question

Preoperative assessment of vital capacity is critical because at least _____ times the tidal volume (VT) is necessary for an effective cough.

answer

3

question

Smoking decreases these lung capacities? therefore increasing the incidence of what?

answer

forced vital capacity and forced expiratory flow 25% to 75%, thereby increasing the incidence of postoperative pulmonary complications.

question

The absolute indications for lung separation using a double-lumen tube historically have been what?

answer

protection against spillage of blood, infectious material, or lavage fluid from one lung. For ventilation in the case of bronchopleural fistula or bullae. A lobectomy or pneumonectomy is also a relative indication.

question

The most important advance in checking the proper position of a double-lumen tube is the introduction of what?

answer

the pediatric flexible fiberoptic bronchoscope.

question

During one-lung ventilation (OLV), the dependent lung should be ventilated using a VT that results in a plateau airway pressure less than_____ with the rate adjusted to maintain PaCO2 within what range?

answer

<25 cm H2O at a rate adjusted to maintain PaCO2 at 35 ± 3 mm Hg.

question

The need for OLV is much greater with a VATS when compared to an open thoracotomy due to?

answer

The fact that it is not possible to retract the lung during video-assisted thoracoscopic surgery as it is during an open thoracotomy.

question

The potential advantages offered by high-frequency positive-pressure ventilation during thoracic anesthesia are?

answer

The lower VT and inspiratory pressures result in a quiet lung field for the surgeon, with minimal movements of airway, lung tissue, and mediastinum.

question

Myasthenia gravis is a disorder of the neuromuscular junction, characterized by?

answer

weakness and fatigability of voluntary muscles with improvement following rest.

question

Common surgery for MG to abate symptoms?

answer

Surgical thymectomy is a commonly performed therapy.

question

In addition to a more comfortable patient, important benefits of adequate pain relief are avoidance of ?

answer

postoperative atelectasis and limited inspiratory thoracic cage expansion.

question

The first 10 flashcards were the keypoints from the beginning of the chapter, the flashcards will now sequentially follow the flow of the chapter

answer

Collin is Awesome

question

The most common cause of cancer mortality in the United States in men, and surpassed breast cancer as the leading cause of cancer deaths in women in 1987.

answer

Lung Cancer

question

Thoracic surgery is known to be associated with high risk, and patient factors that have been associated with increased risk include these 3 things ?

answer

advanced age poor general health status COPD.

question

Dyspnea occurs when the requirement for ventilation is greater than what?

answer

the patient's ability to respond appropriately

question

Dyspnea is quantified by?

answer

the degree of physical activity required to produce it the level of activity possible (e.g., ability to walk on level ground or climb stairs) and management of daily activities.

question

Severe exertional dyspnea usually implies a significantly diminished______ and a (FEV1) of ______. Post-Op Implications include?

answer

ventilatory reserve <1,500 mL possible need for postoperative ventilatory support.

question

Recurrent productive cough for 3 months of the year for two consecutive years is necessary to make the diagnosis of ?

answer

chronic bronchitis

question

Having a cough indirectly increases airway ?

answer

irritability

question

So you're doing a pre-op of some fugly COPD patient and they're coughing up all sorts of shit, since their cough is productive, you should determine?

answer

the volume, consistency, and color of the sputum. Sputum should be cultured to rule out infection and to establish whether there is a need for preoperative antibiotic therapy.

question

Blood-stained sputum or episodes of gross hemoptysis should alert the Senior SRNA to the possibility of ?

answer

a tumor invading the respiratory tract (e.g., the main stem bronchus), which might interfere with endobronchial intubation. "Nurse, glidescope now ******** it!!"

question

Smoking is Bad, the more you smoke and the longer you have smoked...guess what?

answer

you are more prone to postoperative atelectasis and arterial hypoxemia, no shit

question

Patients who can walk up how many flights of stairs are at a reduced risk of peri-op complications?

answer

3

question

The best evaluation of a patients exercise tolerance is what?

answer

quality of life Otherwise healthy patient with good exercise tolerance will generally not warrant additional screening tests

question

In some cases, thoracic surgery may lead to acute lung injury (ALI) postoperatively. Perioperative risk factors that have been identified include ?

answer

preoperative alcohol abuse patients undergoing pneumonectomy

question

Intraoperative risk factors for ALI include ?

answer

high ventilatory pressures and excessive amounts of fluid administration

question

TRALI =

answer

TRALI

question

The presence of central cyanosis (in the buccal mucosa) is usually secondary to ?

answer

arterial hypoxemia

question

If cyanosis is present, the arterial hemoglobin saturation with oxygen is less than? PaO2 <? What does this indicate?

answer

80% or less PaO2 <50-52 mmHg Indicates a limited margin of respiratory reserve I remember from DeVascher that you have to have at least 5 grams of desaturated hemoglobin for cyanosis to appear(something like that)

question

Clubbing of fingers and toes is often seen in patients with?

