Chapter 28, Part 1 Review Exam #3

Front 1

What treatment offers the best prognosis in bronchogenic carcinoma?

Back 1

Resection of affected lung tissue (vs. radiation and chemo)

Front 2

What are the two main questions for preop assessment of patients undergoing pulmonary resection?

Back 2

a. Does the risk of potential postop complications preclude performing the surgery?
b. Will postop pulmonary function be sufficient to allow reasonable quality of life?
- The postop risks must be extremely high before they would preclude the operation

Front 3

How do spirometry parameters change following lobectomy and pneumonectomy?

Back 3

FEV-1 and FVC decline 10% after lobectomy and 33% pneumonectomy

Front 4

List 5 postop complications of thoracic surgery

Back 4

arrhythmias, MI, PE, pneumonia, empyema

Front 5

What has markedly decreased the rate of postop pulmonary complications?

Back 5

The use of video-assisted thoracoscopy (VAT)

Front 6

What should be evaluated prior to small lung resections? 3

Back 6

preop eval of cardiac disease, gas exchange, oxygenation

Front 7

What should be evaluated prior to pneumonectomy?

Back 7

complete PFTs and cardiac testing

Front 8

Patients with cancer: 4 M’s

Back 8

Mass effects, Metabolic effects, Metastases, and Medications

Front 9

List 3 risk factors of pulmonary disease

Back 9

Cigarette smoking, air pollution, industrial chemical exposure

Front 10

Signs of pulmonary disease 6

Back 10

Exertional dyspnea
Productive cough
Poor exercise tolerance
Hemoptysis
Cyanosis
Chest pain

Front 11

Difficulty breathing in the supine position could result from what? 2

Back 11

COPD, compression the airway by a mediastinal mass

Front 12

What does the chest radiograph of a patient with COPD show? 3

Back 12

a. Hyperinflation, increased anteroposterior (AP) diameter, increased vascular markings
b. Bullae of emphysema may also be present
c. Infections or pleural effusions may be noted

Front 13

What does increased PVR result from in the patient with COPD? What is the consequence?

Back 13

compression of the vascular bed; it increases the likelihood of right ventricular failure

Front 14

Why are hormonal abnormalities common in patients with lung tumors?

Back 14

they often secrete endocrine-like substances such as ACTH, ADH, serotonin, parathyroid hormone, and insulin

Front 15

What are two common nutritional problems in patients with lung cancer, associated with increased postop complications?

Back 15

hypoalbuminemia and malnutrition – increased risk of pneumonia

Front 16

What are the factors that characterize patients with low-risk for postop complications? 4

Back 16

A. FEV-1 >2L or 80% of predicted
b. Predicted postoperative (PPO) FEV-1 at least 80% of predicted normal value
c. VO2max >20 ml/kg/min
d. ability to climb 5 flights of stairs

Front 17

What are the factors that characterize high-risk patients?

Back 17

a. FEV1 <2l>< 40% predicted
b. PPO FEV1 < 40%of predicted normal value
c. DLCO < 40% of predicted
d. Inability to climb one fligh of stairs
e. VO2max <10 mL/kg/min
f. Oxygen desaturation > 4% during exercise

Front 18

Chest radiograph should be assessed in lung cancer patients to determine what?

Back 18

if the lesions compress mediastinal structures, cause tracheal shift, or invade the airway

Front 19

What changes are seen on ECG in patients with pulmonary disease?

Back 19

a. changes indicative of RV hypertrophy and strain, such as….
- low-voltage QRS waves and poor R-wave progression over the precordial leads
-R/S ratio greater than 1 in lead V1
-shift toward right axis deviation
b. changes indicative of RA hypertrophy such as….
-initial component of a biphasic P wave in lead V1 to be larger than the second component

Front 20

Increased PVR and RV strain could preclude pneumonectomy - why?

Back 20

because of the added resistance produced by clamping the vasculature of one lung

Front 21

Measurement of preop room air ABGs is useful for what purpose?

