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NA 3 > Thoracic PPT > Flashcards

Thoracic PPT Flashcards

1
Q

Ventilation (V) is approximately _ L /min and pulmonary blood flow (perfusion Q) is approximately _ L/min

A

4L/min (V) 5L/min

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2
Q

The V/Q ratio for the entire lung is _

A

0.8 (4/5)

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3
Q

V/Q must be matched with the lung at the _ - _ level for gas exchange to occur

A

alveolar-capillary

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4
Q

Perfusion in the _ portion of the lung have greater amount of blood flow than the _

A

dependent (bases)

apex

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5
Q

Ventilation is greater in more _ parts of the lung, which are _ portions of the lung

A

compliant
dependent (bases)

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6
Q

Alveoli in the non-dependent portions of the lung, like the _, is more inflated and _ compliant

A

apex
less compliant

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7
Q

Difference between ventilation and oxygenation:

A

ventilation - moving air in and out of lungs, delivers O2 to alveolar space and removes CO2

oxygenation - delivering O2 from the lungs to body’s tissues

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8
Q

When standing, most of the ventilation and perfusion occurs at the _

A

base / dependent portion / zone 3

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9
Q

Which portion of the lung is more compliant?

A

dependent portion / base / zone 3

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10
Q

Which portion of the lung is less compliant?

A

apex, superior portion, “up lung”

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11
Q

Which monitor measures ventilation and which one measures oxygenation?

A

V = capnography
O2 = pulse ox

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12
Q

Pa =
Pv =
PA =

A

pulmonary arterial flow = Pa

pulmonary venous flow = Pv

alveolar pressures = PA

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13
Q

In an upright pt, where does most of tidal volume breath distribute to and why?

A

dependent portion / bases

-perfusion increases from the top - down (apex to base), negative pulmonary pressure is highest at apex of lungs so alveoli are most distended there, dependent alveoli are less distended and more compliant

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14
Q

Lung zones:
Zone 1

A

alveoli are at a HIGHER resting volume, represents alveolar dead space

PA > Pa > Pv

When PA > Pa = perfusion is impeded

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15
Q

Lung zones:
Zone 2

A

Variable relationship between vascular and alveolar pressure; intermediate zone

Pa > PA > Pv

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16
Q

Lung zones:
Zone 3

A

dependent part of lung, alveoli rest at LOWER volumes than zone 1 + 2 so they are more compliant and allow continuous blood flow thru the respiratory cycle

Pa>Pv>PA

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17
Q

An alveolus that undergoes a _ (greater/lesser) degree of volumetric change during a breath is going to be better ventilated. (Q!)

A

greater
-these are the dependent parts of lungs

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18
Q

Ventilation is greatest at the lung _ due to a _ alveolar compliance
Perfusion is greatest at the lung _ due to _

A

base, higher
base, gravity

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19
Q

T/F An alveolus that undergoes a greater degree of volumetric change during a breath is going to be better ventilated than an alveoli that undergoes a smaller degree of volumetric chancge during that breath

A

true
-dependent!!! :)

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20
Q

Most of the Vt is distributed to the _ alveoli

A

dependent

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21
Q

At end expiration, the alveoli near the _ are the largest and the alveoli near the _ are the smallest

A

apex = largest
base = smallest

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22
Q

compliance equation

A

compliance = change in volume / change in pressure

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23
Q

Lung compliance concept that “will be on every test you take for anesthesia board prep” (Q!)

A

volume difference at end expiration and end inspiration is smallest difference at the apex of the lung and greatest in the base of the lung

additionally, the ventilation is greatest at end expiration from the base and smallest at the apex

The more volume change an alveoli experiences will have better ventilation/perfusion (dependent!)

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24
Q

_ and _ _ affect the distribution of blood flow to the lung.

