Nurs614 Exam 3 Thoracic Anesthesia

Front 1

What are the sizes of ETTs

Back 1

37-42 French

Front 2

The rings on the trachea are is only on what surface?

Back 2

The anterior.
When you use a bronchoscope, you should see the rings on top.

Front 3

Distance of R/main stem from carina to the start of the r/upper lobe

Back 3

2.5cm

Front 4

Angle of the r/main stem

Back 4

25 degrees

Front 5

Distance of L/main stem from carina to the start of the l/upper lobe

Back 5

4.5 to 5 cm

Front 6

Angle of l/main stem?

Back 6

45 degrees

Front 7

Dynamics of Spontaneous Breathing?

Back 7

Diaphragm descends causing a negative intrathoracic pressure;
Gas flows from higher pressure to lower pressure;
Greatest gas flow in spontaneous ventilation is to bases.

Front 8

Inhalation is ________ forceful/passive

Exhalation is ________ forceful/passive.

Back 8

forceful
passive

Front 9

How does being vented & anesthesized affect V/Q matching?

Back 9

With a spontaneously breathing anesthetized pt, you get better V/Q matching vs the same pt on a vent but less vs the same pt nonanesthetized & spontaneously breathing.
(It is better not to use MR if we do not need to).

Front 10

What are the dynamics of spontaneous breathing?

Back 10

Apex alveoli (Zone 1) already distended from greater NEGATIVE pleural pressure thus they have less compliance to expand and receive volume increases;
Apex ribs short and expand minimally;
Base alveoli ( Zone 3) have greatest gas flow due to greater change in thoracic pressures during insp.- exp. phases (d/t insp. diaphragmatic downward movement & d/t pale handle effect)

Front 11

What occurs with the pale handle effect?

Back 11

Internal intercostals, pull downward, aid expiration;
External intercostal, elevate ribs, aid inspiration.
Pneumonic; In-Ex,
Ex-In

Front 12

How does intra-pleural pressure changes during inspiration and what is the result?

Back 12

Decreasing intra-pleural pressure during inspiration draws inspired gas into bases of lung where there is the most blood flow.
Pleural press.end exp. –5 cm H2O;
Pleural pressure during insp. –7.5 H2O;
Pleural pressure change 2.5 cm H2O.

Front 13

Normal V/Q matching is 0.8
What are some causes of mismatching?

Back 13

Physiologic shunt
Hypoventilation
Disease states

Front 14

What is happening with ventilation in West Zone 1?

Back 14

Zone 1 represents alveolar dead space b/c alveolar pressure occludes pulmonary capillaries
PA >Pa > Pv

Front 15

What is happening with ventilation in West Zone 2?

Back 15

Pulmonary capillary flow is intermittent and varies during respiration according to arterial-alveolar pressure gradient.
Pa > PA > Pv.

Front 16

What is happening with ventilation in West Zone 3?

Back 16

Pulmonary capillary flow is continuous
Pa > Pv > P A

Front 17

True/false?
V/Q is poorly matched in mechanically ventilated patients

Back 17

True
PPV pushes gas into apices of lung - path of least resistance.
Blood perfuses primarily the dependant parts of lung again due in part to the pull of gravity.

Front 18

How does HPV affects the heart

Back 18

HPV effectively redirects blood flow away from hypoxic or poorly ventilated lung units;
Pulmonary vascular endothelium release potent vasoconstrictor peptides called endothelins;
HPV can lead to inc PVR which --> inc R/heart work.
(Volatile anesthetics above 1 mac and nitrous oxide potentially block HPV).

Front 19

True/false?
HPV has more negative effects on younger hearts

Back 19

True.
A younger heart is less compliant b/c the muscles are very strong

Front 20

Why do we have increased V/Q mismatch in vented pts?

Back 20

There is greater gas flow to apex and greater blood flow to bases which --> V/Q mismatching.
Poorly ventilated alveoli are prone to atelectasis and collapse.