answer

chronic hypoxemia d/t chronic lung disease malignancies congenital heart disease associated with right-to-left shunt

question

A patient's inability to complete a normal sentence without pausing for breath is an indication of?

answer

severe dyspnea

question

The abdomen moving in while the chest moves out is called? and suggests?

answer

Inspiratory paradox diaphragmatic fatigue and respiratory dysfunction.

question

For constant VE, work done against airflow resistance decreases when breathing is ?

answer

slow and deep Think about breathing in AIR slowly and deeply

question

For constant VE, work done against elastic resistance decreases when breathing is?

answer

rapid and shallow (e.g., as in pulmonary infarct or pulmonary fibrosis). Think of a condom being elastic and having sex rapid and shallow, just the tip baby.

question

Wet sounds (crackles) are usually caused by ?

answer

excessive fluid in the airways and indicate sputum retention or edema.

question

Dry sounds (wheezes) are produced by high-velocity gas flow through bronchi and are a sign of ?

answer

airway obstruction

question

Distant breath sounds are an indication of ?

answer

emphysema and possibly bullae

question

One of the most important factors in the evaluation of a patient scheduled for thoracic surgery is the presence of?

answer

Increase in PVR secondary to a fixed reduction in the cross-sectional area of the pulmonary vascular bed

question

The pulmonary circulation is normally a low-pressure, high-compliance system capable of handling an increase in blood flow by recruitment of normally underperfused vessels. This acts as a compensatory mechanism that normally prevents?

answer

An increase in pulmonary arterial pressure

question

In COPD, there is distention of the pulmonary capillary bed with decreased ability to tolerate an increase in blood flow r/t decreased compliance. Such patients demonstrate an increase in PVR when what increases? Results in?

answer

When CO increases d/t decreased ability to compensate for an increase in pulmonary blood flow. Results in Pulmonary Hypertension which eventually causes RV hypertrophy and failure

question

A patient with COPD may present with electrocardiographic features of right atrial and ventricular hypertrophy and strain. These ECG changes include what?

answer

low-voltage QRS complex due to lung hyperinflation and poor R-wave progression across the precordial leads

question

What does RV hypertrophy look like on an ECG?

answer

R/S ratio of greater than 1 in lead V1 (i.e., R-wave voltage exceeds S-wave voltage).

question

An enlarged P wave ("P pulmonale") in standard lead II is diagnostic of ?

answer

right atrial hypertrophy

question

What findings might you see on your COPD patient on CXR?

answer

Regret Also, Hyperinflation and increased vascular markings, but mostly regret

question

So with COPD you have an increased AP chest diameter, if you did a lateral CXR, what might you see?

answer

enlarged retrosternal air space of >2 cm in diameter

question

Why is it important to assess thoracic tumor?

answer

D/t possibility of tracheal/bronchial collapse after induction owing to muscle relaxation

question

What change to PaCO2 would you expect with a patient who has COPD?

answer

Chronic elevation and hence less sensitivity to CO2 as a stimulus to breath as the equilibrium has been reset and elevated. Remember that the hypoxic drive (Low Pa02) is usually > CO2 as a stimulus, hence why you dont flood someone with COPD with 100% 02 as you can actually make them more hypercapnic by decreasing their drive to breath (not enough time but just know this isn't necessarily accepted as true anymore, just an FYI)

question

The "blue bloaters" (chronic bronchitis) are usually ?

answer

cyanotic, hypercarbic, hypoxemic, and usually overweight

question

The "pink puffers" (patients with emphysema) are typically?

answer

thin, dyspneic, and pink, with essentially normal ABG values. They present with an increase in minute ventilation to maintain their normal PaCO2

question

The intra-op PaO2 during OLV correlates to ?

answer

Pre-op Pa02

question

There are three goals in performing pulmonary function tests in a patient scheduled for lung resection. The first goal is to identify?

answer

The patient at risk of increased postoperative morbidity and mortality.

question

The second goal is to identify the patient who will need?

answer

short-term or long-term postoperative ventilatory support

question

The third goal is to evaluate the beneficial effect and reversibility of airway obstruction with?

answer

The use of bronchodilators

question

In thoracic surgery for lung cancer, the specific question is: How much lung tissue may be safely removed without making the patient a pulmonary cripple? This should be weighed against?

answer

The 1-year mean survival rate of the patient with surgically untreated lung carcinoma.

question

Anesthesia and postoperative medications can cause changes in lung volumes and ventilatory patterns, vital capacity is decreased by how much? When does it return to normal?

answer

VC decreases 25% to 50% within 1 to 2 days after surgery and generally returns to normal after 1 to 2 weeks

question

Abdominal Surgery has what effect on TLC?

answer

Decreases TLC

question

After surgery RV increases by 13% and ERV decreases by?

