Ap 2 Thoracic Anesthesia And One Lung

Front 1

What % of CA pts are non-smokers?

Back 1

10%

Front 2

Bronchopulmonary s/s of a presenting CA pt include?

Back 2

Cough-75%
Sputum changes-57%
Chest pain-40%
Dyspnea-30%
Wheezing-10%

Front 3

Extrapulmonary Intrathoracic s/s of a presenting CA pt include?

Back 3

Pleural effusion
Chest wall pain
Dysphagia
SVC syndrome-decreased flow thru the SVC
Brachial Plexus-Horner’s Syndrome, Arm pain
RLN-Hoarseness

Front 4

What is Horner’s Syndrome?

Back 4

Mydriasis-dilation
Anydrosis-dry
Ptosis-droopy eyelid

Front 5

Metastasis occurs primarily to what areas with thoracic CA?

Back 5

CNS
Skeletal
Hepatic

Front 6

What electrolytes are of most concern in CA pts?

Back 6

Na+ - SIADH
Hypercalcemia-paraneoplastic syndromes

Front 7

SIADH is commonly associated with what type of CA?

Back 7

Small cell CA (Oat cell CA)

Front 8

Physical Exam preop of a thoracic CA pt should focus on what body systems primarily?

Back 8

Pulmonary/CV

Front 9

Obtaining certain preoperative labs is guided by what rationale?

Back 9

Survivability of pt from lung removal compared to the type of sx being performed

Front 10

Most thoracic CA is found how?

Back 10

Routine pre-employment physicals because routine CXR can dx CA 7 mths prior to symptoms

Front 11

Where is most CA located?

Back 11

In the lung parenchyma

Front 12

A PTX will cause a tracheal shift in which direction?

Back 12

To the opposite side

Front 13

Thoracic CA will cause a tracheal shift in what direction?

Back 13

To the same side unless mass is large enough to push the trachea away

Front 14

Induction concerns with pts that have Bullous disease include?

Back 14

That high PAP from induction and ventilation can blow the bullae

Front 15

Which type of CA is most aggressive and deadly?

Back 15

Small Cell CA (Oat cell CA)

Front 16

Where is small cell CA usually found on the xray?

Back 16

In the large central airways

Front 17

What areas do small cell CA usually origionate?

Back 17

Neuroendocrine

Front 18

The difference b/t Adenocarcinoma and Squamous Cell CA is?

Back 18

Adeno CA is worse stage for stage

Front 19

Where are Adeno CA’s found on xray?

Back 19

In the periphery of the lung

Front 20

Squamous Cell lung CA grow where in the lung?

Back 20

Main/Lobar/Segmental bronchi which ulcerate thru the mucosa into surrounding parenchyma

Front 21

Large cell CA present where in the lung?

Back 21

Periphery

Front 22

Large cell CA have what concern with sx?

Back 22

Extensive growth causing increased bleeding and necrosis of tissue

Front 23

Concern with EKG changes in CA pts is?

Back 23

Need for further evaluation if CAD is present

Front 24

Concern with Right atrial /ventricular strain and hypertrophy on EKG is?

Back 24

Post pneumonectomy that pulm edema may occur
May need better intraoperative monitoring

Front 25

RVH presents how on EKG?

Back 25

Low voltage and poor R wave progression

Front 26

RAH presents how on EKG?

Back 26

Lead II has tall symmetric P waves

Front 27

Goal of PFT testing?

Back 27

How much lung can be removed and identify who needs post op vent support
Survivability of lung resection

Front 28

Evaluation of the reversibility of obstructive diseases is met by what criteria on the PFT?

Back 28

Response to tx increases PFT values by @ least 15%

Front 29

Normal VC in a patient?

Back 29

60-70 cc/kg

Front 30

VC must be how much for an effective cough?

Back 30

3 x Vt

Front 31

Vital capacity is made up of what values?

Back 31

IRV-3000 cc
Vt-500 cc
ERV-1200cc

Front 32

What is the volume of FRC?

Back 32

2400cc

Front 33

What makes up FRC?