Front 21

What is the the V/Q match in a spontaneously breathing pt?

Back 21

0.8

Front 22

What is the the V/Q match in a anesthesized spontaneously breathing pt?

Back 22

0.7

Front 23

What is the the V/Q match in a PP vent anesthesized pt?

Back 23

0.5

Front 24

What is the the V/Q match in a PP vent anesthesized & paralyzed pt?

Back 24

0.4

Front 25

What type of ventilation is there in open chest ventilation dynamics?

Back 25

Paradoxical ventilation

Front 26

What is the best induction agent for a pt with a pneumothorax?

Back 26

Ketamine is best – it does not depress the heart

Front 27

What is a closed (simple) pneumothorax?

Back 27

No atmospheric communication.
Treatment based on size and severity.
Tx with possible catheter aspiration, thoracostomy, or just observation.

Front 28

What occurs with a communicating pneumothorax?

Back 28

Affected lung collapses on inspiration and slightly expands on expiration.

Front 29

Describe the the damaged resulting a communicating pneumothorax?

Back 29

The tear goes from chest wall to lungs.
The mediastinum is displaced after inhalation.

Front 30

How is a communicating pneumothorax treated?

Back 30

O2,thoracostomy tube, intubation, mech. vent.

Front 31

What occurs with a tension pneumothorax?

Back 31

Air progressively accumulates under pressure within pleural cavity.
Compressing the unaffected lung & great vessels
Treatment; immediate needle decompression

Front 32

What occurs with a hemothorax?

Back 32

Accumulation of blood in pleural space.
Treatment - airway management, support hemodynamics, evacuation.

Front 33

what are the 4 major subcategories of thoracic surgery?

Back 33

Lung Resection (Tumor, Bronchiectasis, Infection);
Tracheal Resection
Thoracoscopic Surgery
Esophageal Surgery

Front 34

Regarding the drainage system of the lungs, which side drain into the other?

Back 34

The left side of lung system drains into the right

Front 35

How is the blood supply distributed between the normal lungs?

Back 35

Right side gets 60%
Left side gets 40%

Front 36

Lung resection is typically d/t?

Back 36

Tumor
Small cell (oat) 20%;
Non Small Cell Ca 80%.

Front 37

What is a bronchiectasis?

Back 37

It is a permanent dilation of the bronchi. It is usually the end result of severe or recurrent inflammation and obstruction of bronchi.

Front 38

What are lung cysts and bullae?

Back 38

They are air filled, thin walled, bronchogenic or alveolar destructive, post infective, infantile or emphysematous cysts.

Front 39

What other chronic conditions often accompany lung cysts and bullae?

Back 39

Most patients have COPD (and CO2 retention).

Front 40

How does lung cysts and bullae affect respiration?

Back 40

There is increased ventilatory volume w/ decreased respiratory diffusion area

Front 41

What risks accompany mechanical ventilation in pts with cysts and bullae?

Back 41

Positive pressure may rupture them & cause tension pneumo,

Front 42

How do pts do after resection of lung cysts & bullae?

Back 42

Respiration usually improved after resection

Front 43

What should be included in the preoperative evaluation for lung resection of cysts and bullae?

Back 43

Laboratory Tests
Prescreen for underlying pulmonary infection,
Tracheal stenosis- positional dyspnea,
airway collapse,
hypoxemia,
anatomic narrowing;
Review ABG, PFT, CXR, V/Q Scan, CT/MRI (lesion and trachea),
Angiography,
Coexisting pathology;
Coags b/c they may need an epidural and want to prevent a epidural hematoma.

Front 44

Preoperative considerations for lung resection?

Back 44

Hematological:
Transfuse if pre-op Hct < 25% - adequate O2 carrying capacity essential;
T&C 2-4 units of blood.
Musculoskeletal:
Lung CA patients may have myasthenic syndrome with increased sensitivity to NDMRs

Front 45

What is Myasthenic Syndrome (Eaton-Lambert Syndrome)?