Back 21

guiding the weaning of O2 and ventilation postop

Front 22

What aspects of an ABG result indicate poor ventilatory function? What is a good indicator of post-op complications?

Back 22

a. CO2 retention (PCO2 > 45)
-hypercapnia is not a reliable predictor of incr. risk of periop pulmonary complications
c. Preop hypoxemia (SaO2 &lt;90%) and desaturation during exercise are predictive of inc. complications following thoracic surgery

Front 23

What PFTs predict complications? 4

Back 23

a. FVC &lt; 50% of predicted
b. FEV1 &lt; 2L
c. FEV1/FVC &lt; 50%
d. DLCO (lung carbon monoxide diffusing capacity) &lt; 50% of predicted

Front 24

Should you assess spirometry before or after bronchodilator therapy?

Back 24

AFTER - represents the patient’s potential lung function once optimized on medications

Front 25

What is the most reliable way to assess PFTs?

Back 25

based on predicted postoperative (PPO) function tests, as opposed to assessing a static value for all patients that doesn’t account of age/gender/height

Front 26

How do you calculate the PPO FEV1? What values are you looking for?

Back 26

a. current FEV1 x fraction of functioning lung (or the fraction of lung segments that will remain after resection)
b. a value of at least 40% of predicted is a good criterion for lung resection
d. less than 35% are at a high risk of postop complications

Front 27

If preop lung function tests indicate an increased risk for periop complications, what further testing can predict postresection lung function?

Back 27

split lung function tests of ventilation and perfusion
b. can multiply current function by the fraction of functioning lung that will remain postop to determine postresection function
c. important to note that removal of a diseased portion of lung may NOT decrease overall lung function

Front 28

How can ventilation be measured?

Back 28

patient inhales one vital capacity breath of a radioisotope, then measure the isotope counts with multiple scanners placed over the chest wall

Front 29

How can perfusion be measured?

Back 29

a. radioisotope injected intravenously and imaged shows the distribution of perfusion to all areas of the lung
b. radionuclide studies have an imprecision rate of 20% in predicting postop pulm function

Front 30

Lung reduction surgery is most useful in which patients? this effect is better appreciated with?

Back 30

a. patients with heterogenous emphysema, where removal of a segment or lobe will result in better pulmonary function overall
b. upper rather than lower lobectomy

Front 31

Describe diffusion capacity and how it is tested? What values are you looking for?

Back 31

a. tests the lung’s ability to allow transport of gas across the alveolar-capillary membrane
b. O2 is difficult to measure
c. Carbon monoxide (CO) is used instead; pt. inhales a small amount of CO, holds the breath for 10 seconds, and the amount of CO in the exhalation is measured. After subtracting the amount of CO that should be expired with dead space air, the resulting amount exhaled provides and indicator of the diffusing capacity of the lungs (DLCO)
d. a value less than 60% of predicted is associated with inc. complications and mortality; less than 40% is high risk
e. this test has good specificity but low sensitivity as an independent measurement

Front 32

Diffusion capacity should be done if patient has evidence of?

Back 32

interstitial lung disease or dyspnea

Front 33

What is the predicted postoperative product?

Back 33

a. product of the predicted values for DLCO and FEV1
b. more reliable than the single measurements alone
c. <1650 in 75% who died

Front 34

Describe the use of maximal oxygen consumption (VO2max) testing, when should the test be performed?

Back 34

a. when used during exercise testing, it is a strong predictor of outcomes
b. VO2max &lt; 10 ml/kg/min (or 50% predicted) assoc. high risk of death following surgery
c. VO2max &lt; 15 ml/kg/min indicates an increased risk
d. VO2max > 20ml/kg/min is favorable, suggesting little risk of complications
e. test should be performed if preop or PPO FEV1 or DLCO are &lt;40% of predicted normal

Front 35

How else can VO2max be estimated?

