Adv Principles Week 5 - Thoracic Surgery

Front 1

Some practitioners prefer which blade for double lumen tube insertion?
A. MAC
B. Miller

Back 1

A. MAC because it offers greater clearance for the tube and may decrease the chance of balloon rupture from the teeth.

Front 2

For laryngoscopy the double lumen tube is lubricated and advanced with the distal curve ____________ anteriorly until the vocal cords are passed.
A. Convex
B. Concave

Back 2

B. Concave, after the cords are cleared the stylet is removed as in standard intubation.

Front 3

During DLT insertion, the cords are cleared and the tube is rotated _____degrees toward the bronchus to be intubated and andvaced to around ______cm in females or _______cm in males.

Back 3

During DLT insertion, the cords are cleared and the tube is rotated _90____degrees toward the bronchus to be intubated and andvaced to around __27____cm in females or ____29___cm in males

Front 4

The tracheal cuff of a DLT requires _______ml of air and the bronchial cuff requires ______ml of air.

Back 4

Tracheal=5-10
Bronchial =1-2

Front 5

Overinflation of the bronchial cuff of a DLT can cause which of the following:(choose all that apply)
a. narrowing of the lumen
b. occulsion of the lumen
c. increased risk of tearing the bronchus.
d. I dont know and I hope I no one pimps me on this question.

Back 5

All are technically true :)

Front 6

The bronchial cuff is a:
a. low volume low pressure cuff
b. low volume high pressure cuff
c. high volume low pressure cuff
d. high volume high pressure cuff.

Back 6

B. Low volume high pressure
-The cuff should therefore be deflated during the prcedure once OLV is no longer needed.

Front 7

True or False: Ausculatation of breath sounds is a simple and highly reliable method of assessing the position of a DLT.

Back 7

False: Simple NOT highly reliable

Front 8

What is the gold standard of verification of DLT placement?
a. vaginal hysteroscopy
b. laryngoscopy
c. laprsocopy
d. fiberoptic bronchoscopy

Back 8

D. Fiberoptic bronchoscopy

Front 9

Which of the following are advantages of fiberoptic inspection of the DLT over auscultation (choose all that apply)
a. guidance during initial placement
b. ability to visualize correct depth of bronchial cuff
c. visualization of proper positioning of the right upper lobe if present
d. removal of aspirated corn from the lung.

Back 9

A, B, C, D

Front 10

You have verified DLT placement in the supine position and need to turn your patient to the lateral position. Do you need to revisualize placement?

Back 10

Yes, because in turning to the lateral position the DLT will commonly wihtdraw from the bronchus by 1 cm.

Front 11

A fiberoptic bronchoscope of 4.9 mm external diameter can be lubricated and passed through an endobronchial tube of size ______french or larger.
a.20
b.25
c.30
d.35
e.37

Back 11

37

Front 12

A fiberoptic bronchoscope of 3.6mm can pass through a _____french tube.
a. 25
b.35
c.45
d.55

Back 12

B. 35

Front 13

When the bronchoscope is placed down the right lumen to determine precise left sided double lumen tube position, the endoscopist should see a clear straight ahead view of the tracheal carina, the left lumen going off into the left mainstem bronchus, and most important the upper surface of the left endobronchial cuff just below the carina.

Back 13

.

Front 14

Box 28-4
Auscultation of breath sounds after placement of a DLT
1. Inflate the tracheal cuff
2. Verify bilateral equal breath sounds. If breath sounds are present on one side , both lumens are in the same bronchus. Deflate the cuff and withdraw the tube 1 to 2 cm at a time until breath sounds are equal bilaterally.
3 . inflate the endobronchial cuff
4. Clamp the endobronchial lumen and open its lumen cap proximal to the clamp
5. verify breath sounds in teh correct lung and the absence of breath sounds in the opposite lung.
6. Verify that breath sounds are equal at the apex of the lung and at the lateral lung. If the apex is diminished withdraw the tube until upper lung sounds return.
7. Verify the absence of air leakage through the opposite lumen cap.
8. Unclamp the endobronchial lumen and verify bilateral breath sounds.
9. Clamp the tracheal lumen and open its cap.
10. Verify breath sounds opposite the lung with the endobronchial lumen and the absence of breath sounds on the other.
11. when absolute lung separation is needed, as in bronchopulmonary lavage, connecting a clamped lumen to an underwater drainage system will show air bubbles if a leak is present.

