Thoracic I Flashcards

Question

What is VO2max?

Answer 1

* Maximum oxygen consumption (VO2max) during exercise testing * ⇓ by 4% during exercise → high risk * **Values:** * **VO2max: \> 20 ml/kg/min** * **Most have no pulm complications** * **High risk → \< 15 mL/kg/min (preop)** * **High M&M** * **Very high risk → \< 10 ml/kg/min** * **Testing: 6-minute test** * Requires little/no lab equipment * VO2max can be estimated from **6-minute walk test: [distance walked (meters) / 30] = VO2max** * 6 min walk (~450 m) → estimated VO2max = 450/30 = 15 mL/kg/min * Examples: VO2max * 5 flights = \> 20 mL/kg/min * 2 flights = 12 mL/kg/min. * ⇑ risk → SpO2 decrease \> 4%

Answer 2

**Diffusing Capacity (ppoDLCO)** * Diffusing capacity (DLCO) is the ability of the lung to perform gas exchange (pt. inhales carbon monoxide and tested) * **High risk → \< 40% of postop predicted value** * correlates with both increased respiratory and cardiac complications * independent of FEV1 (even if FEV1 normal) * **DLCO (not FEV1) → negatively affected by preoperative chemotherapy** * **may be the most important predictor of complications in this subgroup of patients**. * Some authors feel a higher cutoff risk-threshold for ppoDLco of \< 50% may be more appropriate. * Measured- CO inhalation

Answer 3

* One method of estimating the percent of functional lung tissue is based on a calculation of the number of functioning subsegments of the lung removed * Right lung: 3 lobes * Left lung: 2 lobes * Number of subsegments of each lobe is used to calculate the predicted postoperative (ppo) pulmonary function (picture →) * **ppoFEV1 = preop FEV1 (or DLco) % × ( 1 – segment % /100)** * Ex: After a RLL lobectomy * Taking 12 segments out of 42 segments → 12/42= 29% * Taking out 29% of total lung tissue * Equation: * Given: Preop FEV1 [or DLco] 70% of normal * 70% × ( 1 − 29/100) = **50% ppoFEV1** * **Postresection respiratory complications:** * **ppoFEV1:** * low risk = \> 40% * **risk = \< 40% (complications)** * **high risk = \< 30%** * **unacceptably high risk = \< 20%**

Answer 4

* ALWAYS asses Functional Capacity * Functional capacity \> 2 METS → need spirometry * \*ppoFEV1 * \*ppoDLCO * \> 60% (both) → pt should do well * 30-60% → 6 min walk test (get VO2max) * 6 min walk test * Walk \> 400 m → proceed to sx * Walk \< 400 m → get exercise testing and formally calculate O2 consumption * \> 10 ml/kg/min → increased risk * \< 10 ml/kg/min → hold sx and optimize (consider video thoracoscopy) * *Traditionally arterial blood gas data such as PaO2 less than 60 mm Hg or PaCO2 greater than 45 mm Hg have been used as cut-off values for pulmonary resection. Cancer resections have now been successfully done or even combined with volume reduction in patients who do not meet these criteria, although they remain useful as warning indicators of increased risk.*

Answer 5

* Bottom curve- inspiratory effort * O: obstructive dx (baby carriage) * R(E): extraparenchymal dx * Limitation in inspiratory and expiration * R(P): parenchymal restrictive disease * RV: Residual volume; * TLC: total lung capacity. * By convention, lung volume increases to the left on the abscissa. The arrow alongside the normal curve indicates the direction of expiration from TLC to RV * Forced expiration is plotted in all conditions * Forced inspiration is shown only for the normal curve.