Back 45

It is an autoimmune disorder that causes prejunctional decreased in ACh release. There is no improvement with anticholinesterases.
The underlying malignancy is Small Cell Ca of the lung.
The peripheral muscles & pelvis are most affected.
Unlike MG, muscle weakness improve with repeated effort;
Very sensitive to MRs- both NDMR and DMR.

Front 46

Preop considerations for lung resection of cysts and bullae - monitors?

Back 46

Standard Monitors;
Radial arterial line in dependent arm;
Positioning - lateral decubitus;
Mediastinoscopy (A-line right arm)
PAC/CVC in nondependent side of neck;
Pressure readings may be affected by open chest, lateral position and/or surgical manipulation.

Front 47

True/false?
An A-line should be used for all major thoracic surgery

Back 47

True

Front 48

Placement of the axillary roll?

Back 48

It goes 2 finger breaths from axilla

Front 49

Why do we want the Aline on the dependent arm?

Back 49

Aline (and pulse ox )goes on down arm b/c if Aline dampens it is b/c radial pulse is getting pressured.
You will know to reposition the pt.

Front 50

The Inominate artery comes right off the sternal notch. If you lose flow to the Aline during mediastinoscopy,
what would be the reason?

Back 50

The scope may be right on top of this artery

Front 51

Anesthetic techniques for lung resection - type of anesthesia?

Back 51

GETA combined with thoracic epidural.
Epidural analgesia reduces VA requirements but epidural anesthesia may create sympathetic blockade and hypotension.
Consider Pro’s and Con’s of Inhaled Agents vs TIVA (HPV).

Front 52

Anesthetic techniques for lung resection - airway management?

Back 52

The MD may have you place a single lumen tube first for visualization.
Next you place a double lumen tube (the lumens are smaller).

Front 53

Anesthetic techniques for lung resection - induction agent?

Back 53

Induction agents & relaxants per pt & procedure.
If pulmonary status is bad, you may get HPV.

Front 54

Complications in open thoracic surgery?

Back 54

Pneumothorax;
manipulation of lung, heart, and major vessels may interfere with ventilatory exchange and cardiovascular stability intra op and post-op;
lateral decubitus position changes the distribution of blood flow and pattern of ventilation and exposes lower lung to danger of contamination by secretions, blood, or fluids.

Front 55

Location of phrenic nerve?

Back 55

Phrenic nerve starts in neck, goes down from bilat neck down mid chest down to diaphragm

Front 56

Open Thorax Surgery Risks?

Back 56

Dysrhythmias
DVT
PE
MI
Bronchopleural fistula
Chylothorax
Subcutaneous emphysema
Phrenic nerve injury
Recurrent laryngeal nerve injury

Front 57

Lung Resection is often preceeded by which other procedure?

Back 57

Bronchoscopy or mediastinoscopy

Front 58

Lung Resection - placement of incision?

Back 58

Lateral or posterior lateral thoracotomy incision

Front 59

Lung Resection - positioning?

Back 59

Lateral decubitus position

Front 60

Lung Resection - airway management?

Back 60

Lung isolation- double lumen tube

Front 61

Lung Resection - length of surgery?

Back 61

Time = 2-3 hours

Front 62

EBL r/t lung resection =?

Back 62

<500 ml

Front 63

Lung Resection -Postop care?

Back 63

ICU

Front 64

Lung Resection - Mortality =?

Back 64

+/- 1%

Front 65

Pain Score r/t Lung Resection =

Back 65

7-8

Front 66

Lung Cysts and Bullae - airway management?

Back 66

Induction: Positive pressure <10cm H2O
DLT may be needed
NO N2O!
Extubation- smooth, without coughing

Front 67

What is an intraPulmonary hemorrhage?

Back 67

A massive hemoptysis r/t trauma, pulmonary artery rupture, erosion into vessel by tracheostomy, abcess, or tumor.

Front 68

Management guidelines for intrapulmonary hemorrhage?