Back 14

I will definitley not remember all of this.

Front 15

Fiberoptic bronchoscopy to verify placment of a DLT box 28-5
1. insert the scope through the tracheal lumen. Visualize the carina distally.
2. Visualize the endobronchial (BLUE) cuff 1-2mm beyond the carina. Ensure that the cuff is not too proximal or overinflated such as to herniate across the carina and obstruct the contralateral bronchus.
3. Insert the scope through the bronchial lumen. Visualize that the tip of the bronchial lumen is unobstructed. For left side tubes, visualize the LUL bronchus distal to the tube tip. For right sided tubes with a RUL ventilation port, visualize that the RUL bronchus is aligned with the ventilation port.

Back 15

.

Front 16

True or False: Placement of DLT's carry a higher risk compared to laryngoscopy and intubation with endotracheal tubes.

Back 16

False: The risk is the same.

Front 17

Ideal placement of a right sided DLT will reveal the fenestrated bronchial cuff situated adjacent to the RUL takeoff.

Back 17

True. If insertion is too shallow the bronchial cuff may herniate over the carina or frankly obstruct tracheal flow . This would allow ventilation through the brochial lumen only and depending on how shallow the tube is, would ventilate one or both lungs. (figure 28-13 B pg 640)

Front 18

True or False: The threat of obstructing the LUL bronchus with a DLT is great.

Back 18

False: the risk is slight because of the longer distance to the LUL bronchus.

Front 19

T/F: When 80% of the lung is hypoxic (ie. during OLV), HPV will increase PVR and thus increase workload for the right heart.

Back 19

TRUE

Front 20

All of the following decrease HPV except which one:
a. acidosis
b. alkalosis
c. hypocapnia
d. hypoxia
e. high card output
f. hypervolemia

Back 20

D. hypoxia increases hpv

Front 21

What purpose does HPV serve?
a. decreases shunt flow
b. increases shunt flow
c. decreases dead space
d. reduces pulm vascular resistance

Back 21

A. Reduces blood flow to poorly ventilated alveoli thus reducing the shunt

Front 22

Which of the following drugs does not effect HPV?
a. propofol
b. fentanyl
c. NTG
d. cardene

Back 22

A & B do not effect HPV.
note: dopamine, neo, epi preferentially constrict the good areas of the lung over the poorly ventilated (areas of HPV) so the shunt is re-established (pg 642)

Front 23

T/F: inhalation agents should not be used during one lung vent (OLV) b/c they inhibit hypoxic pulm vasoconstriction (HPV).

Back 23

False: They do not affect HPV at less than 1.5MAC. They are preferred b/c they allow the use of high FiO2, provide bronchodilation, decrease airway irritability during manipulation, and are cleared quickly allowing for extubation.

Front 24

T/F: N2O is the preferred agent for OLV.

Back 24

False: it is avoided b/c it can cause increased PVR and prohibits the use of 100% O2.

Front 25

T/F: N2O is a good choice of anesthetic for a pt with Cor Pulmonale.

Back 25

False. N2O increases PVR and thus increases Right heart workload

Front 26

Which of the following is NOT a goal of OLV management:
a. TV 10-15ml/kg
b. TV 6ml/kg
c. modest peep
d. plateau pressures <25cmH2O

Back 26

A is not

Front 27

During OLV your pt becomes hypoxemic. After ruling out physiologic causes, what is one intervention that is almost 100% effective in increasing PaO2?
a. CPAP to the nonventilated lung
b. increase RR of ventilated lung
c. increase TV of ventilated lung
d. manually bag the pt

Back 27

A (pg 643, NAG). This is b/c shunt flow thru the non-ventilated lung is usually the cause of hypoxia

Front 28

During OLV, if PEEP and CPAP aren't maintaining an approp PaO2, what can the surgeon do to improve oxygenation if doing a pneumonectomy?
a. early ligation of the pulm artery
b. work faster
c. allow reverse t-burg positioning
d. nothing

Back 28

A. ligating the PA will resolve the shunt

Front 29

Pleural pressure increases how much for each cm farther down the lung you go?