Answer 6

* **Upper airway lesions** * Ex: tracheal stenosis * Appearance: **fixed plateau during inspiration and expiration** * FEF₅₀/FIF₅₀ratio: unchanged * **Extrathoracic obstruction** * Ex: lesion/tumor located above sternal notch * Appearance: **flattening of inspiratory loop** * Flattening → represents no further increase in airflow bc mass causes AW collapse * FEF₅₀/FIF₅₀ratio: \> 1 * **Intrathoracic obstruction** * Appearance: **flattening of expiratory loop** * Flattening → lesion causes AW collapse during expiration * FEF₅₀/FIF₅₀ratio: \< 1

Answer 7

* Phase II- Split lung testing * Details the function of each lung separately * Measures ventilation and perfusion of each lung via radio isotope * Phase III- Lung isolation * Post-operative condition of the patient is simulated via temporary balloon occlusion of the major pulmonary artery on that side. * Functional testing of the pulmonary vascular bed of the lung to be excised

Answer 8

* Average risk * FEV1\>2 L or 80% predicted * PPO FEV1 \>80$ predicted * PPO FEV1 + PPO DLCO both \>40% * VO2 max \>15 ml/kg/min * ability to climb 3 flights stairs * Elevated risk * FEV1 \<2L or \<40% predicted * PPO FEV1 \<40% predicted * PPO DLCO \<40% predicted * VO2 max \<10 mL/kg/min (on 6 min walk test) * inability to climb one flight stairs * o2 desat \>4% during exercise The National Emphysema Treatment Trial: * preoperative FEV1 or DLCO \< 20% → unacceptably high perioperative mortality rate. * These can be considered as the absolute minimal values compatible with a successful outcome.

Answer 9

* Evaluate comorbidities * Smoking related complications (CAD?) * Cor pulmonale * Paraneoplasm effects * Secreting hormones? * CV dx * MI w/in 6 wks? * Chemo * EKG/CXR * Labs * Lung function testing: * FEV1 and DLCO * VO2max * COPD → blood gas and response to bronchodilators

Answer 10

* Cardiac complications are the second most common cause of peri-operative morbidity and mortality * Elective pulmonary resection is considered “intermediate risk” for cardiac morbidity * CAD secondary to smoking may lead to ischemia * Risk of post-thoracotomy ischemia = 5% (peaks POD 2 & 3) * **Arrhythmia risk:** * 30-50% → post op arrhythmia after pulmonary resection (1^st week highest risk) * Most common: A-fib (60-70%) * **β-Adrenergic blockers** → most effective drug to prevent arrhythmias * Caution: Concerns regarding use in reactive airways diseases. * Diltiazem (CCB) → most useful drug for postthoracotomy arrythmia prophylaxis

Answer 11

* **Factors effecting increased arrythmia incidence:** * **Extent of lung resection** * pneumonectomy- 60% * lobectomy- 40% * nonresection thoracotomy- 30% * **Intrapericardial dissection** * **Blood loss intraop** * **Age (older)** * **Extrapleural pneumonectomy** * Two factors in the early postthoracotomy period interact to produce atrial arrythmias: * (1) increased flow resistance through pulmonary vascular bed bc of permanent (lung resection) or transient (atelectasis, hypoxemia) causes with attendant strain on the right side of the heart * (2) increased sympathetic stimuli and oxygen requirements * maximal on 2^nd postop day as patients become more mobile * Considerations: * COPD pts → more resistant to pharmacologic-induced HR control when they develop posthoracotomy a fib * Require multiple drugs * Most common arrhythmia → Atrial fib/flutter * Due to atrial stretch * Contributing factors * Greater incidence in patients \> 60 years old * **Surgical procedure: Left pneumonectomy (Right makes more sense?)** * Prophylaxis: * Digoxin * Diltiazem/Verapamil/CCB’s * Beta blockers- Esmolol * Amiodarone

Answer 12

* Consider those at highest risk for A fib: * anterior mediastinal mass * Lobectomy * Pneumonectomy * Esophagectomy * Diltiazem (if preserved CV fx and not taking BB) * Amiodarone * Statins * All patients: * Continue BB preop * Magnesium level * Optimize

