Thoracic Anesthesia II Flashcards
What are the main purposes of bronchoscopy?
- Visualization of airways
- Tissue biopsies
- Sputum sampling
- Hemostasis
- Object removal
- Lavage
What is an EBUS?
Endobronchial Ultrasound (EBUS) is a bronchoscope with an ultrasound probe for examining nearby lymph nodes.
What types of anesthesia are used for bronchoscopy?
- GETA/LMA (+/- paralysis)
- MAC
- TIVA
Why is TIVA preferred over volatile anesthetics for bronchoscopy?
TIVA avoids issues with anesthetic depth and operating room pollution from repeated circuit opening.
What is ION bronchoscopy?
A robotic bronchoscopy that uses imaging and robotic algorithms for precise biopsy targeting.
What are key anesthesia requirements for ION bronchoscopy?
- GETA with large ETT (size ≥ 9.0)
- low FiO2
- Room air induction
- Paralysis
- High tidal volume and PEEP
- TIVA preferred
Why is low FiO2 preferred in Ion Bronchoscopy?
By keeping FiO₂ at or below 0.8, there is enough nitrogen present in the alveoli to prevent rapid absorption of gases, maintaining alveolar patency and minimizing collapse.
Reabsorption (Absorption) Atelectasis occurs when alveoli collapse due to an imbalance in gas composition within the lungs. It typically happens when a high concentration of oxygen is used (often 100% FiO₂) because oxygen is absorbed into the bloodstream faster than nitrogen can replace it in the alveoli. Since nitrogen normally helps keep alveoli open by acting as a structural “scaffold,” its absence (due to high oxygen pushing it out) leads to alveolar collapse as the oxygen diffuses away.
What is the goal of bronchoscopic lung volume reduction surgery (LVRS)?
To functionally collapse lung areas (like a lobectomy) to improve V/Q mismatch and quality of life in severe COPD.
What are some potential bronchoscopy complications?
- Mechanical damage (to teeth, lips, tongue, airways)
- Bronchospasm (may need albuterol)
- Bleeding (suction before extubation)
What is mediastinoscopy used for?
Visualization of mediastinal structures like the heart, great vessels, trachea, esophagus, thymus, and lymph nodes.
When is mediastinoscopy indicated?
- Biopsies
- Perform prior to thoractomy to stage cancer
- Diagnose infection, lymphomas, sarcoidosis
What are absolute contraindications for mediastinoscopy?
Prior mediastinoscopy due to scarring or distortion.
Name the four divisions of the mediastinum
- Superior
- Anterior
- Middle
- Posterior
Organs involved in the Superior Mediastinum
- Thymus
- Trachea
- Esophagus
Organs involved in the Anterior Mediastinum
Thymus
Organs involved in the Middle Mediastinum
- Heart
- Roots of Great Vessels
- Trachea
- Main Bronchi
Organs involved in the Posterior Mediastinum
Esophagus
Arteries involved in the Superior Mediastinum
- Aortic arch
- Left common carotid artery
- Left subclavian artery
Arteries involved in the Anterior Mediastinum
Internal thoracic branches
Arteries involved in the Middle Mediastinum
- Ascending aorta
- Pulmonary trunk
Arteries involved in the Posterior Mediastinum
Descending thoracic aorta
Veins involved in the Superior Mediastinum
- Superior Vena Cava
- Brachiocephalic
Veins involved in the Anterior Mediastinum
- Internal thoracic branches
- Parasternal lymph nodes
Veins involved in the Middle Mediastinum
- Superior Vena Cava
- Pulmonary veins
Veins involved in the Posterior Mediastinum
- Azygous veins
- Hemiazygous veins
- Thoracic duct
Nerves involved in the Superior Mediastinum
- Vagus nerve
- Recurrent laryngeal nerve
- Phrenic nerve
Nerves involved in the Anterior Mediastinum
None
Nerves involved in the Middle Mediastinum
- Phrenic nerve
- Vagus nerve
- Sympathetics
Nerves involved in the Posterior Mediastinum
- Vagus nerve
- Splanchnic nerve
- Sympathetic chain
What are serious complications of mediastinoscopy?
- Pneumothorax
- Mediastinal hemorrhage
- Venous air embolism
- Recurrent laryngeal nerve damage
- Compression of airway structures
- Obstruction of Cardiac Output
What monitoring is essential during mediastinoscopy?
Right radial arterial line for detecting brachiocephalic compression and airway pressure monitoring.
What considerations are needed for a patient with a mediastinal mass?
Induction in sitting position and readiness for awake intubation if tracheobronchial compression is anticipated.
What are the three main types of airway blocks?
- Glossopharyngeal
- Superior laryngeal
- Transtracheal nerve blocks
What are the sensory innervation of the glossopharyngeal nerve?
- Posterior 1/3 of tongue
- Vallecula
- Epiglottis
- Pharynx
- Gag Reflex
What does the Superior Laryngeal Nerve provide sensory input to?
- Pharynx
- Glottis
- Aryepiglottic fold
What are common indications for esophagectomy?
Cancers like squamous cell carcinoma (often due to alcohol or smoking) and adenocarcinoma (linked to Barrett’s esophagus).
What are common preoperative issues in esophagectomy patients?
- Malnutrition
- Aspiration risk
- Prior radiation/chemotherapy (lung, cardiac, airway injury)
- Metastasis to lymph nodes.
What are essential anesthesia considerations for esophagectomy?
- Arterial line
- Thoracic epidural for pain
- CVP monitoring
- NGT
- Decision on DLT vs. single lumen tube based on surgeon preference
Mortality rate from esophagectomy?
High mortality (10-15%)
Complications from Esophagectomy
ARDS 10-20% of cases (50% mortality)
What are common postoperative complications after esophagectomy?
- Pneumonia
- ARDS
- Empyema
- Esophageal stricture
- Risk of aspiration FOR LIFE