Back 29

.25 cm for every 1 cm down the lung

Front 30

The increase in pleural pressure as you go down the lung does what to the volume?

Back 30

decreases fourfold

Front 31

Which lung gets more of the TV int eh lateral position: dependent of nondependant?

Back 31

dependent

Front 32

Where is perfusion the greatest in the lateral position: dependent lung or nondependent lung?

Back 32

dependent

Front 33

anesthesia induction has what effect on FRC?

Back 33

decreases almost immediately

Front 34

Back 34

effects of gravity on distribution of pulmonary ventilation and blood flow

Front 35

How does anesthesia affect the dependent lung in the lateral position?

Back 35

it loses a greater amount of FRC than the nondependent lung

Front 36

Why is there a VQ mismatch in the lateral position?

Back 36

relative FRC in nondependent lung increases in contrast to dependent lung, which decreases compliance in the dependent lung. Ventilation is preferentially distributed to nondependent lung, but blood goes ( gravity) to dependent lung-making a VQ mismatch

Front 37

Back 37

VQ relationship in anesthetized, open chest pt

Front 38

Back 38

ventilation in awake vs. anesthetized closed chest pt.

Front 39

Once a pt is induced and mechanically ventilated, what happen to FRC? What can be done about it?

Back 39

Further declines. Can add PEEP to restore FRC

Front 40

An open chest, mechanically ventilated lung has
(increased or decreased) compliance?

Back 40

increased

Front 41

Aggressive treatment of acute or reversible components of respiratory disease greatly decreases the risk of postop complications for Thoracic surgery.

What are some treatable preoperative conditions?

Back 41

-Infection
-excess bronchial secretions
-bronchospasm
-dehydration
-electrolyte imbalance
-cigarette smoking
-alcohol abuse
-malnutrition

Front 42

Transient increases in mucus production may increase complications in pt's who have surgery within ________ months of stopping smoking.

a. 1 month
b. 1/2 month
c. 2 months
d. 3 months

Back 42

2 months

Front 43

All pt's require contiuous monitoring of the ECG during Thoracic surgery. Which leads will help detect more than 85% of ischemia

Back 43

leads II and V5

Front 44

Where are arterial cannula's generally placed for thoracotomies?

Back 44

In dependent arm, where it is more easily stabilized.

Front 45

For mediatinoscopy, the arterial line is typically placed in the right arm for which reason?

Back 45

detects compression of the innominate artery and helps prevent a decrease in cerebral blood flow.

Front 46

What is another monitoring technique that can be used to detect compression of the innominate artery (other than A-line)

Back 46

pulse oximeter probe placed on right hand.

Front 47

This type of monitoring is not required for thoracic surgery but may be useful if the pt's volume status is unclear or if large fluid shifts are anticipated

Back 47

CVC

Front 48

What type of CVP line is more easily kinked in the lateral position

Back 48

external jugular line

Front 49

This type of monitoring may be indicated in the presence of a history of severe C.V. disease, valvular heart disease, or significant PHTN

Back 49

Pulm Artery Cath

Front 50

Type of monitoring intended to provide estimation of left ventricular pressures and facilitate the improvement of cardiac perform. with fluids and cardiovascular drugs

Back 50

Pulmonary artery pressure

Front 51

What 2 things may alter the resistance in pulmonary vessels and reduce the correlation between pulmonary artery occlusion pressure and left ventricular pressure

Back 51

-Lung pathology

-hypoxic pulm. vasoconstriction

Front 52

More than ____% of pulmonary artery catheters float into the right lung

Back 52

90%

Front 53

If the Pulm Catheter floats into the right lung during a right thoracotomy, then, the catheter will likely be in the nondependent, collapsed lung. What would this cause?