Answer 13

* CV response to COPD & CAD → pHTN * **Pulmonary hypertension****- 40-50% pts w/ severe lung disease** * Increased pulmonary vascular resistance * Right ventricular hypertrophy and dilation * LV dysfunction due to CAD, MI, HTN * Vascular Resistance measurements – PA, PAOP/PCWP, C.O., PV Compliance * PAP (pulm artery pressure) \> 25 or systolic \>35: * Increased risk respiratory complications * prolonged intubation * Management: * ECG/ECHO * Needed to determine severity of associated CV disease/pulm HTN * **AVOID HoTN** * \*vasopressin to maintain BP * After pulmonary resection → right ventricular dysfunction proportional to the amount of functioning pulmonary vascular bed that has been removed. * The exact etiology and duration of dysfx unknown. * Hemodynamic problem minimal when the patient is at rest * **Dramatic when exercises** → leading to: * elevation of pulmonary vascular pressures * limited CO * absence of normal decrease in PVR usually seen with exertion **Management of pHTN secondary to Lung Disease (chart →)** * 2 main types of pHTN we focus on: * pHTN d/t left heart disease * **\*pHTN d/t lung disease** * noncardiac surgery more likely to have pHTN due to lung disease * **Paravertebral blocks preferred over thoracic epidural in this population** * 6. May need PA cath to monitor pressures (CO)

Answer 14

* \*Goal: decrease postoperative pulmonary complications (2) * atelectasis * pneumonia * **Reasons for Complications:** * Degree of pre-operative pulmonary dysfunction * Surgical impairment of lung. * Nondependent lung – tissue resected or traumatized * Dependent lung – compression → causing edema and atelectasis * Thoracotomy and Upper Abdominal postoperative incisional pain – **adequate pain management is essential!**

Answer 15

* Stop Smoking * Dilate Airways * B2-sympathomemitic * Phosphodiesterase inhibitors * Inhaled anticholinergics and/or steroids * Mucolytics * Loosen/Remove Secretion * Treat infections * Nutrition/exercise/physiotherapy: Measures to increase motivation and postoperative care * Chest physiotherapy → improve exercise tolerance if \> 1 mo * little improvement if \< 1 mo

Answer 16

* **Cardiac effects of smoking:** * Risk factor for developing CV dx * Carbon monoxide → * decreases O2 delivery * increases myocardial work * Releases catecholamines → coronary vasoconstriction * Exercise capacity decreases * **Respiratory effects of smoking:** * Risk factor for developing pulm dx * Mucocilliary activity decrease * Hyperreactive AW * Pulm immune fx decrease * **Smoking cessation:** * \> 4 wks d/c smoking → Pulmonary complications⇓ * \> 12 hrs d/c smoking → Carboxyhgb [] ⇓ * There is no rebound increase in pulmonary complications if patients stop for shorter (\< 8 weeks) periods before surgery. Intensive smoking-cessation interventions are the most successful. * **Important to avoid smoking postop** * Smoking leads to prolonged period of tissue hypoxemia. * Wound tissue oxygen tension correlates with wound healing and resistance to infection.

Answer 17

* B adrenergic agnoists (ie albuterol, terbutaline) * increase adenylate cyclase-→ increase cAMP→ decrease smooth muscle tone→ bronchodilation * Methylxanthines (ie aminophyllin, theophylline) * phosphodiesterase inhibition→ increase cAMP→ potentiates endogenous catecholamine * improve diaphragmatic contracility, central respiratory stimulant * Corticosteroids (ie methylprednisolone, dexamethasone, cortisol) * antiinflammatory, membrane stabilizing, inhibits histamine release * potentiates b agonists * Anticholinergic (ie glyco, ipratropium) * blocks acetylcholine at postganglionic receptors, decrease cGMP, relaxes airway smooth muscle * Antileukotriene (ie montelukast) * inhibit leukotriene production * antiinfallmatory * used in addition to steroids