answer

25-60%

question

Tidal volume (VT) decreases by how much within 24 hours after surgery ?and gradually returns to normal after?

answer

20% 2 weeks

question

After surgery, pulmonary compliance decreases by 33% with similar reductions in?

answer

FRC secondary to small airway closure

question

FVC, FEV1, MVV, and RV/TLC correlate with what following thoracic surgery?

answer

Post-Op Outcomes

question

An abnormal preoperative vital capacity can be identified in ___% to __% of postoperative deaths.

answer

30-40%

question

A patient with an abnormal vital capacity has a ___% likelihood of complications and a ___% risk of postoperative mortality.

answer

33% 10%

question

What does FEV1 primarily detect?

answer

Obstructive Disease

question

The ratio FEV1/FVC is useful in differentiating between?

answer

restrictive and obstructive pulmonary diseases

question

In restrictive disease, the FEV1/FVC ratio will be?

answer

Normal because both volumes have decreased in proportion to one another so even though the volume is smaller, the ratio is the same.

question

In obstructive disease, the FEV1/FVC ratio will be?

answer

Low d/t trapping of air and a decrease in the FEV1.

question

MVV(Maximum Voluntary Ventilation) is a nonspecific test and is an indicator of?

answer

both restriction and obstruction

question

Although MVV has not been systematically evaluated as a predictor of morbidity, it is generally accepted that an MVV < ___% of predicted value is an indication of ?

answer

<50% high risk

question

A ratio of RV to TLC (RV/TLC) of _____ is generally indicative of a high-risk patient for pulmonary resection

answer

>50% So RV/TLC >50% and MVV < 50% = BAD

question

By multiplying the preoperative FEV1 by the percentage of lung tissue expected to remain following resection, a predicted postoperative FEV1 can be calculated. Patients with a predicted postoperative FEV1 value ____ are at reduced risk and those with predicted postoperative FEV1 ____ are at increased risk.

answer

FEV1 Post-OP >40% Decreased Risk <30% Increased Risk and more likely to need post-op ventilatory support

question

Look over flow volume loops

answer

that is all

question

Why do we care about PFT's and the response or lack of response to bronchodilator therapy? (Well personally I dont give a shit because I'm trying to work in an endo clinic) but for the test you should know that for a positive response to bronchodilator therapy is characterized by?

answer

15% improvement in PFT's and this indicates that treatment should be started before surgery

question

The overall prognosis of COPD and PFT's is better related to the level of spirometric function after bronchodilator therapy rather than ?

answer

Their baseline function

question

What is the purpose of split lung function tests (Regional lung function)?

answer

Predict function of lung tissue that would remain after resection

question

The ability of the lung to perform gas exchange is reflected by the diffusing capacity for?

answer

carbon monoxide

question

Carbon monoxide diffusion is impaired in disorders such as interstitial lung disease, which affects the alveolar-capillary site. A predicted postoperative diffusing capacity for carbon monoxide (DLCO) less than what is associated with increased risk?

answer

<40% is associated with increased risk

question

Predicted postoperative diffusing capacity percent is the strongest single predictor of ?

answer

risk of complications and mortality after lung resection

question

There is little interrelationship of predicted postoperative diffusing capacity percent and predicted postoperative FEV1, indicating that these values should be ?

answer

assessed independently when estimating operative risk

question

The maximal oxygen consumption (VO2 max) is a predictor of postoperative complications and patients with a VO2 max >15 to 20 mL/kg/min are at reduced risk while a VO2 max <______mL/kg/min indicates very high risk for lung resection

answer

VO2 Max <10 ml/kg/min = very high risk

question

Pre-Op general factors leading to complications include?

answer

"WIDE COW" Wheezing Infection Dehydration Electrolyte Imbalance Cigarette Smoking and Cor Pulmonale Obesity Wasting (Malnutrition)

question

How long do you need to stop smoking before surgery to decrease the risk of pulmonary complications?

answer

4-6 weeks

question

Cessation of smoking for how long can decrease the percentage of carboxyhemoglobin and shift the dissociation curve to the right?

answer

48 hours

question

How long you gotta cut them cigs off for before dem lil cilia snakes start cutting on again?

answer

2-3 months bitch

question

It should be emphasized, however, that most of the beneficial effects of cessation of smoking, such as improvement in ciliary function, improvement in closing volume, increase in FEF25-75%, and reduction in sputum production, usually occur when?

answer

2-3 months bitch

question

Guess what, dont go to the OR with an infected patient, treat infections and you just may decrease pulmonary complications from?

answer

17% to 9%

question

Correction of hypovolemia and electrolyte imbalance should be accomplished before surgery because adequate hydration decreases ?

answer

viscosity of bronchial secretions and facilitates their removal from the bronchial tree

question

Commonly used methods for removing secretions from the bronchial tree include?