Back 33

ERV-1200cc
RV-1200cc

Front 34

What is the volume of Inspiratory Capacity (IC)?

Back 34

3500cc

Front 35

What makes up IC?

Back 35

IRV-3000 cc
Vt-500cc

Front 36

Vital capacity is made up of what values?

Back 36

IRV-3000 cc
Vt-500 cc
ERV-1200cc

Front 37

What is the volume of FRC?

Back 37

2400cc

Front 38

What makes up FRC?

Back 38

ERV-1200cc
RV-1200cc

Front 39

What is the volume of Inspiratory Capacity (IC)?

Back 39

3500cc

Front 40

What makes up IC?

Back 40

IRV-3000 cc
Vt-500cc

Front 41

Anesthesia has what affects on lung volumes?

Back 41

All volumes and compliance are decreased except RV; RV increases

Front 42

If RV is increased from anesthesia then why is FRC decreased?

Back 42

The decrease % of ERV is much larger than the increase in RV %

Front 43

Why does it take so long to preoxygenate obstructive patients?

Back 43

Obstructive pts have a much larger increase in dead space-will desaturate faster

Front 44

The effort dependent portion of a flow volume loop is represented where?

Back 44

At the beginning of peak inspiration to the beginning of the FEV 25-75.

Front 45

What portion of the flow volume loop is effort independent?

Back 45

The FEV 25-75.

Front 46

What does the effort independent represent?

Back 46

The inability to make small airways less resistant with any further muscle contraction

Front 47

Flat topping of the flow volume loop represents what?

Back 47

Difficulty with expiration

Front 48

Poor preoperative tests of prediction of outcome include?

Back 48

PaCO2>46
PaO2<60
FVC <50% or 15 ml/k
FEV1<50%
VC<2L or <50%MVV<50% or 50L/min (Maximal ventilatory volume, nml is 170)
Lung volume of RV/TLC >50% (indicates that 3L of volume can’t move b/c TLC is around 6L)
Dlco <50%

Front 49

Split lung function testing can be performed what values are poor indicators for optimal outcome?

Back 49

Predicted post resection FEV1<800ml (normal should be 3300cc)
Flow to the desired resected lung is >70% because then all flow will go to the other lung

Front 50

What is the result of resecting a lung that receives 70% blood flow?

Back 50

RV failure
Flow = Pulm HTN = vessels blow and pt dies

Front 51

FEV1 should normally be what % of FVC?

Back 51

75%

Front 52

Post op Trial of PA occlusion testing will demonstrate poor outcomes if what values are met?

Back 52

PA pressure>35-40 torr
PaO2<45 torr
Severe SOB
PaCO2>60 torr

Front 53

Pts with chronic pulmonary issues may exhibit what blood volume state?

Back 53

Polycythemia due to chronic hypoxia

Front 54

Pts with CA may present with what blood volume state?

Back 54

Anemia due to chemo tx = myelosupression

Front 55

Smoking cessation 24hrs prior to sx demonstrates what benefits?

Back 55

Not much-may have some decrease in COHgb, lower HR, may increase anxiety, secretions, continued reactivity

Front 56

Smoking cessation should be stopped how far in advance of sx for maximal benefit?

Back 56

4-8 wks- increase mucous clearance and small airway secretions, decrease reactivity

Front 57

Preop concerns with pulmonary cripples?

Back 57

Blunting hypoxic drive with anxylysis
Dilation w/ B2 agonists, Theophylline, Cromolyn
Secretion mobilization

Front 58

What is Cromolyn?

Back 58

Mast cell stabilizer that needs given 3 days in advance of required benefit

Front 59

Intraoperative monitoring for pulmonary pts should be guided by what cardiac status?

Back 59

LV functioning

Front 60

Anesthesia for bronchoscopy can be carried out in what manners?

Back 60

MAC w/ topicalization- if SLN block done be sure to check ability to exchange after finished
General + topicalization

Front 61

Your patient is building up CO2 and/or becoming hypoxic and your jet ventilator is not working what will facilitate oxygenation when bronchoscopy is in use?

Back 61

Packing the throat with gauze

Front 62

What crisis may occur with flex bronchoscopy via the ETT?

