Thoracic Anesthesia Pt. 1 (Exam III)

Question 1

How many total lung segments are there?

Answer 1

42

Question 2

How many segments make up the right lung?

Answer 2

22

Question 3

How many segments make up the left lung?

Answer 3

20

Question 4

What is FEV₁?

Answer 4

Forced expiratory volume in 1 second after a full inspiration

Question 5

What is a normal Predicted FEV₁?

Answer 5

80 - 120%

High percentage = healthier lungs

Question 6

What are good predicted FEV₁ values associated with?

Answer 6

Good post-op outcomes

Question 7

What is the formula for postoperative FEV₁?

Answer 7

Postop FEV₁% = Preop FEV₁% x (1 - % of lung tissue removed/100)

Question 8

Given the following:

Preop FEV₁ = 70%
25% of lung tissue removed.

What is the expected Post FEV₁?

Answer 8

Post FEV₁ = 70 x [(1 - (25/100)]

Post FEV₁ = 52.5%

Question 9

Given the following:

Preop FEV₁ = 110%
33% of lung tissue removed.

What is the expected Post FEV₁?

Answer 9

Post FEV₁ = 110 x [1 - (33/100)]

73.7%

Question 10

Postoperative FEV₁ of ____ or less have an increased risk of pulmonary complications.

Postoperative FEV₁ of ____ or less have a very high risk.

Answer 10

40%

30%

Question 11

V/Q:

V = ?
Q = ?

Answer 11

V = Ventilation
Q = Perfusion

Question 12

What PaO₂ and PCO₂ preoperative values are associated with poor postoperative outcomes?

Answer 12

PaO₂ < 60 mmHg
PCO₂ > 45 mmHg

Question 13

What is the most useful test for determing gas exchange capacity?

Answer 13

DLCO (Diffusing Lung Capacity for Carbon Monoxide)

Question 14

How is a DLCO test performed?

Answer 14

• Small amount of CO is inhaled with tracer gas (helium or methane)
• CO high affinity for Hgb
• Exhaled gas analyzed

Question 15

A DLCO test will correlate with what?

Answer 15

Total functioning surface area of alveolar/capillary interface.

Question 16

Is DLCO or FEV₁ affected by chemotherapy?

Answer 16

DLCO is affected by chemotherapeutics

Question 17

What would a high amount of exhaled CO from a DLCO test indicate?

Answer 17

Poor gas exchange

Due to CO not being picked up by the bloodstream at the alveoli.

Question 18

What is the absolute minimum DLCO and FEV₁ needed for thoracic surgery?

Answer 18

20%

Question 19

What is the ideal V/Q ratio?
What is more typical?

Answer 19

Ideal = 1.0
Typical = 0.8

Question 20

Review West Zones

Question 21

Pulmonary arterial pressure ( P_a) is always greater than pulmonary ____ pressure.

Answer 21

venous ( P_v)

Question 22

The absolute pressure of P_a and P_v is greater in the ________ portion of the lung due to hydrostatic gradients.

Answer 22

dependent

Question 23

Blood flow is most dependent on what?

Answer 23

gravity

Question 24

The base of the lung receives how much more blood pressure relative to the apex of the lung? (in an upright person)

Answer 24

20 mmHg increase

Question 26

What lung zone is depicted by 1 in the figure below? What pressures would be exhibited by this lung?

Answer 26

- Zone 1 - P_A > P_a > P_v

Question 27

How much blood flow is seen in a Zone 1 lung? Who has Zone 1 lungs?

Answer 27

- Very little to no blood flow. Zone 1 lungs are a pathologic condition.

Question 28

What lung zone is depicted by 2 in the figure below? What pressures would be exhibited by this lung?

Answer 28

- Zone 2 - P_a > P_A > P_v

Question 29

What lung zone is depicted by 3 in the figure below? What pressures would be exhibited by this lung?

Answer 29

- Zone 3 - P_a > P_v > P_A

Question 30

What lung zone exhibits pulsatile blood flow? What lung zone exhibits non-pulsatile continuous blood flow? What is the reasoning for the difference?

Answer 30

- **Pulsatile** = Zone 2 - **Continuous** = Zone 3 - Gravity: ↑ pressure = ↑ perfusion

Question 31

What lung zone is depicted by 1 in the figure below?