answer

postural drainage vigorous coughing chest percussion deep breathing incentive spirometer

question

The presence of acute wheezing represents a medical emergency, and elective surgery should be?

answer

postponed until effective treatment has been instituted

question

Sympathomimetics bronchodilate via?

answer

cAMP Increased cAMP inhibits MLCK which prevents phosphorylation of MLC20 and leaves the muscle in a dilated state.

question

cGMP via kinases in the lung bronchioles may cause?

answer

bronchoconstriction this 2nd messenger pathway is the cholinergic mechanism for bronchoconstriction

question

Phosphodiesterase inhibitors work how? examples?

answer

Prevent breakdown of cAMP and hence increase cAMP with the usual sequelae Theophylline, Aminophylline, Caffeine etc

question

How do steroids decrease wheezing?

answer

Indirectly by decreasing mucosal edema and stabilizing lysosomal membranes leading to a decrease in the amount of pro-inflammatory mediators.

question

How does cromolyn sodium work?

answer

Mast Cell stabilizer which inhibits degranulation and histamine release

question

In his notes, he asks how Parasympatholytic drugs work?

answer

He says inhibit formation of cGMP with examples being atropine and ipratropium. (He's partially right )

question

Dysrhythmias occur commonly both during and after thoracic surgery, making the usual need for continuous electrocardiographic monitoring even more important as cardiac manipulation may cause?

answer

Intraoperative supraventricular tachyarrhythmias

question

Dysrhythmias that occur during OLV may also be a sign of ?

answer

inadequate oxygenation or ventilation

question

Postoperative dysrhythmias following thoracic surgery may be related to?

answer

sympathetic nervous system stimulation from pain or to a decreased pulmonary vascular bed following lung resection

question

Continuous blood pressure readings via an A-line are critical during thoracic surgery because surgical manipulations may result in?

answer

Cardiac compression and there may be sudden bleeding. Immediate recognition of these changes allows time for proper identification of the etiology and the institution of appropriate treatment.

question

For thoracotomy, place A-line where?

answer

Dependent arm to monitor for axillary artery compression

question

For mediastinoscopy, place A-line where?

answer

Right arm to detect compression of innominate artery

question

The patient undergoing a pulmonary resection, and especially a right pneumonectomy, is at risk for ?

answer

postoperative pulmonary edema It is especially important to not fluid overload such a patient, as the likelihood of postoperative edema is greater with increased intraoperative fluid administration

question

The central venous pressure (CVP) may not accurately reflect intravascular volume status, and is no longer recommended as?

answer

a guide for fluid responsiveness

question

SVV > what indicates fluid responsiveness?

answer

13% Less than 9%, unlikely to respond and 9-13% is the gray zone SVV for OLV is well correlated

question

In general, avoid the subclavian approach with CVL/CVP etc with lung surgery, if you cause a pneumo in the only lung you have functioning, then you will?

answer

be publicly shamed as an SRNA and forever be relegated to south main

question

Are PA catheters the bomb for reflecting LVEDV/P?

answer

Heck nah, changes in ventricular compliance can under or over estimate the PCWP and you know this mann!!!

question

What is SvO2?

answer

you better know by now

question

2 PA complications during surgery?

answer

Rupture of PA due to standing at the side of the bed too long holding a retractor and accidentally stapling the PA to the patient because everyone forgot they were there.

question

The use of intraoperative mPAP has been reported to be an indicator of safety for lung resection under thoracotomy. The authors concluded that following occlusion of the main PA, upper safety limits of ___mm Hg for right, and ___mm Hg for left thoracotomy could be used

answer

33 mmHg for Right 35 mmHg for Left

question

Currently, the use of the PA catheter for monitoring during thoracic surgery is generally unnecessary, and may be reserved for patients with ?

answer

pulmonary hypertension

question

TEE may be used to help determine if it is necessary to utilize cardiopulmonary bypass during?

answer

lung transplantation

question

TEE can be used to assess?

answer

Ventricular fx Dynamic Valvular fx Wall Motion Mediastinal Mass resection Detection of Pericardial Effusion

question

Although data are presently limited, it has been reported that decreased cerebral oximetry values by absolute cerebral oximetry during OLV have been correlated with?

answer

postoperative complications

question

The use of noninvasive cardiac output monitoring for thoracic surgery is currently?

answer

not recommended at this time due to poor correlation with thermodilution techniques

question

There is normally a small arterial-to-alveolar CO2 difference of approximately ?

answer

4 - 6 mm Hg

question

During OLV, systemic hypoxemia is usually a greater problem than hypercarbia, why?

answer

Because CO2 is approximately 20 times more diffusible than oxygen and PaCO2 is more dependent on ventilation, compared with PaO2, which is more dependent on perfusion.