Back 62

Barotrauma if small enough bronchoscope isn’t used
Need to D/C any existing PEEP with brochoscopy

Front 63

What is the largest brochoscope that will fit in a # 7.0 ETT?

Back 63

5.7 mm OD scope- barely

Front 64

What is mediastinoscopy mainly used for?

Back 64

Sampling of nodes
Usually a diagnostic tool

Front 65

What is the Azygous Vein?

Back 65

Major vein draining the upper portion of the body into the SVC

Front 66

What two divisions of the mediastinum will your sx usually involve?

Back 66

Superior-Trachea, Brachiocephalic, Aortic Arch, Esophagus, Thoracic duct
Anterior-Small vessels, and Thymus

Front 67

Where should the ETT position be for a mediastinoscopy?

Back 67

Off to the left side of the head

Front 68

Where should the Aline be for a mediastinoscopy?

Back 68

Right side- and A line on the left- both sides will indicate if BP is lost

Front 69

Complications of mediastinoscopy?

Back 69

Hemmorrhage-0.73%
Air embolism if hemorrhage is venous
PTX-0.66%
RLN injury-0.34%
Apparent Cardiac Arrest- loss of right radial pulse and pressure due to compression of the Brachiocephalic vein.

Front 70

PTX would occur mostly on what side?

Back 70

The right due to three lobes

Front 71

RLN injury would occur why?

Back 71

Because it loops around the aortic arch on the left and the Brachiocephalic on the right.

Front 72

What might one see that would clue you in to check the RLN injury prior to extubation during sx?

Back 72

A lot of vagal symptoms during surgery

Front 73

Anesthetic considerations for Anterior and Superior mediastinal masses should include what considerations?

Back 73

Potentially disastrous
Careful planning
AP/Lat CXR
Plan for intubation- no quickies

Front 74

What are the absolute indications for one-lung ventilation?

Back 74

Isolation to prevent contamination/hemorrhage
Control for ventilation
Fistulas
Bullae/Cyst
Bronchial disruption
Lavage

Front 75

Relative indications for one-lung ventilation include?

Back 75

Surgical exposure
Thoracic aneurysm
Pneumonectomy
Lobectomy
Esophageal sx
Thoracoscopy

Front 76

What is the difference between the Carlens left, White right, and Shaw-bilateral DLT?

Back 76

The Shaw does not have a carinal hook

Front 77

Sizes of DLT for males and females?

Back 77

Males Females
37
35
39 37
41 39

Front 78

In the spontaneously breathing patient the dependent lung exhibits what characteristics?

Back 78

Best ventilated and best perfused but not necessarily the best VQ match b/c diaphragm contracts on the dependent lung.

Front 79

The formula for compliance is?

Back 79

Change in volume / Change in pressure

Front 80

Normal compliance in the spontaneously breathing patient is?

Back 80

100-150 cm/H2O

Front 81

Normal compliance in the controlled ventilated pt is?

Back 81

50-100 cm/H2O

Front 82

What do we actually see in the OR?

Back 82

25-50 cm/H2O

Front 83

What happens to compliance in the anesthetized patient?

Back 83

decreases

Front 84

What happens in the open chest during anesthesia in the lateral position?

Back 84

Up lung will hyperinflate and come out of the opening and inflate even more until ruptures
Blood flow in the dependent lung increases - Expansion decrases in dependent lung----Up lung more zone 1

Front 85

What key factors will occur in the open chest?

Back 85

Mediastinal shifting will occur in either anesthesthetized or spontaneous ventilated states
Rebreathing or wasted ventilation in the spontanesously breathing patient

Front 86

What occurs to blood flow during conversion to one-lung ventilation?

Back 86

Shunt will 
PaO2 will  significantly which is normal
Dependent lung will receive 30% of the bloodflow and increase from 60%

Front 87

What occurs with HPV in one lung lateral position anesthesia?

Back 87

HPV is blunted

Front 88

What agents will decrease HPV?