Back 35

a. if a patient can climb five flights of stairs, VO2max >20
b. if a patient cannot climb one flight of stairs, VO2max <10

Front 36

List some preoperative conditions that, if treated, greatly reduce the postop risk (8)

Back 36

a. infection
b. excess bronchial secretions
c. bronchospasm
d. dehydration
e. malnutrition
f. electrolyte imbalance
g. smoking
h. ETOH abuse

Front 37

Describe the importance of timing of smoking cessation

Back 37

transient increases in mucus production may increase complications in patients who have surgery within 2 months of smoking cessation

Front 38

What are the 5 components of an aggressive preop respiratory preparation regimen?

Back 38

a. Terminate stimulus for bronchoconstriction and secretions: QUIT SMOKING
b. Dilate the airways: DRUGS
c. Loosen secretions: HYDRATION
d. Remove secretions: POSTURAL DRAINAGE, CHEST PT, COUGHING
e. Increase patient participation: EDUCATE, MOTIVATE, COUGH, IS, EXERCISE, WT LOSS

Front 39

Monitoring of what ECG leads detects more than 85% of ischemia?

Back 39

II and V5

Front 40

What is the purpose of the airway pressure monitor? 2

Back 40

a. detects changes in airway compliance
b. assists in identifying proper placement of double-lumen tubes (DLTs)

Front 41

Why is an arterial line suggested for thoracic surgery? 2

Back 41

a. arterial BP instantly identifies hypotension with surgical manipulation
b. frequent sampling for ABGs

Front 42

Where should the arterial line be placed, based on procedure? thoracotomy? mediastinoscopy?

Back 42

a. thoracotomy: the dependent arm, where it is more easily stabilized
b. mediastinoscopy: right arm, detects compression of the innominate artery and helps prevent dec. CBF

Front 43

Describe the use of CVP monitoring in thoracotomies

Back 43

inc CVP or pulm. cap. wedge pressures are associated with greater lung injury and prolonged mechanical ventilation after complex pulm. surgery

Front 44

Is the use of pulmonary artery pressure monitoring helpful? What may it help avoid?

Back 44

b. not helpful in predicting postop complications; right heart catheterization may even promote cardiac complications
d. may be useful in preventing fluid overload (which can worse postop pulm function)

Front 45

Where should the axillary roll be placed in a thoractomy?

Back 45

caudal to the axilla

Front 46

What nerve can be damaged with the placement of leg safety strap?

Back 46

peroneal nerve in the area of the fibular head of the dependent leg and the femoral head of the nondependent leg

Front 47

SPONTANEOUSLY BREATHING, UPRIGHT POSITION (normal lung) blood perfusion increases lineraly from the?

Back 47

apex(where flow is very low) to the base (where flow is the greatest) of the lung (West Zones)

Front 48

in the normal lung, pleural pressure is most negative at the?

Back 48

apex, which keeps alveoli distended

Front 49

How much does pleural pressure increase for every cm down the lung?

Back 49

0.25 cm H20

Front 50

Which alveoli are less distended and therefore more compliant, nondependent or dependent?

Back 50

dependent, (they can expand by a greater volume for a given pressure change because they are starting at a lower resting volume)

Front 51

Where is most of a tidal breath distributed to in the normal lung?

Back 51

the dependent alveoli; this is optimal because the higher ventilation in the dependent base matches the higher perfusion in the dependent base

Front 52

In the awake lateral there is less...?

Back 52

vertical distance present to cause differences in the intrapleural pressure and blood pressure gradients

Front 53

In the awake lateral patient describe the dependent lung. 2

Back 53

1. abdominal contents displace the diaphragm in a cephalad manner on the dependent side
2. the dependent hemidiaphragm can contract further in a higher position in the thorax; thus, during inspiration the diaphragmatic contraction causes more of the Vt to fill the dependent lung

Front 54

Which lung in the awake lateral patient is better perfused?