question

For the following cards, indicate which lung has more perfusion and which one has more ventilation

answer

You can do it

question

Lateral Position, awake, breathing spontaneously, chest closed

answer

More perfusion and ventilation to the dependent lung

question

Lateral Position, awake, breathing spontaneously, chest OPEN

answer

Essentially just intubate them to alleviate issues. The nondependent lung can cause a mediastinal shift as well as paradoxical breathing exaggerated during inspiration.

question

Lateral Position, anesthetized, breathing spontaneously, chest closed

answer

Increased Perfusion to dependent lung Increased Ventilation to non-dependent lung Results in V/Q mismatch

question

Lateral Position, anesthetized, breathing spontaneously, chest open

answer

Increased Perfusion to dependent lung Increased Ventilation to non-dependent lung Results in V/Q mismatch even greater than chest closed because the non-dependent lung is even more compliant now

question

Lateral Position, anesthetized, paralyzed, chest open

answer

Increased Perfusion to dependent lung Increased Ventilation to non-dependent lung Results in V/Q mismatch even greater than chest open because the non-dependent lung is even more compliant now d/t diaphragm paralysis

question

OLV, anesthetized, paralyzed, chest open-R to L shunt creation

answer

OK... 2 lung ventilation in the lateral position divides the blood flow 40/60 with 60% preferentially going to dependent lung, makes sense. Normally 10% of CO reflects a physiologic shunt being split 5% per lung making the % of CO participating in gas exchange 35/55% respectively. Now OLV, OLV creates an obligatory R to L transpulmonary shunt, the 35% of the blood going to the NDL should be added to the shunt but HPV mitigates this by decreasing blood flow by 50%, so 35/2 = 17.5% plus the original 5% totaling 22.5% NDL shunt plus the 5% for the DL equals a total shunt for both lungs of 27.5% resulting in a PaO2 of ~150.

question

Because 72.5% of the perfusion is directed to the dependent lung during OLV, the matching of ventilation in this lung is important for adequate gas exchange. The dependent lung is no longer on the steep (compliant) portion of the volume-pressure curve because of reduced lung volume and FRC related to?

answer

GA paralysis pressure from abdominal contents compression by the weight of mediastinal structures and suboptimal positioning on the operating table All these create a low V̇/Q̇ ratio and a large P(A-a)O2 gradient.

question

OLV absolute indications?

answer

"CUVI" C-ontrol of distribution of ventilation to only one lung in the case of bronchopleural fistula/cutaneous fistula/cyst/bullae/trauma etc U-nilateral Lung Lavage V-ATS I-solation of each lung to protect the other lung in cases of infection or massive hemorrhage

question

Relative Indications for OLV, high priority?

answer

"T-LUMP" Thoracic AA Pneumonectomy Lung Volume reduction Min Invasive cardiac surgery Upper Lobectomy

question

Relative Indications for OLV, low priority?

answer

Esophageal Middle/Lower Lobectomies Mediastinal mass resection, thymectomy Bilateral sympathectomies

question

The most widely used means of achieving lung separation and OLV?

answer

DLT

question

DLT goes on what side?

answer

Left r/t higher risk of upper lobe obstruction on right side

question

What size DLT to place? Man? Woman ? How deep?

answer

Largest DLT that fits r/t to decrease in airway resistance and less likely to dislodge 39 fr Man, 37 fr Woman Average depth is 29cm

question

Some authors have suggested using the patient height as a basis for selecting a DLT. However, the correlation between airway size and height is ?

answer

extremely poor

question

Inflate bronchial cuff with how many cc's of air?

answer

<2 cc

question

The depth required for insertion of the DLT correlates with the height of the patient. For any adult 170- to 180-cm tall, the average depth for a left-sided DLT is _____cm? and for every 10-cm increase or decrease in height, the DLT is advanced or withdrawn ____cm.

answer

29 cm 1 cm

question

Mac or Miller for DLT insertion?

answer

Mac is preferred

question

The insertion of the DLT is performed with the distal concave curvature facing ?

answer

Anteriorly

question

After the tip of the tube is past the vocal cords, the stylet is removed and the tube is rotated ?

answer

90 degrees to whichever side is desired

question

It is important to remove the stylet before ?

answer

rotating and advancing the tube to avoid tracheal or bronchial laceration.

question

Advancement of the DLT ceases when ?

answer

moderate resistance to further passage is encountered, indicating that the tube tip has been firmly seated in the main stem bronchus

question

Which cuff is inflated first?

answer

Tracheal to ensure bilateral breath sounds and proper placement

question

If breath sounds are not equal, the tube is probably too far down, and the tracheal lumen opening is in a main stem bronchus or is lying at the carina, this can be alleviated by?

answer

Withdrawal of the tube by 2 to 3 cm (this usually restores equal breath sounds)

question

make sure to ventilate both lungs with cuffs inflated and then selectively clamp each side to watch?