Back 68

Immediate intubation;
100% O2;
Suction airway;
Ideally rigid bronchoscopy;
Lung isolation if unilateral involvement identified
(may advance ETT to unaffected side to isolate if DLT difficult;
Fiberoptic bronchoscopy confirmation of isolation);
May need thoracotomy and surgical repair.

Front 69

What is a bronchopleural fistula with empyema?

Back 69

An abnormal communication between bronchial tree and pleural cavity containing pus

Front 70

Causes of bronchopleural fistula with empyema?

Back 70

Pulmonary resection, bronchus or bulla rupture, penetrating chest wound, lung cyst or empyema cavity.

Front 71

Risk associated with bronchopleural fistula with empyema?

Back 71

Positive pressure ventilation may contaminate healthy lung, Tension Pneumo.

Front 72

Bronchopleural fistula with empyema - tx goal?

Back 72

Awake drainage under seal; Isolation of affected lung - DLT (lumen to unaffected side).

Front 73

What is a bronchopleural fistula?

Back 73

An abnormal communication between bronchial tree and pleural cavity.

Front 74

Management of bronchopleural fistula?

Back 74

RSI may be done if small air leak and NO empyema.

Front 75

Risk associated with bronchopleural fistula?

Back 75

Contamination, Tension Pneumo

Front 76

Bronchopleural fistula- tx goal?

Back 76

Minimal gas leak through fistula

Front 77

Indications for tracheal surgery?

Back 77

Stenosis, tumor, congenital defect (rare).

Front 78

Symptoms of tracheal obstruction?

Back 78

May note wheezing.
Flow volume loop may help determine location of the obstruction.

Front 79

Anesthetic management for tracheal surgery - premedication?

Back 79

Minimal premedication. (we want to avoid airway obst).

Front 80

Anesthetic management for tracheal surgery - induction?

Back 80

Consider inhalational induction or awake FOB to avoid complete obstruction with loss of muscle tone.

Front 81

Anesthetic management for tracheal surgery - emergence?

Back 81

If tracheal resection, consider neck flexion to reduce tension on the reanastomosis.

Front 82

Anesthetic management for tracheal surgery - airway management?

Back 82

Have a surgeon in the room b/c we may need to do a tracheostomy

Front 83

Whay are thoracoscopic surgeries done?

Back 83

As diagnostic and interventional procedures.

Front 84

What other procedures may accompany the thoracoscopic surgery?

Back 84

Bronchoscopy
Mediastinoscopy
Bronchoalveolar Lavage

Front 85

What is the anesthesia plan for the thoracoscopic surgery?

Back 85

The anesthetic plan is similar to open thoracic procedures.

Front 86

Mediastinscopy Procedures Anesthesia Technique - positioning?

Back 86

Upright & Supine

Front 87

True/false?
Mediastinscopy Procedures Anesthesia Technique - AIRWAY Risks decrease after pt is intubated?

Back 87

False.
AIRWAY Risks is present throughout procedure.

Front 88

Mediastinscopy Procedures Anesthesia Technique - type of anesthesia?

Back 88

GETA with paralytic.
Consider Pro’s & con’s of IA vs TIVA

Front 89

Mediastinscopy Procedures Anesthesia Technique - airway management?

Back 89

Standard ETT vs. Double-lumen tube

Front 90

Mediastinscopy Procedures Anesthesia Technique - COMPLICATIONS?

Back 90

#1 Rupture/laceration to major vessels;
#2 Pneumo/Hemo thorax;
Intermittent occlusion of innominate artery (CVA risk);
Tracheal collapse, tension pneumomediastinum, mediastinitis, chylotorax;
Phrenic nerve/RLN. injury.

Front 91

What are the surgical approcahes for mediastinoscopy?

Back 91

Cervical approach
Anterior approach
(Chamberlain Procedure)

Front 92

Monitoring for Endoscopy - monitors?

Back 92

Standard Monitors;
Radial arterial line? (L radial vs. R);
Lateral decubitus position(A-line in dependent arm)
Mediastinoscopy (A-line right arm). If aline, SaO2.