A

Gravity
hydrostatic pressure

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25
Q

When standing upright, less blood flows to the _ of the lung and more blood flows to the _

A

apex
base

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26
Q

There are _ (higher/lower) V/Q ratios towards the apex and _ (higher/lower) ratios towards the base

A

higher ratio at apex
lower ratio at base

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27
Q

V/Q terminology confusion:

-Higher V/Q ratio at _ and lower at _

-V/Q mismatch is HIGHER at _ and lower at _

-V/Q match is HIGHER at _ and lower at _

A

V/Q Ratio: Apex > Base

V/Q Mismatch: Base > Apex

V/Q Match: Apex > Base

-don’t confuse these differences on exams

ex) V/Q 4/5 = 0.8
apex: 5/4 = 1.25

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28
Q

Positions and dependent / non-dependent lung regions:
-Sitting

A

Dependent: base
Non-dependent: apex

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29
Q

Positions and dependent / non dependent lung regions : Supine

A

D: posterior

ND: anterior

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30
Q

Positions and dependent / non dependent lung regions: L Lateral Decubitus

A

D: Left lung

ND: right lung

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31
Q

Positions and dependent / non dependent lung regions: R Lateral decubitus

A

D: Right lung

ND: Left lung

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32
Q

Position effects on V + Q: awake lateral

A

diaphragm -> cephalad on DEPENDENT SD

More Vt in D lung on inspiration and

Q > in D lung

Gas exchange is still efficient

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33
Q

Position effects on V + Q: anesthetized lateral closed chest, SV

A

FRC decreases immediately

V is preferentially distributed to the ND lung but gravity dependedn BF preferentially distributes to D lung -> V/Q mismatch

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34
Q

Positions and dependent / non dependent lung regions: Anesthetized, paralyzed, MV

A

diaphragm no longer contributes to V of lower lung. V shifts to path of least resistance; preferring the ND lung

V/Q mismatch further deteriorates

prolly on test!

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35
Q

Positions and dependent / non dependent lung regions: Anesthetized, open chest

A

after thorax is opened, lung detaches from chest wall

V prefers ND lung

if MV and open chest, there is no resistance so V goes to nondependent lung -> extreme V/Q mismatch

prolly on test

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36
Q

Positions and dependent / non dependent lung regions: Anesthetized, open chest, OVL

A

little resistance to V of the ND lung

-gravity promotes Q to the D lung

-when OVL is started and ND lung isn’t ventilated, V is directed to the D lung and remaining Q going to ND lung creates a shunt BUT HPV reduces shunt bu 50% by diverting a lot of blood to D lung

this is how body keeps V/Q ratio matched

-prolly on test

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37
Q

What is HPV and how does it work

A

hypoxic pulm vasoconstriction
-reflex mechanism that causes pulm arteries to vasoconstrict in response to ALVEOLAR HYPOXIA and shunt blood away from hypoventilated lung tissue to areas of better oxygenation

-OLV - whenever the non-ventilated lung is still perfused, a mismatch occurs

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38
Q

Inhibitors of HPV

A

MAC > 1 - vasodilates
Mitral Stenosis - increased Pulm vasc pressure
Volume overload - periph vasodilation
Hypovolemia - vasoconstricts and overdistends alveoli
HYPOthermia - increased PVR
Infection - vasodilates
Vasodilators - vasodilates
Metabolic Alkalemia - vasodilates
Vasoconstrictors - increases pulm BF

-want euvolemia, moderate Vt, avoid excessive PEEP, hypocapnia, and alkalosis

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38
Q

Lung CA
-pancoast syndrome

A

tumor on apex of lungs
-spreads to ribs and vertebrae
-compresses stuff
-hard to intubate potentially
-bad prog

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39
Q

4 Ms of Lung CA

A

Mass effect (abscess, obstructive PNA, distortions, SVC or pancoast syndrome,
Metabolic effects (LEMS, hyperCa, cushing)
Mets (brain, bone, liver, etc)
Medications (Bleo)

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40
Q

Clinical hallmark of COPD

A

smoking

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41
Q

PFTs showing _ % improvement post-bronchodilator are good results

A

> 12%

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42
Q

PFTs purpose before thoracic or lung procedures

A

predict postop complication risk

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43
Q

The maximum volume of air that the lungs can hold after a maximum inhalation is the:

A

TLC
~6L

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44
Q

TLC =

A

TLC = Vt + ERV + IRV + RV

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45
Q

IC (insp capacity) =

A

IC = IRV + Vt

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46
Q

FRC =

A

ERV + RV

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47
Q

VC =

A

IRV + Vt + ERV

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48
Q

The volume of gas expired rapidly and forcefully after one breath is:

A

FVC ~5L

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49
Q

The volume of gas expired forcefully in 1 sec:

A

FEV1 ~4L

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50
Q

FEV1/FVC can show:

A

differences between obstructive or restrictive dz

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51
Q

If both FEV1 and FVC are low and ratio is =/<0.7 and TLC is increased, the dz pattern is:

A

obstructive
-emphysema

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52
Q

If both FEV1 and FVC are low and ratio is =/>0.7 and TLC is decreased, the dz pattern is:

A

restrictive
-asthma

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53
Q

Normal FEV1/FVC is _ in 1 sec

A

0.7 or 70%

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54
Q

A FEV1/FVC of _ is a sign of severe reduced lung function

A

0.4 or 40%

55
Q

Describe the obstructive breathing pattern on the F/V loop

A

Insp volume is large
Ability to exhale is decreased from alveoli retaining air

TLC is increased

56
Q

Describe the restrictive breathing patter on the F/V loop

A

unable to deeply inspire from constricted airway/alveoli
unable to exhale large volume because didn’t breathe in much

TLC is decreased

57
Q

Describe the breathing pattern with tracheal stenosis on the F/V loop

A

unable to inhale much volume past the obstruction
expiration takes longer from obstruction and unable to release all volume before needing to inhale again

TLC is increased

58
Q

Pack/year index =

A

PPD smoked x yrs smoking at that rate

59
Q

Smoking cess < _ wks doesn’t alter risk for complication

A

<4wks
<1 month = more secretions actually

60
Q

If pt is cyanotic, arterial oxyhgb is _ % or less and PaO2 is < _ mmHg, indicating reduced respiratory reserve

A

<80% OxyHgb and < 50mmHg PaO2

61
Q

Dx criteria for chronic bronchitis=

A

recurrent productive cough for 3 months of the year for 2 years straight

62
Q

What s/s should alert CRNA to possibility of a tumor in the aurway?

A

blood stained sputum or gross hemoptysis

63
Q

Which 2 aspects of COPD increase risk for RVH and RV failure?

A

Lung hyperinflation from airway inflammation increases RAP, decreasing venous return and RV preload

Pulm HTN from COPD increases afterload on RV increasing strain to pump forward into lungs

64
Q

Risk factors for RVH beyond COPD

A

acidosis
sepsis
hypoxia
increased amounts of PEEP

65
Q

EKG s/s of RVH

A

low voltage QRS
poor R wave prog
enlarged P wave

66
Q

What happens to lung volumes with anesthesia? (Q!)

A

errthng drops from decreased muscle tone

67
Q

Absolute reasons for OLV (Q!)

A

VATS

Isolating lung
-abscess/hemorrhage/infection

Controlling vent distribution
-bronchopleural fistulas, ULcysts or bullae, major disruption or trauma

UL lavage

68
Q

Relative reasons for OLV

A

Surgical exposure
-TAA
-Pneumonectomy
-Esophageal Surgery

69
Q

Directions for placing DLT

A

-concave part inserted facing anterior
-pull stylet when just past VC, turn 90 deg L so proximal opening is facing anterior and advance
-inflate tach cuff, listen for BBS
-inflate bronchial cuff, open cap, listen for BS on surgical sd
-clamp bronchial sd, open cap, and listen for BS on other sd
-use fiberoptic to confirm placement when supine and after repositioning

70
Q

What kind of trauma can occur from DLT placement?

A

airway

71
Q

DLT sizes for men: (Q!)