answer

watch for absence of movement and breath sounds on the ipsilateral (clamped) side; the ventilated side should have clear breath sounds, chest movement that feels compliant, respiratory gas moisture with each tidal ventilation, and no gas leak.

question

If peak airway pressure during two-lung ventilation is 20 cm H2O, it should not exceed____cm H2O for the same VT during OLV.

answer

40 it shouldn't increase more than double the pre-OLV pressure, if it does, suspect malposition

question

Complications of DLT include?

answer

VC damage Tracheal Rupture Post-op Hoarseness (DLT 44% vs 17% Bronchial Blockers)

question

The upper surface of the blue endobronchial cuff should be?

answer

just below the tracheal carina

question

The use of a DLT is associated with a number of potential problems, the most important of which is ?

answer

malposition

question

The mean distance from the carina to the right upper lobe orifice is ?

answer

2.3 ± 0.7 cm in men and 2.1 ± 0.7 cm in women.

question

The mean distance between the left upper lobe orifice and the carina is? significance?

answer

5.4 ± 0.7 cm in men and 5 ± 0.7 cm in women. The average distance between the openings of the right and left lumens on the left-sided disposable tubes is 6.9 cm. Therefore, an obstruction of the left upper lobe bronchus is possible while the tracheal lumen is still above the carina.

question

There is also a __% variation in the location of the blue endobronchial cuff on the disposable tubes because this cuff is attached to the tube at the end of the manufacturing process.

answer

20%

question

OLV in a patient with a Tracheostomy?

answer

Advance normal ETT down appropriate side using bronchoscope or blindly, soften tube by warming first

question

OLV with difficult airway?

answer

Awake FOI with DLT/SLT SLT with Bronchial Blocker SLT and then tube exchanger

question

Single-lumen tracheal tube with a movable endobronchial blocker?

answer

Univent

question

The disadvantages of the Univent tubes are?

answer

correct positioning difficult to achieve/maintain external diameter is large, may change to SLT at end of surgery blocker can dislocate Seal and effective OLV difficult Bronchial Blocker stiff, hard to direct

question

Fi02 is generally maintained at 100% to protect against hypoxemia and during OLV, the VT should be maintained at what?

answer

Same VT during DLV

question

< 8 ml/kg VT with OLV may lead to?

answer

Atelectasis and a decrease in FRC

question

>15 ml/kg VT with OLV may lead to?

answer

May recruit more alveoli at the expense of increasing PVR and then shunting more blood to the NDL and increasing the shunt and decreasing Pa02.

question

However, recommended VT with OLV is actually?

answer

6-8 ml/kg with 5 cm PEEP

question

Keep EtCO2 at?

answer

35 +/- 3 mmHg

question

Hypocarbia can lead to what in the DL and the NDL?

answer

In the DL it increases PVR In the NDL it inhibits HPV via a vasodilator effect and hence when combined with the increase in blood flow from the DL, the shunt fraction increases and decreases Pa02. Side note...hypocarbia does not directly increase PVR in the DL, hypocarbia still has a vasodilating effect but if you're hypocarbic then you have over ventilated the DL and this increases alveolar pressure which compresses pulmonary vessels and increases PVR, important concept.

question

Shunt effect on PaCO2?

answer

Little effect due to the diffusing capacity of CO2(20x greater) and the fact that ventilation is correlated with CO2 levels which is still being maintained with OLV.

question

What is the recommended mode of ventilation during OLV?

answer

Pressure Ventilation with low VT and a small amount of PEEP (5 cm H20)

question

PEEP via the notes does what?

answer

Increases FRC Improves V/Q Prevents airway and alveolar collapse Increases Lung Volume Increases PVR If only to DL, increases shunt %

question

Essentially PEEP may work in someone with a diseased lung on OLV with a low Pa02 but will have the opposite effect in?

answer

Patients with a higher Pa02 with an adequate FRC as it would actually shunt blood away from the DL making matters worse

question

In summary, in most circumstances PEEP alone would not improve arterial oxygenation, unless ?

answer

it could increase FRC to normal values

question

The single most effective maneuver to increase PaO2 during OLV is the application of?

answer

CPAP to the nondependent lung (10 cm H20) Def gonna be a question lol

question

How to apply CPAP to the NDL?

answer

Give a full breath to NDL, then place continuous pressure on lung which shunts blood away from NDL as well as causing 02 exchange in NDL

question

Don't give CPAP to NDL in what surgery? why?

answer

VATS, as it may increase incidence of post-op air leak d/t possibility of stapling across a partially inflated lung

question

If CPAP to NDL does not improve hypoxemia, then you may?

answer

Add 5-10 cm H20 PEEP to DL Recruitment manuevers(sustained @ 40 cmH20 to be effective) Intermittently inflate/deflate NDL Have surgeon clamp PA to NDL (If applicable) Avoid fluid overload

question

After initiation of OLV, depending on the lung pathology and the intensity of HPV, PaO2 can continue to decrease for up to ?