Front 93

What type of anesthesia is used for a flexible bronchoscopy?

Back 93

MAC or GETA

Front 94

What type of anesthesia is used for a rigid bronchoscopy?

Back 94

GETA

Front 95

Risks involved with rigid bronchoscopy?

Back 95

Hypercapnea
Hypoxemia
Air Leaks

Front 96

Anesthetic considerations for rigid bronchoscopy?

Back 96

Anesthesia machines vs Jet Ventilation(HFJV)
Side-arm ventilation port
Sanders Bronchoscopes (venturi effect w/jet vent).

Front 97

Flexible Esophagoscopy - type of anesthesia?

Back 97

MAC or GETA

Front 98

Rigid Esophagoscopy - type of anesthesia?

Back 98

GETA with muscle relaxants

Front 99

Endoscopic Complications?

Back 99

Facial, dental, laryngeal injury;
Airway rupture, pneumothorax;
Hemorrhage;
Airway obstruction – blood, FB, edema.

Front 100

Endoscopy - Anesthesia Considerations?

Back 100

Small ETT vs. DLT;
Laser tube and laser precautions;
Short-acting hypnotic agent;
IA vs TIVA;
Short-acting opioids;
Short-acting MR;
LA post-op.

Front 101

Median sternotomy is done for?

Back 101

Thymectomy
Mediastinal masses
Sternotomy for Bilateral Pulmonary Resection

Front 102

Thymectomy is usually done for?

Back 102

Treatment of choice for Myasthenia Gravis

Front 103

What are the surgical approaches for a thymectomy

Back 103

Sternal incision or cervical approach

Front 104

What is myasthenia gravis?

Back 104

It is an autoimmune disease that affects the post junctional ACh receptors. 1:20,000
F > M

Front 105

What % of MG pts have thymomas?

Back 105

10% of MG pts
Theory is, it is r/t the ACh-antibodies

Front 106

S/S MG?

Back 106

Ocular, pharyngeal, skeletal-muscle weakness

Front 107

Test for MG ?

Back 107

Increased strength after
admin of Tensilon (edrophonium 10mg)

Front 108

Tx of MG?

Back 108

Anticholinesterases (pyridostigmine), corticosteroids, immuniosuppressants, plasmaphoresis,
thymectomy.

Front 109

Anesthetic Considerations for
Myasthenia gravis – MG medications?

Back 109

Continue anticholinesterase meds (hold day of surg.)

Front 110

Anesthetic Considerations for
Myasthenia gravis – Post-Op Ventilation?

Back 110

Postop ventilation if, MG:
present for > 6yrs;
coexisting with COPD;
is tx'd with anticholinesterase dose of >750 mg/day

Front 111

Anesthetic Considerations for
Myasthenia gravis – anesthesia?

Back 111

GETA
Relaxants - (+++) NDMR
and (--) DMR

Front 112

Indications for esophageal surgery?

Back 112

Resection of neoplasms
Anti reflux procedures
Repair traumatic or congenital lesions

Front 113

Considerations for esophageal surgery?

Back 113

Chronic malnutrition r/t CA illness (low protein --> leaky capillaries);
Swallowing difficulty;
Hypovolemia r/t difficulty swallowing;
Esophag lesions r/t ETOHism;
Aspiration risk.

Front 114

Monitoring for esophageal surgery?

Back 114

Arterial line
CVP
foley

Front 115

Esophageal Surgery - type of anesthesia?

Back 115

General anesthesia with
DLT & epidural analgesia intra-op/post-op.
Post-op intubation for aspiration precaution.

Front 116

Surgical approaches for
upper esophageal lesion?

Back 116

Transverse cervical incision for proximal anastomosis, Right side thoracic incision and midline abdominal incision for resection and closure.

Front 117

Surgical approaches for
middle esophageal lesion?

Back 117

Right side thoracotomy (Ivor Lewis approach)

Front 118

Surgical approaches for
lower esophageal lesion?