Back 54

dependent, V/Q remains unchanged and gas exchange remains efficient

Front 55

ANESTHETIZED LATERAL, SPONTANEOUSLY BREATHING, CHEST CLOSED describe the FRC once upon induction

Back 55

Total FRC decreases

Front 56

What is further decreased besides FRC in the anesthetized lateral spontaneously breathing, chest closed patient?

Back 56

also reduces proportion of favorable zone 3 area

Front 57

ANESTHETIZED LATERAL, SPONTANEOUSLY BREATHING, CHEST CLOSED, describe lung volumes and place on the compliance curve.

Back 57

Lung volumes in both lungs are lower, and their place on the compliance curve is shifted: lungs are less compliant when they are at very high volume (alveoli distended) or very low volume (alveolar atelectasis)

Front 58

Describe the nondependent lung in the anesthetized lateral, spont. breathing, closed chest patient?

Back 58

the proportion of FRC in the nondependent lung increases in contrast to the dependent lung; as the dependent lung loses FRC, its volume becomes so low as to decrease its compliance and it shifts to a flatter, less compliant portion of the curve. The nondependent lung moves from a flat, noncompliant portion of the curve to a more compliant position

Front 59

Describe changes that occur in the ANESTHETIZED, PARALYZED, VENTED, LATERAL, CHEST CLOSED patient

Back 59

diaphragm no longer contributes to ventilation of the lower lung, and FRC further declines as the compression from abdominal viscera is no longer counteracted by the force of the contracting diaphragm

Front 60

In the ANESTHETIZED, PARALYZED, VENTED, LATERAL, CHEST CLOSED patient, ventilation shifts to follow?

Back 60

path of least resistance, favoring the nondependent lung

Front 61

In the ANESTHETIZED, PARALYZED, VENTED, LATERAL, CHEST CLOSED there is further deterioration of?

Back 61

V/Q ratio

Front 62

In the ANESTHETIZED, PARALYZED, VENTED, LATERAL, CHEST CLOSED what helps restore FRC and the V/Q ratio?

Back 62

PEEP

Front 63

In the ANESTHETIZED, VENTED, OPEN CHEST patient, describe what occurs b/c of the open chest?

Back 63

open chest greatly reduces resistance to gas flow in the nondependent lung by detaching the lung from its pleural connection with the chest wall, causing further loss of ventilation of the dependent lung

Front 64

In the ANESTHETIZED, VENTED, OPEN CHEST the mediastinum shifts?

Back 64

further downward because of loss of negative intraplueral pressure in the nondependent lung, which helped to distend it, which further decreases ventilation to the dependent lung

Front 65

What diminishes the effects of mediastinal shift and paradoxical respiration?

Back 65

PPV

Front 66

During mechanical ventilation, the open chest provides no? higher proportion of ventilation goes to?

Back 66

resistance, and the greatly increased compliance of that lung allows a higher proportion of ventilation to go to the nondependent lung (the least perfused area of the thorax)

Front 67

The less ventilated, better-perfused dependent lung contributes to?

Back 67

physiologic shunt (as blood flows through the atelectatic areas without acquiring oxygen)

Front 68

What are the absolute indications for OLV?

Back 68

a. infectious contamination of one lung or massive hemorrhage of one lung
b. control of the distribution of ventilation in the case of:
1. bronchopleural fistula
2. bronchopleural cutaneous fistula
3. surgical opening of a major conducting airway
4. giant unilateral lung cyst or bullae
5. tracheobroncheal tree disruption
6. life-threatening hypoxemia r/t unilateral lung disease
c. unilateral bronchopulmonary lavage for pulm. alveolar proteinosis

Front 69

What are the relative indications for OLV?

Back 69

a. surgical exposure – high priority
1. thoracic aortic aneurysm
2. pneumonectomy
3. thoracoscopy
4. upper lobectomy
5. mediastinal exposure
b. surgical exposure – medium priority
1. middle and lower lobectomies and subsegmental resections
2. esophageal resection
3. procedures on the thoracic spine
c. post CPB pulmonary edema/hemorrhage after removal of totally occluding unilateral chronic pulmonary emboli
d. severe hypoxemia r/t unilateral lung disease

Front 70

What are 4 different methods that can be used for OLV?

