VATS – Flashcard

Enables gas exchange at the same time as a variety of instruments changed and maneuvers.
Is very stimulating. Must take into account the fitness of the patient for this procedure. Patient can have a large, even massive pressor response. Risks of hemodynamic, cardiac, or cerebral complications. General anesthesia is the norm for rigid bronchoscopy.

Used predominately for the insertion of DLTs and bronchial blockers for lung separation.
Can be done with topical anesthesia particularly in the very sick.

For short procedures, Propofol and opioid supplementation like fentanyl or alfentanil followed by a short acting paralytic such as anectine.
For longer procedures, more of a TIVA technique with a propofol drip and remifentanil drip with possible paralytic. Pressor response ablation and hemodynamic stability are easily achieved with the TIVA technique.
These techniques are good for procedures such as: foreign body removal, tracheal and bronchial laser resection, and tracheo-bronchial stenting. Sometimes have to compete for airway control with surgeons.

Bad record of awareness. Propofol is protective, BIS monitor, benzo prophylaxis

Manufacturers of bronchoscopy equipment paid little attention to ability to ventilate the patient during these procedures until recently. Rigid bronchoscopy includes equipment with an attachment which makes ventilation possible. A luer fitting with clip, a port for attachment of a jet or high frequency jet ventilator. Ventilation bronchoscope: An attachment that fits on top of the bronchoscope to seal the system, allows volatile agent and oxygen delivery.

Jet ventilation issues: uncontrollable volumes, barotrauma and air-trapping, and no ETCO2 monitoring. In an emergency, the suction port can be used for ventilation. A small ETT can be jammed into the rigid bronchoscope, connected to circuit, and hand ventilated.

Sick patients are destabilized by the excess pharmacology and surgical manipulation. Normal airway pathology may be
slow to re-establish. CO2 retention is a possibility. Recovery end-point is the cough. “the cough and nothing but the cough” in its entirety must be heard before the patient is safe – “so help me cough”.

◦ Coordinated deep inspiration
◦ Closed glottis
◦ Forced expectorating expiration
Can always have obstruction from secretions, blood clots, tumor, laser debris, or pus. May need to re-insert RB or an ETT for a recovery period of IPPV

Extrinsic and intrinsic lesions of the trachea can present as life-threatening emergencies. First aid measure include: airway humidification, steroids, inspiration of oxygen-helium mixtures which can increase laminar flow and decrease turbulent flow. RSI is less likely to precipitate total obstruction when compared to a gas induction sequence.

Before the fiberoptic revolution, difficult airways were not so common, but nevertheless occurred. Rigid bronchoscopy allows for jet ventilation or provides an easy way to place a bougie over which an ETT can be inserted.

Erosion of major blood vessel in the bronchial tree occasionally results in unstoppable bleeding. Hard to see through rigid bronchoscope. Acute hemorrhage is best treated by tamponade with an epinephrine soaked pledget on an applicator through the rigid bronchoscope. May need to use DLT or bronchial blocker.

Most are pin hole leaks presenting post-operatively through which the contents of a pneumonectomy-space leak into the bronchial tree, causing infection and aspiration in the remnant lung. Treatment: drain and isolate lung if required.

almost anything small can be inhaled. Extraction may be easy or prolonged.

Metal rigid broncoscopes reduce the risk, but the risk is not totally negated. Plastic material of fiberoptic bronchoscope is ignitable by the laser. Mandatory that the rigid bronchoscope be ventilated by an air (21%) oxygen driven system.

Advent of self-expanding devices have made it easy for insertion of fiberoptic bronchoscope. May need rigid bronchoscope for solid wall stents.

Able to check placement of DLT or position an endobronchial tube. Used as a guide to difficult intubation. 10% of left-sided DLT will tend to enter the right main bronchus. Observation and auscultation prior to fiberoptic bronchoscopy is helpful before performing FOB.