answer

45 minutes

question

If there is any doubt about the stability of the patient, or if the patient becomes hypotensive, dusky, or tachycardia, what should occur?

answer

DLV should be resumed until the problem has been resolved

question

Preferred anesthetic technique for OLV? why?

answer

A balanced anesthetic technique using inhalational agents with low rates of propofol infusion alone or in combination with remifentanil is the technique of choice during OLV as this would have the least inhibitory effect on HPV.

question

Anesthesia choice in patients with reactive airways undergoing thoracic surgery? Induction choice?

answer

IA for anesthesia Ketamine for induction d/t bronchodilator effect

question

Fentanyl does not appear to influence bronchomotor tone, but morphine may increase tone by?

answer

a central vagotonic effect and by releasing histamine

question

Difference in Pa02 with different IA gases?

answer

No

question

Difference in HPV with IA gases?

answer

Des blunts HPV more

question

Propofol vs IA gas?

answer

Propofol has less HPV but also decreases RV EF compared to gas

question

Sevo may have better clinical outcomes in comparison to propofol with OLV r/t?

answer

Decrease in inflammatory mediators

question

The neuromuscular blocking drugs of choice for thoracic procedures are those that lack a histamine-releasing or vagotonic effect and that have some sympathomimetic effect, In this respect, these 4 MR's probably represent the best choice?

answer

pancuronium, vecuronium, rocuronium, and cisatracurium probably represent the drugs of choice.

question

Current theory for HPV?

answer

Redox Theory

question

All IA inhibit HPV to some extent, when does it become significant?

answer

> 1 MAC

question

IV anesthetics have what effect on HPV?

answer

Little effect

question

Factors associated with an increase in pulmonary artery pressure antagonize the effect of increased resistance caused by HPV and result in increased flow to the hypoxic region, such indirect inhibitors of HPV include?

answer

mitral stenosis volume overload thromboembolism hypothermia vasoconstrictor drugs A large hypoxic lung segment

question

Direct inhibitors of HPV include ?

answer

Inhaled Nitric Oxide infection vasodilator drugs(NTG and SNP) hypocarbia and metabolic alkalosis

question

LA's for a bronchoscopy, first pretreat with?

answer

Drying agent The local anesthetics most commonly used are lidocaine and tetracaine

question

General anesthesia for bronchoscopy is often combined with topical laryngeal anesthesia so less general anesthesia is needed. A balanced technique uses what?

answer

N2O/O2, incremental doses of an intravenous drug such as propofol, an opioid, and a neuromuscular blocking drug. May use LMA/ETT

question

How much does CO2 rise the first minute when apneic? Every minute after?

answer

~6 mm Hg 1st minute ~3 mm Hg every minute after

question

Apneic Oxygenation utilizes oxygen insufflated at how many L/min?

answer

10-15 Liters a minute, not indicated for persons unable to handle the increase in CO2

question

Oxygen from a high-pressure source (50 psig) is delivered, using a controllable pressure-reducing valve and toggle switch, to a 2.5- to 3.5-cm 18- or 16-gauge needle inside and parallel to the long axis of the bronchoscope. When the toggle switch is depressed, the jet of oxygen entering the bronchoscope entrains room air, and the air-oxygen mixture resulting at the distal tip of the bronchoscope emerges at a pressure to provide adequate ventilation and oxygenation

answer

Sanders Injection System The advantages of the Sanders system are that because continuous ventilation is possible (because the presence of an eyepiece is not necessary for ventilation of the lungs), the duration of the bronchoscopy procedure is minimized, but the efficiency also permits extended bronchoscopy. A disadvantage is that entrainment of air by the oxygen jet results in a variable FIO2 at the distal end of the bronchoscope, ventilation of the lungs may be inadequate if compliance is poor, and adequacy of ventilation may be difficult to assess.

question

If putting fiberoptic scope for bronch through ETT, do what?

answer

Turn off PEEP bc scope causes PEEP and barotrauma can occur.

question

In all patients, insertion of the fiberoptic bronchoscope is associated with?

answer

hypoxemia

question

The average decline in PaO2 with a bronch is ?

answer

20 mm Hg and lasts for 1 to 4 hours after the procedure.

question

Mediastinal masses may really pose a challenge to the airway, is the patient dyspneic when supine? if so, not good, be prepared, think about?

answer

Awake FOI, difficult airway cart etc

question

Is the mediastinal mass obstructing >50% of the trachea, is it compressing Cardiothoracic structures? Be prepared, In severe cases of airway compression,what should be done according to barash?

answer

the femoral vessels should be cannulated prior to induction of anesthesia so that if the airway is lost completely cardiopulmonary bypass can be instituted immediately.