Back 88

Aminophylline, B2 agonists, CaCh blockers, DBT,Epi.Isuprel, IA, Minoxidil,NTG, Nipride

Front 89

In a left sided DLT if the bronchial tube is clamped airflow goes where?

Back 89

The trachea to inflate the right lung

Front 90

The left mainstem is how long?

Back 90

5 cm

Front 91

The right mainstem is how long?

Back 91

2.5 cm

Front 92

The DLT should reside where at the lip if properly seated?

Back 92

27-30cm

Front 93

How long is the trachea?

Back 93

12 cm

Front 94

The posterior portion of the trachea is what shape?

Back 94

D shape-flat on the bottom

Front 95

The anterior landmarks for the trachea include?

Back 95

The tracheal rings which disappear as you move further into the bronchi

Front 96

What posterior landmarks should you look for during fiberoptics in the trachea?

Back 96

Longitudinal elastic bundles, which go all the way down

Front 97

What should you be able to identify on the right side during fiberoptics?

Back 97

The carina
The upper lobe-superiorly
The bronchus intermedius
Superior segments of the posterior lobe-take off is posterior view
Middle lobe-view is directly anterior

Front 98

What should you be able to identify on the left side during fiberoptics?

Back 98

The carina
The upper lobe: anterior/superior
The superior segment of the lower lobe-view is posterior

Front 99

What guides the choice to place left or right sided tubes?

Back 99

Technical difficulty

Front 100

How do you verify correct position of a DLT?

Back 100

Auscultation of both sides with clamping
Visualization- of one sided chest excursion
Fiberoptically
H2O seal leak test

Front 101

The caution of using the H2O leak test is what?

Back 101

Keeping the water below the level of the patient so when negative pressure is created the pt is not lavaged.

Front 102

Postoperative pain management for thoracotomies may include?

Back 102

Intercostal nerve block-may be given in the field
IV PCA pump
Epidural-thoracic vs lumbar w/ narcotics/LA

Front 103

Standard parameters for one lung ventilation include?

Back 103

Use of 100% O2
Vt-10 cc/kg- may start lower and titrate upwards until excursion interferes with sx field
PaCO2 checks b/c ETCO2 is inaccurate
Baseline ABG-2 lung then recheck 15 min after on one lung (may take 45 min to deteriorate)
Compare to ETCO2
Avoiding PAP >40
Clamping the NDL (up portion of tube)
Suction may be applied to the NDL

Front 104

Your patient is now on one lung ventilation and begins to have pulmonary decompensation, your sequence of actions to correct with evaluation of each step includes?

Back 104

100% O2-if not already there
Evaluate tube position with use of FO
CPAP-NDL
Peep to DL
Jet ventilation – may need to consider using earlier on
Back to 2 lung ventilation
Banding the PA-Can only be done in Pneumonectomy

Front 105

Why is CPAP used before peep?

Back 105

Because Peep increases the amt of shunting by increasing the size of the alveoli

Front 106

How much CPAP should be used?

Back 106

2-4 liter flow

Front 107

What should be known about using CPAP and Peep?

Back 107

Peep should never exceed the CPAP amt

Front 108

Lateral positioning concerns for injury include?

Back 108

Long thoracic nerve impingements
Brachial plexus injuries
Suprascapular nerve injuries

Front 109

Thoracic nerve injuries include what defects?

Back 109

Scapular winging

Front 110

Brachial plexus injuries include what injuries?

Back 110

Wrist drop, claw hand, ulner nerve palsies

Front 111

Suprascapular injuries include what defects?

Back 111

Diffuse pain

Front 112

One of the most critical steps prior to surgical initiation in one lung ventilation and VAT procedures is?

Back 112

Lung isolation must preceed the trocar insertion

Front 113

Fluid management for pulmonary procedures is?

Back 113

Dry, dry, dry

Front 114

What governs the use of inhalation agents during sx?

Back 114

Whether or not increased risk of crumping due to HPV

Front 115

Complications of VAT procedures?

Back 115

CO2 embolism
Hemorrhage
Myocardial depression-due to pressing on the heart > with more medial lesions

********Don’t recover well sometimes

Front 116

Thoracotomy complications include?