Answer 31

Zone 4

Question 32

Which lung zone is defined by the following: 1. Alveoli maximally distended 2. Complete compression of capillaries 3. Ventilation but no blood flow (**dead space**)

Answer 32

Zone 1 ( P_A > P_a > P_v )

Question 33

Which lung zone is defined by the following: 1. Restricted venous flow 2. Arterial flow exceeds P_A 3. Ventilation but no blood flow (**dead space**)

Answer 33

Zone 2 ( P_a > P_A > P_v )

Question 34

Where is lung zone 2 located in relation to the heart?

Answer 34

3cm above the heart

Question 35

Which lung zone is defined by the following: 1. Unrestricted blood flow 2. More compliant alveoli & greater ventilation. 3. Vasculature more distended

Answer 35

Zone 3 ( P_a > P_v > P_A )

Question 36

In which lung zone will blood flow vary with the cardiac cycle and respirations?

Answer 36

Lung Zone 2

Question 37

Which lung zone's blood flow is unaffected by the cardiac cycle and respirations?

Answer 37

Zone 3

Question 38

Zone 1 is _____ in healthy patients.

Answer 38

absent

Question 39

In a normal healthy lung P_a will be ______ than P_A.

Answer 39

greater → P_a > P_A

Question 40

What two common things will produce zone 1 ventilation?

Answer 40

- Positive Pressure Ventilation = ↑ alveolar pressure. - Hemorrhage/shock/hypovolemia = drop in arterial pressure.

Question 41

Why does blood flow in pulses in Zone 2 of the lungs?

Answer 41

Systole = P_a > P_A Diastole = P_A > P_a

Question 42

For accurate measurement of PCWP, the PA catheter must be place in which pulmonary zone?

Answer 42

Zone 3

Question 43

Which zone has the greatest perfusion and highest hydrostatic pressures?

Answer 43

Zone 3

Question 44

Which pulmonary function test is used to determine if lung disease is obstructive, restrictive, or normal?

Answer 44

FEV₁/FVC Ratio

Question 45

What is a normal FEV₁/FVC ratio in healthy adults?

Answer 45

70 - 85%

Question 46

What are the most common disease processes exhibiting obstructive patterns?

Answer 46

- COPD (Bronchitis & Emphysema) - Asthma - Cystic Fibrosis

Question 47

What is the most common comorbidity in the thoracic surgical population?

Answer 47

COPD

Question 48

What condition is characterized by the following: - Decreased area for gas exchange - Air-trapping - Hyperinflation of lung tissue

Answer 48

COPD

Question 49

What environmental factors other than smoking have been implicated in lung cancer?

Answer 49

- Asbestos - Radon - Diesel gas - Heavy metals

Question 50

Do the below factors describe SCLC or Non-SCLC? - Less aggressive - Affects smokers & non-smokers - More common - Better prognosis

Answer 50

Non-Small Cell Lung Cancer

Question 51

Do the below factors describe SCLC or Non-SCLC? - Fast-growing - Aggessive - Associated with smoking - Starts in bronchi - Metastasizes

Answer 51

Small Cell Lung Cancer

Question 52

What lung cancer is most sensitive (susceptible) to radiation therapy?

Answer 52

SCLC

Question 53

What are the sub-categories of Lung resection? (partial lobe removal)

Answer 53

- Sleeve - Wedge - Segment

Question 54

What is pleurodesis?

Answer 54

Obliteration of pleural space to prevent recurrence of fluid, pus, or blood build up.

Question 55

What is the most common thoracotomy approach?

Answer 55

Anterolateral

Question 56

Differentiate lung separation vs lung isolation?

Answer 56

**Separation = Adequate** lung deflation **Isolation = Complete** lung deflation

Question 57

What is DLT sizing for women?

Answer 57

Question 58

What is DLT sizing for men?

Answer 58

Question 59

What direction should a left-sided DLT be turned once at the vocal cords?

Answer 59

To the left

Question 60

What should tidal volume be set to on an isolated lung?

Answer 60

4 - 6 mL/kg (increase rate to maintain normocapnia)

Question 61

100% O₂ must be avoided in chemo patients who have received _______.

Answer 61

bleomycin

Question 62

What are the cons of hyperoxemia from excessive FiO₂?

Answer 62

- Absorption atelectasis - Coronary vasoconstriction

Question 63

What type of shunt occurs from one lung ventilation?