A

39 or 41 fr

72
Q

Avg depth of L sd DLT is _ cm

A

29cm

73
Q

Inflate the blue/bronchial cuff on a DLT with _of air

A

2-3mL

74
Q

T/F the bronchial cuff on a DLT should be left uninflated until lung isolation is needed for the procedure

A

T

75
Q

T/F Checking DLT placement with a pediatric fiberoptic is the standard of care

A

T

76
Q

Most common problems with DLT are usually _ (Q!)

A

MALPOSITIONING

77
Q

If there is a sudden change in ventilation during a case using a DLT, what should be checked first?

A

if there is mispositioning of the DLT

78
Q

Managing OLV

A

Start w 100% FiO2 then wean to keep HPV
Vt of 4-6mL/kg + PEEP 5 (or cut Vt in 1/2), RR to keep PaCO2 35-40
Recheck DLT with fiberoptic after placement + repositioning

79
Q

Managing OLV (Q!)
-high peak pressures (>40cmH2O)

A

make sure DLT isn’t malpositioned!

80
Q

Managing OLV (Q!)
-hypoxic (1st resort, 2nd resort, last resort)

A

1st resort: CPAP 5cm to non dependent lung

2nd resort: PEEP 5-10 to lung being ventilated, recruitment maneuvers

Last resort: tell surgeon 2 lung ventilation is needed and may need it intermittently

81
Q

Single most effective maneuver to increase PaO2 during OLV is:

A

CPAP to nondependent lung (Barash)

-per Lori tweaking FiO2, Vt, PEEP usually works fine tho

82
Q

HPV shunting during OLV is effective in decreasing the CO to the nonventilated lung by _%

A

50%

83
Q

HPV begins within seconds and is fully established in _ min

A

15 min

84
Q

Mediastinoscopy (Q!)
-scope placement

A

via suprasternal notch incision
-scope is ANTERIOR to trachea + POSTERIOR to the aortic arch and R innominate artery
-L RLN is at risk, same with tons of vessels (innominate artery)

85
Q

Mediastinoscopy is helpful in staging lung CA but can have obstructions to airway/ procedure. What can we do for induction/maintenance if this is the case?

A

LA + awake fiberoptic for induction
-maintain spont vent
-may need sitting up position
-if mass compressing SVC may need fem line
-airway may be compressed if supine, consider side lying or prone if possible

86
Q

Mediastinoscopy
-CI

A

previous mediastinoscopy + serious scarring

relative: SVC obstruction, tracheal deviation, TAA

87
Q

Mediastinoscopy
-most common complication

A

hemorrhage
-R innominate

88
Q

Mediastinoscopy (Q!)
-where to place A line/BP cuff and pulse ox

A

A line/BP cuff and/or SpO2 probe on R finger to monitor for compression of R subclavian artery

89
Q

Mediastinoscopy
-anesthesia goals

A

regular tube
position: head is turned 90 deg
short case - avoid excessive paralytic/reverse well
avoid bucking on emergence
meds: LTA kit, lidocaine, precedex, narcs
A line/pulseox on R finger to watch for R subclav compression

90
Q

Thoracotomy
-regional option

A

thoracic epidural T6-T8
paravertebral blocks

very painful

91
Q

Thoracotomy
-anesthesia goals

A

pain control (chest tube placed after)
T+S expect high blood loss up to 1L
check DLT after repositioning laterally with fiberoptic
check ABG 15 after OLV is started
unclamp and reinflate lung afterwards manually ventilating up to 30cm pressure or whatever surgeon asks for, watch for lung inflation on screen
emerge awake, sitting up, avoid coughing (precedex)

92
Q

Video-assisted Thoracoscopic Surgery (VATS)
-supplies needed

A

2 diff sizes of DLT
backup ETT + blade
clamps
Glide/Fiberoptic (purple/turquoise at RO)
CPAP capabilities
long suction caths
A line ready, 2 big IVs
tape for EKG leads
temp control + positioning crap