Back 118

Extended left thoraco-abdominal incision

Front 119

Considerations for pt positioning in the lateral position using the flexed table?

Back 119

Secure tubes and lines;
Take command of turning procedures;
Proper padding and assessment of pressure points is essential;
Head, neck, eyes in neutral position;
Padding for axilla and lower extremities;
Reassess breath sounds, vital signs, monitors, arterial and PA lines, IV’s at reasonable intervals.

Front 120

Anesthetic technique for open thorax case?

Back 120

Combined epidural and IA;
OLV techniques for surgical exposure and minimal damage to operative lung;
Maintain oxygenation in patients;
Ensure the patient is comfortable, warm and awake at end of surgery.

Front 121

Preinduction for open thorax case?

Back 121

Place lumbar epidural catheter;
Admin test dose 3 ml lidocaine (1.5%) w/ epi 1:200K
If no hypotension;
Confirm functioning epidural catheter.

Front 122

Induction for open thorax?

Back 122

Standard induction;
Intubate with SLT >8mm;
SLT will be replaced with DLT after Bronchoscopy.

Front 123

Maintenance of anesthesia in open thorax surgery:

Back 123

O2 and isoflurane -1.0-1.5%
(less if using epidural);
Avoid N2O, especially during OLV;
FiO2 = 100%
Lidocaine 10 ml via lumbar epidural every 45 min.
or anesthetic of choice.

Front 124

Blood and fluid requirements
for open thorax surgery?

Back 124

IV – 2 large bore access -
possibly CVC;
Restrict IV fluids -
administer 1000-1500 ml NS/LR (MAX);
+/- 1 unit autologous blood if available.
Use vasopresser if hypotensive
Ephedrine 5-10mg IV bolus or
Phenylephrine 50-100ug IV bolus.

Front 125

Reason for lung isolation in open thorax surgery?

Back 125

Separate lungs to prevent contralateral contamination &
allow selective ventilation

Front 126

Open thorax surgery - emergence?

Back 126

Prior to closing chest, inflate lungs to 30-40cm H2O to reinflate atelectactic areas and to check for leaks;
Surgeon inserts CTs to drain pleural cavity and aid lung reexpansion;
Pt is extubated in OR, or DL-ETT is exchanged for SL-ETT (HV-LP) if patient is to remain intubated;
CTs to 20cm H2O suction, except in pneumonectomy, then water seal only;
Pnt transferred in head-up position to ICU on monitors and NRBM O2.

Front 127

What are the Single-Lumen Endobronchial Tubes?

Back 127

Inability to clear material from operative lung;
Potential for limited ventilation - nonintubated surgical lung.

Front 128

True/false?
Single-Lumen Endobronchial Tubes are more commonly used than DLT

Back 128

False
They have been replaced by double-lumen tubes today

Front 129

Types of Bronchial blockers?

Back 129

McGill catheter
Fogerty catheter
Foley catheter
Univent tube

Front 130

Double-Lumen Endobronchial tubes have been used since?

Back 130

1940’s

Front 131

True/false?
Double-Lumen Endobronchial tubes are available in right-sided version only?

Back 131

False.
They are available in right- and left-sided versions.
Some use only L tube, others always intubate the nonoperative bronchus.

Front 132

True/false?
Double-Lumen Endobronchial tubes must be placed with the aid of fiberoptic bronchoscope (FOB)

Back 132

False.
They are placed with or without aid of fiberoptic bronchoscope (FOB)

Front 133

Sizes of Double-Lumen Endobronchial tubes?

Back 133

39-41 Fr Men
35-37 Fr Women

Front 134

Most common error with insertion of DLT is?

Back 134

Advancement of DLT too far in bronchus causing only distal lumen ventilation of one lung

Front 135

Regarding One Lung Ventilation:
Ventilation/Perfusion is altered by?