Answer 18

* Deep breathing * Weight loss * Use of oxygen * Realistic post-op expectations * Stay intubated/ventilator * Post-op respiratory care procedure spirometry, chest PT, ambulation

Answer 19

* Humidification and warming of inspired gases * Dry gases → secretions become thick * Suctioning * Prevents increase in airway resistance and alveolar collapse * Chest Physiotherapy * \*\*Mucociliary flow decreased by high FiO2, low inspired gas temp and inflation of ETT cuff * Mucolytics * Mucomyst 2-5ml 5% to 20% solution q 6-8 hours * Bronchoscopy (therapeutic)

Answer 20

* Dyspnea * Cough and sputum production * **\*\*Recent URI** * **Increased risk bronchospasm/laryngospasm** * Hemoptysis * Wheezing and/or use of brochodilators/steroids * History of previous pulmonary post-op complications * History of smoking * Age, general history, other significant disease history * Breathing frequency/pattern * Body habitus * **\*\*Site of proposed surgery/Emergent surgery**

Answer 21

* Classification: Chronic Bronchitis and Emphysema * Causative Factors: * **Tobacco Abuse - MAJOR** * Alpha₁ antitrypsin deficiency→emphysema in young patients * **Manifestation:** **impairment of expiratory flow** * **Retention of gases** * Assessment of severity based on FEV₁ % of predicted values * stage I: \> 50% predicted * stage II: 35 - 50% * stage III: \< 35%. * Stage I patients should not have significant dyspnea, hypoxemia, or hypercarbia, and other causes should be considered if these are present. * Stage II and III → do have those symptoms * **Pathological manifestations:** * **CV:** * **RV dysfunction (up to 50% COPD pts)** * **Pulm:** * Increased dead space ventilation * result in diversion of inspired air into (nonobstructed) ventilated, but poorly perfused, regions of lung. * Increased FRC * gas trapping * flow limitation * Stage II or III → increased CO2 at rest

Answer 22

* **Management:** * **Preop: ALL COPD patients should have maximal bronchodilator therapy** * Need to admin O2 postop d/t unavoidable fall in FRC * The attendant rise in Paco2 should be anticipated and monitored (blood gases) * **Dysfunctional right ventricle → poorly tolerant of sudden increase in afterload** * Ex: change from SV to controlled ventilation → compromised RV fx * RV fx becomes critical in maintaining CO as pulmonary artery pressure rises. * RV ejection fraction does not increase with exercise in COPD patients as it does in normal patients. Chronic recurrent hypoxemia is the cause of the RV dysfunction and the subsequent progression to cor pulmonale. * **Bullae:** * Normal SV → intrabulla pressure slightly negative in comparison to surrounding parenchyma * PPV → pressure in bulla becomes positive in relation to adjacent lung tissue * Bulla expands w/ attendant risk of rupture, tension pneumo, and bronchopleural fistula * OK to do PPV → but keep aw pressures low * high suspicion of pneumo * have equipment ready for chest drain/one lung isolation if necessary * **Auto-PEEP:** * Auto-PEEP becomes even more important during mechanical ventilation. * **Directly proportional to TV** * **inversely proportional to expiratory time**. * **Allow for adequate expiratory time** * Auto-PEEP has been found to develop in most COPD patients **during one-lung anesthesia** * Patients with obstructive disease → risk for both intraoperative & post-operative pulmonary complications * **GOAL:** Minimize the risk of postop respiratory failure. * VA blunt airway reflexes and reflex bronchoconstriction (bronchodilation) * → consider the CV effects * Judicious use of opioids – prevent and/or treat postop pain but avoid respiratory depression.