There is a high risk of patient awareness, there is a significant pressor response to the presence of a bronchoscope, different jet ventilation systems can be efficient, fire in the airway is always a risk when lasers are used so should use 21% O2 air mix, and finally you should use your assessment skills for tube placement along with the fiberoptic bronchoscope.

Video-Assisted Thoracoscopic Surgery

Under local anesthesia in 1910 by Jacobeaus, a Swedish physician.

inability to illuminate the thoracic space and lack of adequate field of vision which held back the development of this technique.

Diagnostic procedures.

Advances in optical systems, endoscopic equipment, and video technology lead to use in more complicated procedures.

Video equipment including telescope, light source, camera, image processor, monitor;
Higher light output power because blood in the operative field will absorb up to 50% of the light;
Single lung anesthesia is necessary to deflate the operative lung;
and proper positioning of the patient.

diagnosis of pleural diseases, cancer staging, management of persistent pneumothorax, retained hemothorax, infected pleural space, collections including empyema and pericardial drainage or window, apical bullectomy, and thoracic sympathectomy which cures palmar hyperhidrosis

Thoracic duct ligation AKA chylothorax, removal of thoracic cyst, vagotomy, lobar resection, thymectomy for myasthenia gravis, and esophageal surgery

Pleural symphysis caused by previous thoracic surgery or pleurodesis, bleeding disorders, end-stage pulmonary fibrosis, respiratory insufficiency, and hemodynamic instability

Plays a bridging role between the medical and aggressive surgical managements. In the treatment of pneumothorax, VATS is superior to pleural drainage and has a complication profile similar to that for thoracotomy. VATS is associated with better preserved cellular immunity and less inflammatory and immunomodulatory response when compared with conventional thoracotomy, which may have an effect on tumor biological behavior.

Anesthesia has been performed under local, regional, or general anesthesia. Pre-medication may include anxiolytics. General anethesia is usually induced with an intravenous agent such as propofol or etomidate. Anesthesia is maintained with an inhalational agent in an air/oxygen mixture. Nitrous oxide is preferably avoided because of the risk of expansion in closed air-filled spaces.

CO2 may be used to insufflate the pleural cavity so as to accelerate lung deflation. Rapid or excessive insufflation of the gas may cause mediastinal shift resulting in: hemodynamic instability, bradycardia, hypotension, hypoxia, and surgical emphysema.

extra caution is recommended for patients with a higher risk profile.

patient age, duration of the VATS procedure, redo-VATS, patients with immune deficiency, conversion to open thoracotomy

Can be oncologically equal to conventional open procedures with an experienced surgeon.

shorter length of hospital stay, decreased post-operative pain, presevered pulmonary function, superior cosmetic result, shorter recovery time, improved delivery of adjuvant chemotherapy, and lower morbidity in patients with poor lung function

Has not been defined although tumors >6 cm in diameter may not be removed without rib spreading. Thoracoscopic procedures are largely dependent on complete lung isolation. Communication between the surgeon and anesthetist is critical.

Thoracotomy. This is necessary when there is an unexpected change in the patient’s condition such as chest wall invasion or the need for a more extensive approach.

1.6 – 2.5% by McKenna et al. in large series by experienced thoracoscopic surgeons.

The patient cannot tolerate one-lung ventilation or develops cardiovascular instability

Anesthetist to provide excellent operating conditions while ensuring patient safety.

segmental or wedge resections

These are very useful surgical techniques facilitating the preservation of lung tissue. These techniques are very good for the excision of benign lesions as maximum lung function is preserved. In malignant disease, cure rate is reduced when compared to lobectomy but is still appropriate in patients unfit for “definitive surgery”. These techniques are only possible if the lesion is located in peripheral lung tissue and is well circumscribed.

can be performed via VATS or thoracotomy. One lung ventilation is often useful but not an absolute requirement. A double lumen tube is useful and should be used if possible. Usually a left-sided tube is ideal.

