DLT placement?

A

Preoperative CXR

96
Q

What is the gold standard for measuring physical activity?

97
Q

What is the ideal minimum for VO2max in thoracic surgery patients?

What VO2 max will have an increased risk of complications?

A
  • VO2 max >20 ml/kg/min
  • VO2 max <15 ml/kg/min will have an increased risk
98
Q

Complications will decrease with smoking sessions of _______ weeks

99
Q

Carboxyhemoglobin concentration decreases after ______ hours of smoking cessation.

100
Q

Smoking causes prolonged tissue _________

101
Q

Who will be high-risk thoracic surgery patients and have increase possibility of postop ventilatory support?

A
  • Advanced age
  • Malnutrition/frail/poor general health
  • COPD
  • Pulmonary HTN
  • Obesity
  • Low FEV1
  • Low VO2Max/Low exercise tolerance
  • Dyspnea
  • Smoking
102
Q

How long should thoracic surgery be delayed after bare metal stenting?

103
Q

How long should thoracic surgery be delayed after drug-eluting stenting?

104
Q

What is the most common concurrent disease with thoracic surgery?

105
Q

Considerations for COPD patients undergoing thoracic surgery

A
  • Assessment of severity made with FEV1 predicted
  • ABG analysis to monitor hypercapnia
  • Supplemental O2 to maintain PaO2 60-65
106
Q

Why will patients with RV failure not tolerate positive pressure ventilation?

A

Can not tolerate a sudden increase in RV afterload

107
Q

What arrhythmia will most likely develop within the first week after thoracic surgery?

A

Atrial Fibrillation

108
Q

Causes of Atrial Fibrillation

A
  • Increased Pulmonary Vascular Resistance
  • Right heart strain
  • Increased sympathetic stimuli
  • Transient hypoxemia
  • O2 demand increased
  • Blood loss
109
Q

Why is an arterial line typically used during thoracic surgery?

A
  • Monitor transient compression of heart/great vessels
  • Beat-to-beat assessment
  • Serial ABG’s
110
Q

Central lines are typically reserved for these thoracic surgeries.

A

Pneumonectomies/redo thoracotomies

111
Q

What anesthetic agent should be avoided in thoracic surgery due to the risk of absorption atelectasis?

A

Nitrous Oxide

112
Q

What nerve injury is common in thoracic surgery?

A

Brachial plexus injury

113
Q

What are 2 ways to avoid acute lung injury in thoracic surgery?

A
  • Avoid fluid overload
  • Avoid hyperinflation
114
Q

Postoperative Analgesic Options for Thoracic Surgery Patients

A
  • Ketamine
  • Precedex
  • PCA pump
  • Opioids
  • Paravertebral/Intercostal blocks
  • Anti-inflammatories
  • Thoracic epidural
115
Q

Pulmonary complications from thoracic surgery

A
  • Atelectasis
  • Pneumonia
  • Respiratory failure (15-20% of pts)
116
Q

How does one-lung ventilation impact the right ventricle (RV)?

A

↑ RV Pressure → RV Dysfunction

117
Q

Which ventilation mode is less inflammatory? PCV or VCV?

118
Q

The benefit of using a thoracic epidural for thoracic surgery

A

Loss of vasomotor tone and peripheral venous pooling will significantly decrease RV preload.

Advanced Principles C (11 decks)

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