Back 70

a. a traditional single lumen ETT advanced into the non-operative lung
b. bronchial blockers
c. Univent ETT (built-in bronchial blocker in a second lumen)
d. double lumen tube (Carlens, White, or Robertshaw)

Front 71

Describe bronchial blockers

Back 71

a. catheter with an inflatable balloon that blocks the bronchus
b. a separate ETT is then placed in the trachea

Front 72

When is a bronchial blocker useful? 5

Back 72

useful in patients with difficult airways, patients already intubated, nasal intubations, peds, VAT procedures

Front 73

What are two current types of bronchial blocker?

Back 73

8F Fogarty embolectomy catheter and the Wire-Guided Endobronchial blocker (WEB)

Front 74

What is a Univent tube?

Back 74

integrated ETT with a 2nd lumen for deployment of the bronchial blocker
-after intubation, the blocker is advanced into the bronchus with the fiberoptic scope

Front 75

T or F. A univent tube can easily be passed through a stoma in postlaryngectomy patients

Back 75

True

Front 76

What are the sizes available for a univent tube?

Back 76

6-9mm, external diameter is larger than a single lumen tube

Front 77

What is a double-lumen tube?

Back 77

two bonded catheters, each with its own lumen – one for ventilating the trachea, and one for ventilating the bronchus

Front 78

What is a Carlens DLT?

Back 78

left sided DLT with a carinal hook to aid in stabilizing the tube

Front 79

What is a white DLT?

Back 79

right sided DLT, carinal hook

Front 80

What is a robertshaw DLT?

Back 80

right or left sided, no carinal hook; sizes 26, 28, 35, 37, 39, 41F

Front 81

How do you size males and females of the Robertshaw DLTs?

Back 81

Actually determined by height, but females usually get a 35-37, males 39-41

Front 82

Distance from the carinal bifurcation to the left and right mainstem bronchi?

Back 82

left – 4 to 5 cm
right – 2.5 cm

Front 83

Which side should the DLT be placed on based on the side of surgery?

Back 83

left sided placement for either right or left sided surgery unless there is a contraindication to left sided placement

Front 84

What are contraindications to DLTs on one or both sides? 4

Back 84

a. internal lesions of the trachea or main bronchi
b. compression of the trachea or main bronchi by an external mass
c. presence of a descending thoracic aortic aneurysm which can compress or erode the left main bronchus
-it may still be possible to use the DLT on the unaffected side
e. difficult airways in which DL is impossible is a contraindication to DLT on either side

Front 85

Why are DLTs associated with an increased aspiration risk?

Back 85

they take longer to place and verify placement

Front 86

In the case of a patient already intubated with a single lumen tube who cannot tolerate extubation, how should ventilation be managed?

Back 86

manual ventilation can be coordinated to surgical requirements

Front 87

What are some options for ventilating pediatric patients undergoing thoracic surgery? 2

Back 87

a. intentional endobronchial intubation
b. jet ventilation (combination of surgical pneumothorax and low mean airway pressures of jet ventilation should allow adequate deflation of the operative lung)

Front 88

Which method for lung separation has the highest failure rate in practitioners with limited experience?

Back 88

they are all the same

Front 89

What are the indications for a Fogarty occlusion catheter? 5

Back 89

a. critically ill patient
b. small bronchus
c. difficult airway
d. nasotracheal intubation
e. use with a standard ETT at least 6.0 mm

Front 90

What are the indications for a Univent blocker? 2

Back 90

a. selective lobar blockade
b. difficult airway requiring lung separation

Front 91

What are the indications for WEB blockers? 4

Back 91

a. critically ill patients
b. selective lobar blockade
c. difficult airway
d. nasotracheal intubation requiring lung separation

Front 92

All lung separation devices should be placed and confirmed via what?

Back 92

fiberoptic bronchoscopy