question

Relative contraindication for a mediastinoscopy?

answer

SVC syndrome Tracheal Deviation Thoracic Aneurysm

question

For a Mediastinoscopy, the patient will receive GA with MR to avoid coughing, ensure adequate IV access and think about placing what? Why?

answer

A-line The instrument is advanced along the anterior aspect of the trachea and passes behind the innominate vessels and the aortic arch putting the patient at risk for potential blood loss

question

Complications of Mediastinoscopy include?

answer

Hemorrhage Pneumothorax RLN damage

question

What are the 1st and 2nd most common complications of Mediastinoscopy ?

answer

hemorrhage (0.73%) d/t the proximity of major vessels and the vascularity of certain tumors Pneumo (0.66%), often right sided and recognized @ the time it occurs, treat with chest tube

question

With Thoracoscopy & VATS, the surgeon will induce a pneumo to allow visual working space, this can lead to hemodynamic compromise, increases in PIP and increases in what commonly measured parameter?

answer

EtCO2

question

Anesthesia technique for Thoracoscopy & VATS?

answer

This procedure may be performed using local, regional, or general anesthesia; the choice depending on the expected duration of the procedure and the physical status of the patient

question

With VATS, the operated lung should be deflated as soon as possible after tracheal intubation and positioning because it may take how long for complete lung collapse to occur?

answer

over 30 minutes Apply suction to airway to facilitate deflation.

question

With VATS, insufflation pressures should be maintained as low as possible and the CO2 inflow rate kept at ?

answer

<2 L/min

question

Significant hemodynamic changes can be produced when pressures as little as what are used to insufflate CO2 into the chest cavity?

answer

5 mm Hg

question

The potential advantages offered by high-frequency positive-pressure ventilation during thoracic anesthesia are?

answer

lower VT and inspiratory pressures result in a quiet lung field for the surgeon, with minimal movements of airway, lung tissue, and mediastinum.

question

High Frequency Ventilation is how many breaths/min?

answer

60-120 (1-2 hz)

question

High Frequency Jet Ventilation is how many breaths/min?

answer

100-400

question

High Frequency Oscillatory Ventilation is how many breaths/min?

answer

400-2400

question

Vent settings for Lung Bullae?

answer

Spontaneously breathing with low PC ventilation

question

A-line goes in what arm for Trachea resection?

answer

Left Arm to permit continuous measurement of blood pressure during periods of innominate artery compression.

question

Relative contraindication to tracheal resection or reconstruction?

answer

presence of lung disease sufficiently severe to require postoperative ventilatory support

question

Is Myasthenia more common in men or woman?

answer

Women 6:4

question

NDMR dose for MG?

answer

1/10 (May not even use MR)

question

Gabapentin has been successful in reducing pain following thoracic surgery, side effects included ?

answer

dizziness and drowsiness

question

Gabapentin may reduce the incidence of ?

answer

postoperative delirium

question

When to admin Gabapentin?

answer

administer 900 mg 1 to 2 hours preoperatively

question

Intercostal nerve blocks can decrease pain and improve postoperative respiratory function. The intercostal blocks can be performed internally or externally before or after surgery using a standard technique. However, the easiest method is?

answer

during thoracic surgery, have the surgeon perform the blocks under direct vision from inside the thorax while the chest is open.

question

LA for intercostal blocks utilized for thoracic surgery?

answer

Bupivacaine 0.25% to 0.5%, in doses of 2 to 5 mL can be placed in the five intercostal spaces around the incision and in intercostal spaces where chest tubes will be placed. This provides 6 to 24 hours of moderate pain relief, but patients still complain of diaphragmatic and shoulder discomfort caused by the chest tubes

question

Who is more likely to suffer from post-op and chronic pain after thoracotomy ?

answer

Women

question

What % of patients will have atelectasis with thoracotomy?

answer

100% !!

question

The tracheas of many patients can be extubated shortly after thoracic surgical procedures;however, these patients should be observed in the operating room for at least?

answer

5 minutes following extubation, and many will require a high FIO2 by face mask

question

Why is SVT common with pneumonectomy or in patients with Cor Pulmonale?

answer

RV strain leads to dysrhythmias

question

Most important lung capacity to optimize post-operatively?

answer

FRC

question

The low cardiac output syndrome must be differentiated from hypovolemia resulting from ?

answer

intrathoracic hemorrhage tamponade pulmonary emboli mechanical ventilation with PEEP.

question

How much bleeding necessitates re-exploration?

answer

200 ml/hr

question

What nerves are at risk of surgical ligation?

answer

Intrathoracic and RLN

question

The ______ plexus is especially vulnerable to trauma during thoracic surgery.

answer

Brachial

question

2 major post-op concerns with thoracic surgery?

answer

Hemorrhage and pneumothorax

Thoracic Anesthesia in Barash Chapter 37 C.R. – Flashcards

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