93
Q

DLT
-unable to place

A

Try smaller size

Try gently twisting thru VC with DL

Place single lumen tube, ventilate, use exchange cath/bougie, remove ETT, and place DLT that way

  • do not shove this thing in, don’t let techs take away fiberoptic until case is over
94
Q

DLT
-unable to deflate nondependent lung

A

Check placement with fiberoptic, is bronch cuff overinflated?

apply mild/gentle suction to noninflated port and suction air out of “up” lung
-this can take up to 10 mins

95
Q

Extubation criteria for thoracic cases
-VATS

A

Awake
Full reversal
no coughing

96
Q

Extubation criteria for thoracic cases
-Pneumonectomy

A

Awake
High fowlers

97
Q

Extubation criteria for thoracic cases
-Esophagectomy

A

Awake
maybe in ICU

98
Q

Rigid Bronch
-indications

A

Remove larger foreign bodies
Deeper biopsy
Washout
Tumor staging
Bleeding
Dilation of tracheal or bronchial strictures
Inserting stents
Tumor ablation/ tracheobronchial laser therapy

99
Q

Rigid bronch (Q!)
-meds

A

TIVA is best

LTA kit
Lidocaine + Propofol induction
Prop/Precedex gtt
Ketamine pushes/ Remi gtt
Esmolol before inserting scope (0.5mg/kg)
Decadron ~12mg

100
Q

Rigid Bronch (Q!)
-anesthesia method
-case tips

A

TIVA
LMA 1st then manual vent thru rigid bronch sideport

OPA + bag if desatting
mouth guard
extention tubing
EXPECT HTN + tachy - stimulating then not at all

101
Q

Rigid bronch
-complications

A

VC injury
pneumo
teeth damaged
desatting
HTN/ tachy
airway trauma
gum tears
hemorrhage

102
Q

Flexible bronch
-indications

A

biopsy
removing small foregin object
tumor staging
washout
diagnostics

103
Q

Flexible bronch
-which airway device is used

A

larger (~1-1.5 size up) ETT

104
Q

T/F A pneumonectomy can either be achieved via VATS or thoracotomy

A

true

105
Q

Pneumonectomy
-suppliesq

A

L sd DLT + backups + fiberoptic/glide
Thoracic epidural (T6-T8)
T+C - 2 units ready (give albumin/blood instead of fluids)
2 big IVs
A line ready
ABG after 15 mins OLV
foley, temp control, positioning crap, tape

106
Q

Pneumonectomy
-meds

A

Albumin/blood
Phenyl gtt

possibly: Dig, Milrinone, NTG, hydral

107
Q

Pneumonectomy
-anesthesia goals

A

KEEP PT DRY (surg will assess RV function/ PVR when clamping PA, avoid tweaking things unless needed)
Check ABG after 15 min OLV
Give albumin or blood if needed
Surg will ask for 20-30cm PIP for valsalva to check for leaks after sutures
awake extubation

108
Q

Pneumonectomy
-PPS

A

post-pneumonectomy space

-chest tube not always places, PPS shrinks over time as body adjusts around it and replaces space with fluid, mediastinum shifts towards PPS

109
Q

Pneumonectomy (Q!)
-main complication

A

RV can dilate and function decreases from increased RV afterload from increased PAP and PVR

cut off PA on dz lung so all BF going to the remaining PA

others: resp fail, pulm edema, dysrhtyhmias, cardiac herniation

110
Q

Esophagectomy (Q!)
-induction

A

RSI
-esophagus can be full

111
Q

Esophagectomy
-supplies

A

ETT + DLT + glide/fiberoptic
Thoracic epidural maybe
A line
2 large IV
2 units PRBC
temp control

DO NOT PLACE OGT/NGT UNLESS SURG ASKS

112
Q

Esophagectomy
-fluid status

A

pt will be extra dry
-emaciated from bowel prep and tumor impeding PO intake
-higher Hgb = pt is drier, follow UO too

ask surgeon, use ALBUMIN if fluids needed or phenylephrine; surg doesn’t want pt too wet so they can suture