Back 135

Numerous factors affect oxygenation and ventilation:
GA
Lateral positioning
Open chest & OLV
Surgical manipulation

Front 136

In one lung ventilation,what is the main component of
oxygenation?

Back 136

Amount of shunt is main component of oxygenation

Front 137

How does HPV affect oxygenation in one lung ventilation?

Back 137

Hypoxic Pulmonary Vasoconstriction may limit shunting unless it is blunted.
(Pulmonary pathology may also limit shunting).

Front 138

What should you do when switching to or from 2-lung and 1-lung ventilation

Back 138

Always hand-ventilate prior to switching.

Front 139

Ventilation guidelines for one lung ventilation - PIP?

Back 139

Maintain PIP below 35 cmH2O

Front 140

Ventilation guidelines for one lung ventilation - mV?

Back 140

Maintain mV w/o causing Auto-PEEP

Front 141

Ventilation guidelines for one lung ventilation - ETCO2?

Back 141

Maintain ETCO2 as with 2-lung ventilation;

Front 142

Ventilation guidelines for one lung ventilation - TV?

Back 142

Use larger TV (8-10 ml/kg)

Front 143

Ventilation guidelines for one lung ventilation - PEEP?

Back 143

PEEP 5mmHg
(Some auto PEEP may be generated, depending on size of DLT).

Front 144

Ventilation guidelines for one lung ventilation - RR?

Back 144

Adjust RR to maintain PaO2

Front 145

How does one lung ventilation affect compliance & resistance?

Back 145

Compliance is reduced and resistance is increased.
PIPs will be higher

Front 146

What is the greatest risk with OLV?

Back 146

Hypoxemia.
If pulse oximetry is <94% or PO2 <100, recheck DLT or BB

Front 147

O2 Management duringOne Lung Ventilation - alogarithm for desaturation

Back 147

D/C N2O
Increase FiO2 = 1.0
Check tube position and suction as needed;
CPAP to non-dependent lung (5-8 cmH2O);
If still no improvement, add PEEP to dependent lung;
Apneic oxygenation to NVL;
Reinflate NVL w/ 100% FiO2 prn, 2-lung vent;
Have surgeon clamp NVL PA or go to Bypass.

Front 148

One Lung Ventilation - emergence guidelines.
Prior to surgeon closing chest, what should you do?

Back 148

Inflate lungs to 30 cm H2O to reinflate atelectactic areas and to check for leaks.

Front 149

One Lung Ventilation - emergence guidelines.
Why does the surgeon insert a CT?

Back 149

To drain pleural cavity and aid lung reexpansion.
CT(S) 20cmH2O suction, except in pneumonectomy, where water seal only is used.

Front 150

One Lung Ventilation - emergence guidelines.
How & when is extubation done?

Back 150

Patient is extubated in OR, or DL-ETT is exchanged for SL-ETT (HV-LP) if patient is to remain intubated.

Front 151

One Lung Ventilation - emergence guidelines.
When transferring the pt from the OR, what position should the pt be in?

Back 151

In the "head elevated" position (to ICU on monitors and NRBM O2).

Front 152

Your pt had chest surgery involving the lungs & CTs where placed. The pt suddenly has an arrest. What is the first thing to check?

Back 152

The chest tube

Front 153

List Lung Isolation complications r/t trauma?

Back 153

Dental and soft tissue injury;
laryngeal injury caused by large diameter tube;
TracheoBronchial wall ischemia/stenosis.

Front 154

True/false?
Spontaneous ventilation is sub-atmospheric pressure process.

Back 154

True.
It is negative pressure ventilation where gas is “sucked” in.

Front 155

Besides trauma, what are other complications of Lung Isolation?

Back 155

Malposition
(too distal/proximal advancement of tube);
Hypoxemia;
Aspiration.

Front 156

True/false?
Mechanical Ventilation is positive pressure.

Back 156

True.
It is above atmospheric pressure and gas is “pushed” in.

Front 157

What are the ventilatory dynamics that pulls more gas to the dependant areas of lungs with spontaneous ventilation?

