Gruneisen, Nur 635: Thoracic Anesthesia; Pulmonary Procedures

Front 1

Name some diagnostic reasons for performing a bronchoscopy.

Back 1

Diagnosing etiology for:
cough
hemoptysis
atelectasis
unresolved pneumonia
r/o metastases
abnormal CXR

Front 2

Name some therapeutic measures of bronchoscopy.

Back 2

removal of foreign body
evacuation of accumulated secretions
evaluation/treatment of aspiration
lung abscess
reposition or placement of ETT
laser surgery of airway

Front 3

Indicatins for a rigid bronch include:

Back 3

removal of FB(easier to remove)
control of bleeding(more room to see and suction)
allows for larger biopsy section

Front 4

Rigid broncoscopy is usually not done under general anesthesia.
True or False

Back 4

False, it is usually done under GA with rigid ventilating bronchoscope.

Front 5

How is the ventilatin maintained during a rigid bronchoscopy?

Back 5

the bronchoscope has a side arm for connection to anesthesia source.

Front 6

One benefit of the scope for anesthesia personnel is:

Back 6

it allows for instant recognition if the scope enters bronchus (must ask the surgeon to pull scope back)

Front 7

Why may manual ventilation necessary during a rigid bronch?

Back 7

manual ventilation is necessary to allow for interruption while the surgeon suctions or biopies; a leak will be present

Front 8

What are 3 methods of ventilation for a rigid bronchoscopy?

Back 8

1) spontaneous
2) positive pressure with O2 through side port
3) apneic oxygenation

Front 9

What is the technique for apenic oxygenation?

Back 9

1) prepxygenate well
2) induce patient
3) paralyze
4) insufflate O2 at 10-15 L/min through small catheter placed above the carina

Front 10

Short acting muscle relaxants are acceptable to use for a rigid bronchoscopy.
True or False

Back 10

True, if the patient is easy to ventilate with mask.

Front 11

If done correctly, how long can apneic oxygenation provide adequate O2 for?

Back 11

30 min is proper denitrogenation is done.

Front 12

When is apneic oxygenation most beneficial?

Back 12

When is is used for short periods of time when the surgeon needs a quiet field.

Front 13

Intermittent ventilation may be obtained by:

Back 13

using the bag attached to the rigid bronchoscope

Front 14

What must be in place before ventilation is possible with a rigid bronchoscope?

Back 14

the eyepiece

Front 15

Name 2 drawbacks to intermittent ventilation during a rigid bronch.

Back 15

1) limits amount of time the surgeon has to work after he sees what he is looking for
2) may be a leak around to scope (packing oropharynx helps)

Front 16

With apneic ventilation, periods of apnea must be limited to less than 5 min to prevent build up of CO2.
True or False

Back 16

True

Front 17

During apnea, CO2 increases by ____mm Hg the first min and by ______ mmHg each min after.

Back 17

6, 3-4

Front 18

How much would PaCO2 rise to after 10 minutes if it was 30 mm Hg at start of apnea?

Back 18

63-72 mm Hg

Front 19

Describe jet ventilation.

Back 19

O2 is intermittently "jetted" thru the ventilating port of the bronchoscope.

Front 20

How is expiration managed with jet ventilation?

Back 20

Expiration is passive thru the bronchoscope or glottis.

Front 21

Name 3 potential risks of jet ventilation.

Back 21

CO2 build up, barotrauma, and pneumothorax

Front 22

Which gas law does jet ventilation identify with?

Back 22

Bernoulli's law: speed of flow increases as diameter of pipe decreases, pressure is least where speed is greatest.

Front 23

Key points to the Sander's jet Ventilator:

Back 23

1) connects to 50 psi oxygen line
2) black knob regulates downstream pressure
3) lever triggers ventilation(manually cycled)
4) gauge shows downstream pressure
5) clear tubing and metal tip can connect to cannula or small-bore access

Front 24

What must be used with sleep apnea patients to ensure a passive pathway for exhalation?

Back 24

a proper fitting oral airway

Front 25

Two additional methods of ventilation for rigid bronchoscope include:

Back 25

1) mechanical ventilator to bronchoscope sidearm
2) high-frequency positive pressure ventilator to bronchoscope

Front 26

A draw back to mechanical ventilator to bronchoscope technique is:

Back 26

gas leaks that might cause light anesthesia

Front 27

A drawback to high-frequency pp ventilator to bronchoscope technique:

Back 27

hypoventilation at high breath rates (500 breaths/min)

Front 28

The flexible bronch may be done under local or general; the most common technique used is:

Back 28

awake, fasting patient under topical anesthetic

Front 29

The most common topical anesthetic used for flexible bronch is:

Back 29

4% lidocaine

Front 30

Name 7 ways that the topical anesthetic may be applied to the airway.

Back 30

1) nebulized
2) gargle viscous lidocaine
3) pledgets soaked in local to each piriform fossa
4) transtracheal injection
5) sprayed on vocal cords under direct visualizatin with laryngoscope
6) superior laryngeal nerve block
7) if nasal approach, 4% cocaine to nares, then viscous lidocaine through nares.

Front 31

Flexible bronchoscopy with an awake patient who has had sedation may pose a risk for:

Back 31

aspiration

Front 32

If using GETA for a flexible bronch, what should one keep in mind when selecting an ETT?

Back 32

Tube size needs to be large enough to accomodate bronchoscope girth.

Front 33

Prolonged suctioning during a flexible bronch may cause:

Back 33

atelectasis

Front 34

One should use a muscle blocker if using GETA for flexible bronch.
True or False

Back 34

True

Front 35

A superior laryngeal nerve block provides anesthesia from the _________ to the level of the _________.

Back 35

epiglottis, cords

Front 36

Using a SLN block is acceptable anesthesia for any patient who requires intubation for the procedure.
True or False

Back 36

True

Front 37

Which local anesthetic is a good choice for a SLN block?

Back 37

Lidocaine 0.5%

Front 38

What nerve does the SLN branch from?

Back 38

Vagus

Front 39

Which branch of the SLN is the target for a SLN block?

Back 39

internal branch of the SLN

Front 40

Which are of the nerve should be targeted to place a SLN block?

Back 40

where the nerve enters the thyrohyoid membrane, just inferior to the caudal aspect of the hyoid bone.

Front 41

Describe the process for a SLN block.

Back 41

1) place pt supine with neck extended
2) displace hyoid bone toward you (side to be blocked)
3) insert 25 gauge short needle until contact is made with greater cornu of hyoid
4) walk off caudal edge of hyoid and advance 2-3 cm
5) inject 2-3 ml local and 1 ml as you withdrawal the needle
(see pp page 4 slides 5 & 6 for pic)