113
Q

Esophagectomy (Q!)
-anesthesia goals

A

keep pt on dry side

if HOTN - phenylephrine, albumin -ask surg

check Hgb and monitor UO for fluid status (Hgb increasing = dry)

TRANSHIATAL IS HARDEST: Surg pulling stomach thru neck incision compresses heart and tanks BP (albumin+pressors)

tape very well, lots of manipulation

long case, may need sections of colon, carefully sparing vagus nerve!

have blood ready

extubate in ICU, awake

pts will have G tube after these

114
Q

Esophagectomy (Q!)
-most common complications

A

1. RESPIRATORY
2. Cardiac
3. Wound Infection
4. Anastomotic leak

115
Q

Esophagectomy (Q!)
-why is transhiatal approach harder

A

very hypovolemic
bowel prep
secure ETT VERY WELL lots of movement
unable to reach airway after induction
neck incision on L sd
pulling stomach up thru neck incision compresses heart and tanks BP

116
Q

Esophageal Rupture (Q!)
-clinical presentation

A

s/s:
neck/back pain
cyanotic
hydrothorax
emphysema
pneumomediastinum
septic

117
Q

Esophageal Rupture (Q!)
-causes

A

vomiting violently
straining with weights
child birth pushing
severe alcoholism
crush injury/trauma/ MVA

118
Q

Esophageal Rupture (Q!)
-surgical case required
-how would you intubate?

A

Thoracotomy + RSI or awake intubation

119
Q

Tracheal Resection
-supplies

A

2 large IVs
A line
Cordis + CVP
Swan if bypass may be needed
smaller ETT

120
Q

Tracheal Resection
-meds

A

corticosteroids
diuretics
racemic epi
avoid fluids!

121
Q

Thymectomy
-MG tx

A

only tx that removes CAUSE of MG

122
Q

Thymectomy
-MG drugs

A

continue pyridostigmine thru DOS or give Neostigmine if pt missed dose

-have blood in room + give stress dose steroid

123
Q

Thymectomy (Q!)
-MG + NDMR?

A

They will need LESS
-they have less AChR that are functional so they’re more sensitive to MR
-also can be sensitive to Neostigmine reversal and have weakness from cholinergic crisis

124
Q

Thymectomy
-postop MV considerations (4)

A

-sternotomy performed?
-MG dz duration > 6yr?
-Chronic resp condition?
-Pyridostigmine dose > 750mg/day?

125
Q

Pulm Decortication (Q!)
-clinical presentation

A

pt sick AF + pleura thick AF (need to be scraped off)

-empyema, clotted hemothorax, TB, mesothelioma, lung CA, staph infection, extreme COPD

-pt very fatigued, tachypneic, already tubed, acidotic, low PaO2, hard to ventilate (stiff/ restrictive dz)

126
Q

Risk factors for ALI from thoracic cases:

A

Preop: ETOH, previous pneumonectomy, poor PFT, hypervolemic

Intraop: high ventilatory pressures, excessive IVF

127
Q

If DLT is on L sd and TRACHEAL lumen clamped, the _ lung will inflate (Q!)

A

Left

128
Q

If DLT is too far into the L sd, the _ lung will inflate (Q!)

A

Left

129
Q

If DLT is on the L sd and BRONCHIAL lumen is clamped, the _ lung will inflate (Q!)

A

Right

130
Q

Awake Lateral Position OLV (Q!)

A

diaphragm displaced cephalad and on dependent sd

Insp: diaphragm causes Vt to go in dependent lung

Perfusion is better in dependent lung

V/Q stays efficient

131
Q

VC = (Q!)

A

VC = Vt + ERV + IRV

132
Q

TLC = (Q!)

A

TLC = Vt + ERV + IRV + RV

133
Q

IC =

A

IC = IRV + Vt

134
Q

FRC =

A

FRC = ERV + RV

NA 3 (6 decks)

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