Back 116

Post op recovery respiratory impairment due to resection of intercostals
Increased Pain
Extubation issues
Need to change from DLT to SLT

Front 117

Postoperative ventilation considerations should include?

Back 117

Is the pt paralyzed
Settings used in OR for DL ventilation
100% FiO2

Front 118

Concern for intercostal nerve blocks are?

Back 118

It is the #1 block for highest risk of LA toxicity

Front 119

The tx of choice in MG pts is?

Back 119

Thymectomy

Front 120

What is the purpose of thymus tissue?

Back 120

Lymphoid like tissue utilized for the processing of immune cells

Front 121

MG is a problem involving what etiology?

Back 121

Autoimmune disease- Intolerance of T and B cells of the Ach receptor sites. T-cells activate antibodies for the receptor sites. The process starts in the thymus gland, which causes a destruction of Ach receptors

Front 122

What types of receptors are lost?

Back 122

Nicotinic receptors

Front 123

What drug is used to dx MG?

Back 123

Edrophonium

Front 124

What drug is used to tx MG?

Back 124

Pyridiostigmine

Front 125

What main s/s are seen with MG?

Back 125

Ocular (Ptosis and diploplia from extraocular muscle weakness)
Bulbar-throat (pharyngeal/laryngeal muscle weakness)

Front 126

An overdose of MG medications (cholinesterase inhibitors) causes what situation?

Back 126

Cholinergic crisis increase in Ach, which causes the SLUDBBM s/s and weakness

Front 127

Non-sx tx of MG includes?

Back 127

Cholinesterase inhibitors
Immunosuppressive tx

Front 128

Plasmapheresis
Sx tx includes?

Back 128

Thymectomy-75-80% remission

Front 129

What two approaches are noted with thymectomy?

Back 129

Sternal splitting-better visualization
Transcervical-shorter recovery but poor visualization may result in incomplete removal

Front 130

Chronic use of Pyridiostigmine impairs anesthesia how?

Back 130

Unpredictable response to Anectine due to inhibition of plasma cholinesterase

Front 131

What considerations should be given to NDMR with MG pts?

Back 131

If dose of Pyridiostigmine taken for the day then NDMR will be increased effects
Titrate in using 1/10th 1/20th doses

Front 132

What anesthetic considerations should be given to MG pts?

Back 132

Vent suppression from inhalation/barbs/opioids

Front 133

Eaton Lambert syndrome?

Back 133

Autoimmune basic lesion that decreases a release of Ach by nerve stimulation that results from a voltage gated calcium channel IgG antibody (presynaptic)

Front 134

The difference between LE and MG re: muscle relaxants?

Back 134

MG resistant to Succs
LE sensitive to all MR

Front 135

Differential dx of LE can be obtained by performing what actions?

Back 135

Extremity strength increases after exercise in LE and shows no improvement after anticholinesterase drugs

Front 136

S/S of Lambert Eaton syndrome?

Back 136

Mostly c/o of extremity strength weakness and increased fatigability of extremities mostly Lower extremities

Front 137

Tx of Eaton Lambert syndrome includes?

Back 137

4-Aminopyridine, which promotes calcium influx and calcium-dependent presynaptic release of AcH

Front 138

Associated diseases of Lambert-Eaton include?

Back 138

Small lung carcinoma

Front 139

What piece of equipment in imperitive in broncho-alveolar Lavage?

Back 139

DLEBT
Stryker frame

Front 140

Which lung is done 1st?

Back 140

The worst one

Front 141

How does photodynamic tx work?

Back 141

Accumulation of photofrin in the tumor and when exposed to light then the substance is chemically excited and the tumor destructs by free radicals and oxygen singlets.

Front 142

Concerns with pts taking this medication?

Back 142

Need to be covered up-in the OR can get severe sun burns

Front 143

What occurs with oxygenation during pulmonary lavaging?

Back 143

increases

Front 144

What procedures can be done via thoracotomy?

Back 144

Segmentectomy
Lobectomy
Isolated lesions
Spontaneous Pneumo
Laser
Pleurodesis
Pneumonectomy