Malignancy or benign lesions localized to a lobe. The surgery is usually performed through a thoracotomy. Difficulties may arise from tumors invading the chest wall or infections causing pleural thickening or adherence of the lung to the chest wall which results in: increased surgical time, extensive tissue dissection with potentially increased trauma to remaining lung tissue, and the potential for significant bleeding.

“good” lung from contamination of infective material is vital. Careful selection of an appropriate endobronchial tube or bronchial blocker should be done well in advance of induction of anesthesia.

Pt may be on powerful antibiotics or other anti-microbial agents that may have significant toxic effects especially on the renal system. It is important to think about the proposed procedure (or change in procedure) and what physiological impact this may have on the patient.

Most VATS and thoracotomies require the patient to be placed in the lateral decubitus position which requires arching of the table to widen the intercostal spaces on the operated side. Care should be taken to prevent extubation. Protection of eyes and nerve areas is essential to prevent potential nerve damage. Humidification of the anesthetic gases and forced air warming may be used to maintain body temperature.

All thoracoscopic surgeries should be treated as major procedures because of the pathophysiological changes and the potential for morbidity and mortality. Ambulatory surgery is therefore NOT appropriate. A thorough H&P exam with special attention to the cardiorespiratory status is necessary for all patients.

full blood count, serum electrolyte levels, ECG, chest radiographs and CT scans help to make a diagnosis and identify potential problems with airway management

Provide info about the severity of restrictive or obstructive disease including: forced vital capacity (FVC), forced expiratory reserve volume in 1 second (FEV1), and FEV1/FVC ratio. Pre-op optimization of respiratory function is achieved by bronchodilators, cessation of smoking, incentive spirometry, and physiotherapy.

Standard monitoring includes ECG, NIBP, Pulse ox, ETCO2 monitoring, volatile agent concentration, temperature, and peripheral nerve stimulator. Monitoring airway pressure, TV, and minute volume assist in the management of ventilation. Pressure volume loops help in detecting changes in lung compliance and elastance.

A-line monitoring is useful. CVP line may not be required unless the pt has significant history of cardiac problems or poor cardiorespiratory reserve.

Maintain stable CV function, optimize oxygenation and ventilation, minimize airway reactivity and preventing ventilatory depression in the post-operative period. Recognize: pathophysiological changes of lateral decubitus position, problems during one-lung ventilation, existing disease processes, and CO2 insufflation.

Benzo for premedication. Robinol is best avoided because it may cause the patient difficulty in clearing secretions. Induction of anesthesia can be with either propofol or etomidate. Rapid securing of the airway with protection of the healthy lung tissue is vital in patients with infective pathology where contamination is likely.

can be maintained with TIVA or volatile anesthetics. Narcotic analgesia attenuates stress response. Reduces MAC requirement and provides analgesia. Short-acting opiates like alfentanil and remifentanil are very useful. They cause little post-op respiratory depression and help to significantly reduce intra-operative cardiovascular stress.

short-medium acting relaxants should be used such as atracurium which has additional advantage of spontaneous degradation especially if an Eaton-Lambert syndrome exists.

Normocapnea or permissive hypercapnea should be the aim to minimize potential barotrauma or volutrauma. The use of pressure-controlled ventilation is preferred but has the disadvantage that tidal volumes are compliance dependent.

Provide anesthesia, suppress airway reflexes, induce bronchodilation, but have some inhibitory effect on the mechanism of HPV. HPV is a unique autoregulatory mechanism which results in pulmonary vasoconstriction in response to regional alveolar hypoxia (PaO2 = 30 mmHg). Is helpful in minimizing shunt. TIVA has no effect on HPV.

The surgeon should be aware as soon as possible so that the problem is managed smoothly and efficiently. If such communication is not established and the operative lung needs to be re-inflated without notice, disaster could result if this coincided with a critical stage of the procedure and can result in bleeding.

caused by ventilation-perfusion mismatch. Is treated by increasing inspired oxygen concentration, applying PEEP to the ventilated lung, and applying CPAP to the non-ventilated lung with occasional two lung ventilation.