Back 53

it would give a false low reading for cardiac output

Front 54

What is the most frequent position chosen for surgical exposure during thoracotomy

Back 54

lateral decubitus

Front 55

Why is an axilla roll used for the lateral decubitus position?

Back 55

to prevent compression of the neurovascular bundle and forward rotation of the humeral head

Front 56

Hyperabduction of the arms in the lateral decubitus position is prevented to keep what from happening?

Back 56

keeps the brachial plexus from stretching against the humeral head

Front 57

Lateral flexion of the neck can cause what?

Back 57

compression of the jugular veins or vertebral arteries, compromising cerebral circulation

Front 58

What are two pressure points of concern in the lateral position

Back 58

-peroneal nerve:

* in area of the fibular head of dependent leg

* and the femoral head of the nondependent leg if a stabilizing strap is placed over the patient

Front 59

In the spontaneously breathing, upright person, blood perfusion increases __________ from:

a. apex to base of lung
b. base to apex of lung

Back 59

increases linearly

from apex to base

Front 60

In what portion of the lung are flows greatest in the upright position.

Back 60

greatest in the base

very low rates in the apex

Front 61

Where is pleural pressure most negative?

Back 61

the apex of the lung

*this keeps alveoli distended

Front 62

Are dependent alveoli more or less distended

Back 62

less distended and therefore more compliant

Front 63

is most "tidal breath" distributed to the non-dependent or dependent alveoli

Back 63

dependent

Front 64

Lung Zones (think tic-tac-toe)

Zone 1
Zone 2
Zone 3

Back 64

1= "PA">Pa>Pv
2= Pa>"PA">Pv
3= Pa>Pv>"PA"

Front 65

The tendency of the top of the lung to collapse inward creates a relatively ___________pressure at the apex, and the tendency of the bottom of the lung to spread outward creates a relatively ______pressure at the base

Back 65

negative

positive

Front 66

Pleural pressure increases by _____cm H2O per centimeter of lung dependency

Back 66

0.25cm H2O

Front 67

What is a life threatening complication of DLT placement?

Back 67

Vocal cord paralysis

Front 68

What effect does hypoxemia have on the pulmonary arteries (except for the proximal pulmonary arteries)?

Back 68

vasoconstriction

Front 69

Onset and resolution of HPV occur very fast/slow following changes in tissue Po2?

Back 69

Fast

Front 70

HPV is triggered by ________ hypoxemia?

a. arterial
b. alveolar

Back 70

b. alveolar

Front 71

HPV decreases the blood flow to the nondependent lung by?
a. 20%
b. 30%
c. 50%
d. 60%

Back 71

c. 50%

Front 72

Name the symptoms of Mediastinal Mass

Back 72

Sweats
Syncope
Orthopnea
Hoarseness
Inability to lie flat
Chest pain or fullness
Superior vena cava Obstruction
Cough(especially when supine)

Front 73

What can reveal whether the supine position of a patient with Mediastinal Mass will exacerbate obstruction intraoperatively?

Back 73

Comparison of flow rates obtained with the patient in the upright and supine positions

Front 74

The following tests may further delineate the size and effects of a mediastinal mass?
A. Computed tomography
B. Transesophageal echocardiography
C. Abdominal radiograph
D. MRI

Back 74

A, B, D.

Front 75

Flow-volume loops DO/DO NOT demonstrate a high correlation to the degree or severity of airway compression.

Back 75

Caution: They DO NOT.

Front 76

What type of gas mixture can improve airflow during partial obstruction? and why?

Back 76

Helium-O2
The use of low-density gas decreases turbulence past a stenotic area, improving flow and decreasing the work of breathing.

Front 77

What is Mediastinoscopy?

Back 77

-Passing a scope into the mediastinum via an incision above the suprasternal notch.

Front 78

What are complications of mediastinoscopy?

Back 78

-pneumothorax
-Hemorrhage
-Arrhythmias
-Bronchospasm
Laceration of the esophagus
Chylothorax secondary to laceration of the thoracic duct.

Front 79

What is Superior Vena Cava syndrome?