Back 157

Negative pleural pressures coupled with the pale handle effect.

Front 158

What does opening the thorax do to lung dynamics?

Back 158

Opening thorax alters negative intra-thoracic pressures.

Front 159

How does SLV result in V/Q mismatch?

Back 159

Single lung ventilation gives 100% gas to one lung, blood flow is split between both lungs --> V/Q mismatch

Front 160

How many lobes does the left lung have?
Right lung have?

Back 160

Two
Three

Front 161

What structures comprise the conducting zone of the lung?

Back 161

Trachea, bronchi, bronchioles, and terminal bronchioles (1st thru 16th division of the lungs)

Front 162

What structures comprise the transitional and respiratory zones?

Back 162

respiratory bronchioles, the alveolar ducts, and the alveoli

Front 163

During spontaneous ventilation, where is the greatest blood flow?

Back 163

At the base of the lungs

Front 164

During spontaneous ventilation, where is the greatest gas flow?

Back 164

Dependent area

Front 165

What is V/Q?

Back 165

The ratio of ventilation to perfusion

Front 166

What is normal V/Q

Back 166

0.8

Front 167

Where does most perfusion in the lung go to during spontaneous ventilation?

Back 167

The base (dependent region)

Front 168

Where does most perfusion in the lung go to during mechanical ventilation (positive press.)?

Back 168

West Zone 3 (the most dependent part of the lungs).

Front 169

Where does most gas flow in the lung go to during spontaneous ventilation?

Back 169

The dependent region of the lungs

Front 170

Where does most gas flow in the lung go to during spontaneous mechanical ventilation (positive press.)?

Back 170

To the nondependent region

Front 171

Which has more ventilation-apex alveoli or basilar alveoli?

Back 171

Apex Alveolar

Front 172

Which intercostals aid inspiration, expiration

Back 172

Internal intercostals - expiration;
External intercostal - inspiration

Front 173

Describe the pale handle effect?

Back 173

The internal intercostals, pull downward to aid expiration;
the external intercostal elevate ribs, aid inspiration.

Front 174

The pleural cavity has a positive or negative pressure?

Back 174

Negative

Front 175

Where is the greater negative pleural pressure, apex or base

Back 175

Apex

Front 176

Where is the greater pleural pressure, apex or base?

Back 176

Base

Front 177

Where is the greatest change of pleural pressures during a normal respiratory cycle- apex or base?

Back 177

Base

Front 178

Atelectasis is caused by...

Back 178

Alveoli not participating in gas exchange

Front 179

How does general anesthesia contribute to atelectasis formation?

Back 179

Internal & external intercostals do not participate in respiration when the pt is anesthetized, resulting in less expansion at the base of the lungs thus resulting in atelectasis.

Front 180

What is the better choice for lowering CO2 in a ventilated patient considering atelectasis formation, increase rate or increase tidal volume?

Back 180

Increasing TV

Front 181

What is the difference between an open pnemothorax vs a closed pneumothorax?

Back 181

In the open pneumothorax there is damage to the lungs/chest that result in communication with the atmosphere while with the closed pneumothorax, there is no atmospheric communication.

Front 182

Describe a tension pneumothorax?

Back 182

Damage to the pleura causing a one-way valve at the point of rupture. Air gets sucked into the pleuaral space but cannot get out.

Front 183

What is a hemothorax?

Back 183

Blood in the pleural space

Front 184

Name three lung isolation tubes/ techniques

Back 184

McGill catheter
Fogerty catheter
Foley catheter

Front 185

How does single lung ventilation alter V/Q matching

Back 185

It causes shunting b/c 100% of the blood is going to one lung

Front 186

What other intra-operative factors affect V/Q mismatch during a single lung ventilation case?

Back 186

Amount of shunt is main component of oxygenation;
Hypoxic Pulmonary Vasoconstriction may limit shunting unless HPV is blunted
Pulmonary pathology may limit shunting;
Lateral position decreases blood flow to NonDependent lung by gravity.