Re-inflation of the non-ventilated lung is needed, not only to reverse the atelectasis, but also to check for significant air leaks. A pressure of 40 cmH2O is suggested as sufficient for this purpose. Careful controlled ventilation will reduce the risk of barotrauma and volutrauma of the ventilated lung. A pressure controlled mode of ventilation is preferred with the aim to keep peak pressures less than 35 cmH2O with clearance of CO2.

The thoracic cavity is closed and airtight with appropriate chest drains connected to underwater seals. Ensure muscle power has returned using nerve stimulator. A degree of permissive hypercapnea is acceptable. Suctioning of the airway is necessary to remove secretions and debris. Extubation of the patient in the sitting position once they are actively attempting to remove the tube is best.

Enables patient the ability to cough to clear secretions, have good chest expansion to clear CO2 and avoid hypoxia. Post-op thoracic pain may contribute to atelectasis and pulmonary complications by preventing deep respirations and coughing.

acetaminophen, NSAIDs, Oral opiates, PCA, local anesthetic infiltration, intercostal nerve blockade, paravertebral block, epidural analgesia.

with low dose bupivacaine and fentanyl provides excellent analgesia. The epidural can be run throughout the procedure so reducing the need for large amounts of opiates. Avoiding opiates will prevent depression of respiratory drive and reduce sedation. Patient better able to cough and clear secretions.

has a good analgesic effect and is often put into place by the surgeons at the end of surgery. Cannot be used to provide intra-operative analgesia.

Routine monitoring of the patient is vital in the recovery room. Portable chest X-ray may be needed to confirm re-expansion of the collapsed lung. Patients should be recovered in an upright position and given supplemental oxygen.

The earliest problem is chest pain either in the axillary, scapular, or back region. This probably results from thermal damage to the parietal pleura and the periosteum over the ribs.

May be caused either by injury to the blood vessels or by lung perforation.

Pt may have pre-existing lung disease, lung deflation and pain may encourage sputum retention, decreased functional residual capacity (FRC), ventilation perfusion mismatch, and atelectasis.

Resection of the entire lung is necessary when lesser lung resection techniques will not provide a curative procedure. Mortality rate is about 5%. Surgery is performed through a thoracotomy incision. Hilar structures are dissected and ligated. Main bronchus is divided to leave as short a stump as possible. Bronchial stump is tested by applying a positive pressure of at least 40 cmH2O to the airway.

The use of a DLT to the non-operative side is the ideal. It protects the remaining lung from contamination with blood, secretions, or infective material from the removed lung. Allows for airway toileting once the lung is removed. With one-lung ventilation, hypoxia is always a potential problem. Early clamping of the main pulmonary artery reduces shunt and will improve oxygenation. Cardiovascular monitoring is of great importance. An a-line is useful for accurate and responsive blood pressure monitoring as well as ABG analysis.

CVP very useful in helping with fluid monitoring especially right heart filling pressures. With loss of pulmonary vascular compliance, right myocardial function may be compromised and lead to the development of post-pneumonectomy pulmonary edema. Avoidance of excessive crystalloids with the use of colloids or blood has been suggested as a mechanism to reduce the development of pulmonary edema.

Careful management of ventilation of the non-operative lung is crucial to prevent volu- or barotrauma. Use of a pulmonary artery catheter is not recommended due to difficulty in placing catheter. Also, following lung resection, inflation of the balloon may be detrimental to myocardial function as even more of the vascular bed is occluded.

during the resection of the lung significant arrhythmias may occur due to handling of the hilum and manipulation near the heart. Reduction of venous return due to occlusion of the vena cava may occur. Anti-arrhythmic agents may be necessary intra-operatively or post-operatively.

The same techniques as were discussed following lobectomy should be employed. Special care should be taken with fluid balance if epidural analgesia is used. Changes in the ECG may occur following surgery. If pericarditis occurs, this could be confused with ischemia. A-fib is common.