Back 79

-A venous engorgement of the upper body caused by compression of the superior vene cava by a mass.

Front 80

Compression of great vessels by Mediastinal Mass can lead to the following:
A. Chylothorax
B. Sudden hypoxemia
C. Hypotension
D. Cardiac Arrest

Back 80

B, C, D.

Front 81

What type of gas mixture can improve airflow during partial obstruction? and how?

Back 81

-Helium-O2 mixture
-The use of low-density gas decreases turbulence past a stenotic area, improving flow and decreasing the work of breathing.

Front 82

True or False:
Pain after an open thoracotomy is generally more easily managed than after thoracoscopy.

Back 82

False-the reverse is the case(because the incision in thoracoscopy is smaller, and spreading of the ribs is avoided).

Front 83

True or False:
Patients for thoracic procedure are generally at risk for cardiopulmonary morbidity.

Back 83

True.

Front 84

What are Bullae?

Back 84

-Air-filled spaces of lung tissue resulting from the destruction of alveolar tissues and consolidation of alveoli into large pockets.

Front 85

During general anesthesia for bullous disease, to reduce the risk of rupture of bullae, what type of ventilation is desirable?

Back 85

Spontaneous ventilation

Front 86

What type of gas should be avoided in bullous disease because it rapidly enlarges the air-filled spaces?

Back 86

Nitrous oxide

Front 87

Absolute Indications for seperation of the two lungs (Double-Lumen Tube Intubation) or OLV:
A. Isolation of one lung from the other to avoid spillage or contamination
B. One lung doesn't like the other
C. Control the distribution of ventilation
D. Unilateral bronchopulmonary lavage

Back 87

C. Control the distribution of ventilation
D. Unilateral bronchopulmonary lavage

Front 88

Relative Indications for seperation of the two lungs (Double-Lumen Tube Intubation) or OLV:
A. Surgical exposure - high priority
B. Surgical exposure - medium (lower) priority
C. Postcardiopulmonary bypass pulmonary edema/hemorrhage after removal of totally occluding unilateral chronic pulmonary emboli
D. Severe hypoxemia related to unilateral lung disease

Back 88

A. Surgical exposure - high priority
B. Surgical exposure - medium (lower) priority
C. Postcardiopulmonary bypass pulmonary edema/hemorrhage after removal of totally occluding unilateral chronic pulmonary emboli
D. Severe hypoxemia related to unilateral lung disease

Front 89

What type of double-Lumen Tubes to intubate left bronchus?

Back 89

Carlens with carinal hook OR
Robertshaw with no carinal hook

Front 90

What type of double-Lumen Tubes to intubate right bronchus?

Back 90

White with carinal hook OR
Robertshaw with no carinal hook

Front 91

How do you determine tube size for right and left double lumen tube?

Back 91

Determined by measurements of tracheal width from chest radiograph

Front 92

Which lung separation devices are placed using fiberoptic bronchoscopy?

Back 92

Left-sided DLT, Fogarty occlusion catheter, & Univent blockers
Right sided DLT & WEB blockers with guided technique

Front 93

Which lung separation devices use a standard ETT at least 6mm in diameter?

Back 93

Fogarty occlusion catheter and Univent blockers

Front 94

Which lung separation devices use a standard ETT at least 8mm in diameter?

Back 94

WEB blockers

Front 95

Which lung seperation devices is indicated for Majority of elective left or right thoracic surgical procedures?

Back 95

Left-sided DLT

Front 96

Which lung seperation devices is indicated for distorted left bronchus anatomy; left pneumonectomy?

Back 96

Right-sided DLT

Front 97

Which lung seperation devices is indicated for critically ill patient, small bronchus, difficult airway, nasotracheal intubation?

Back 97

Fogarty occlusion catheter

Front 98

Which lung seperation devices is indicated for selective lobar blockade, difficult airway requiring lung separation?

Back 98

Univent blockers

Front 99

Which lung seperation devices is indicated for critically ill patients, selective lobar blockade, difficult airway, nasotracheal intubation requiring lung seperation?

Back 99

WEB blockers