Answer 63

Right to Left Shunt *Venous blood returning to heart has not been oxygenated. Causes relative hypoxemia*.

Question 64

How is One-Lung ventilation shunt lessened during thoracic surgery?

Answer 64

- Surgical manipulation (obstructs blood flow to non-ventilated lung). - **Lateral Positioning** (increased perfusion to dependent, ventilated lung) - HPV reduces blood flow in operative lung

Question 65

Describe Hypoxic Pulmonary Vasoconstriction.

Answer 65

Alveolar hypoxia results in **vasconstriction** of pulmonary vasculature (↑PVR).

Question 66

Due to HPV, blood preferentially moves to ______ ventilated areas.

Answer 66

more

Question 67

What happens if atelectasis occurs in the dependent (non-operative) lung?

Answer 67

Atelectasis → HPV → Dependent lung vasoconstriction → blood shunted to non-ventilated, operative lung.

Question 68

HPV is desired in the ________ lung.

Answer 68

operative **Not wanted in the non-operative, dependent lung**.

Question 69

Which drug class attenuates HPV? How so?

Answer 69

All VAA's via vasodilation

Question 70

What VAA dosage will start to attenuate HPV?

Answer 70

1 MAC

Question 71

HPV being decreased will cause an ______ shunt and ________ oxygenation.

Answer 71

Decreased shunt and worsening oxygenation

Question 72

What factors will attenuate/decrease the effects of HPV?

Answer 72

- **VAA > 1 MAC** - Alkalosis - Hypocapnia - Hypothermia - Hemodilution - Vasodilators

Question 73

What are the most common complications associated with One-Lung Ventilation?

Answer 73

- DLT Malposition - Airway ETT Trauma - Bronchospasm - Hypoventilation - Hypoxemia

Question 74

What can occur if 100 FiO₂ is administered to a patient receiving bleomycin?

Answer 74

Free Radical oxidative damage & pulmonary toxicity

Question 75

How is persistent hypoxemia associated with OLV treated?

Answer 75

- **Resume two lung ventilation** - Surgeon ligation of pulmonary artery

Question 76

What is the best predictor of difficult DLT placement?

Answer 76

CXR

Question 77

What is the gold standard for cardiopulmonary fitness?

Answer 77

V̇O₂ Max

Question 78

What is the average healthy male V̇O₂ max?

Answer 78

30 - 40 mL/kg/min

Question 79

What is the average healthy female V̇O₂ max?

Answer 79

27 - 32 mL/kg/min

Question 80

There is an increased risk for thoracic surgery if a patient's V̇O₂ max is less than ________.

Answer 80

15 mL/kg/min

Question 81

There is much less risk during thoracic surgery if a patient's V̇O₂ max is greater than _______.

Answer 81

20 mL/kg/min

Question 82

Complications associated with smoking are reduced as soon as __ weeks after quitting smoking.

Answer 82

4 weeks

Question 83

________ concentrations decrease just 12 hours after quitting smoking.

Answer 83

Carboxyhemoglobin

Question 84

What endocrine disorder can result from SCLC? Why?

Answer 84

Cushing's due to SCLC causing increased cortisol production

Question 85

Other than Cushing's disease, what disorder is associated with SCLC?

Answer 85

Lambert Eaton Myasthenic Syndrome

Question 86

How long must thoracic surgery be delayed after bare metal coronary stenting?

Answer 86

4 - 6 weeks

Question 87

How long must thoracic surgery be delayed after drug-eluting coronary stent placement?

Answer 87

6 months

Question 88

What is the most common concurrent disease associated with thoracic surgery?

Answer 88

COPD

Question 89

What cardiac disease is common in COPD patients?

Answer 89

RV failure

Question 90

What is the most common EKG complication associated with thoracic surgery?

Answer 90

Atrial Fibrillation (Due to ↑ PVR & SNS stimulation)

Question 91

Where should a CVL be placed on a thoracotomy patient?

Answer 91

Ipsilateral Non-operative side

Question 92

What VAA should be avoided in thoracic surgery?

Answer 92

N₂O

Question 93

What type of nerve injury is common with thoracic surgeries?

Answer 93

Brachial Plexus injuries

Question 94

How is Acute Lung Injury best avoided?

Answer 94

- Avoid fluid overload - Avoid hyperinflation

Question 95

What typically causes acute lung injury?

Answer 95

- Hypervolemia - Excessively high ventilatory pressures