Answer 23

* Previously thought chronically hypoxemic/hypercapnic patients relied on hypoxic stimulus for ventilatory drive and became insensitive to Paco2. * This explained the clinical observation that COPD patients in incipient respiratory failure could be put into a hypercapnic coma by the administration of a high concentration of oxygen (FiO2**).** * **In actuality, only minor fraction of increase Paco2 in such patients is caused by a diminished respiratory drive, bc** **minute ventilation is basically unchanged****.** * The Paco2 rises because a high FiO2 causes a relative decrease in alveolar ventilation and an increase in alveolar dead space and **shunt by the redistribution of perfusion away from lung areas of relatively normal ˙ V/˙ Q matching to areas of very low ˙ V/˙ Q ratio because regional hypoxic pulmonary vasoconstriction (HPV) is decreased** and also as a result of the Haldane effect. * **However, supplemental oxygen must be administered to these patients postoperatively to prevent hypoxemia associated with the unavoidable fall in functional residual capacity (FRC). _The attendant rise in Paco2 should be anticipated and monitored._ To identify these patients preoperatively, all stage II and III COPD patients need an arterial blood gas analysis.**

Answer 24

At risk for hemodynamic collapse with positive pressure manual ventilation via bag valve mask. * Severely flow-limited patients are at risk for hemodynamic collapse with the application of positive-pressure ventilation because of dynamic hyperinflation of the lungs. Even the modest positive airway pressures associated with manual ventilation with a bag/mask at induction can lead to hypotension because these patients have no increased resistance to inspiration but a marked obstruction of expiration. In some of these patients, this has contributed to the “Lazarus” syndrome, in which patients have recovered from a cardiac arrest only after resuscitation and positive-pressure ventilation were discontinued

Answer 25

* RV ⇑ * FRC ⇑ * TLC – normal/⇑ * RV:TLC ⇑

Answer 26

**Emphysema** * PaO_2: \>60 * PaCO_2: Normal * Appearance: * Thin, anxious, purse lips * Accessory muscles * Dyspnea * Scant secretions * Markedly diminished breath sounds * With resp infx r-sided heart compromise * CXR: hyperinflation low diaphragm **Bronchitis** * PaO₂\< 60 * PaCO₂ \> 45 * Appearance: * Overweight, cyanosis dusky appearance * “Blue bloater” * Cough * Copious secretions * Diminished breath sounds * R-sided heart failure /cor pulmonale * CXR: bronchovascular markings

Answer 27

* Controlled ventilation * slower frequency 6-10 bpm * Larger TV * keep PIP \<40 cm H2O * longer Expiration time to minimize V:Q mismatch * Ventilator setting: * larger TV * slower RR * longer I:E ratio * Considerations: * Judicious use of opioids * No N2O * due to risk of bullae * Regional techniques with sensory above T6 are **not** recommended

Answer 28

* Regional * –Good choice extremity surgery, +/- lower abdominal; consider that patient can not tolerate additional IV sedation * levels \>T6 should be avoided as they need their accessory muscles! * General – * IV administration of opioids and lidocaine prior to airway instrumentation will decrease reactivity * Increased risk bronchospasm * No specific agent ‘ideal”-consider co-morbidities * VA produce brochodilation and are rapidly eliminated * Short acting NMB * Judicious opioid use → resp depression * Less tolerance for respiratory depressant effects of all drugs * Ex: benzos, opioids * Humidification and low gas flow → for thick/dry secretions

Answer 29

* Maintenance * Ventilation * Tidal volumes * keep airway pressure \< 40 cm/h20 * 6-8 ml/kg * Slow rate (6-10 breaths per minute) * Sufficient time for exhalation * Be aware of pulmonary barotrauma, rupture of bullae, and auto-PEEP * Consider baseline PaCO2 a rapid correction to “normal values” may result in metabolic alkalosis * Spontaneous ventilation → may result in hypercapnia * Bad for RHF * Emergence * Post-operative respiratory status is the priority issue * Calm and awake * Adequate pain control (pain free breathing and improved coughing) **Extubation** * Postop mechanical ventilation → risk patients * Preop FEV1/FVC ratio \< 0.5 * Preop PaCO2 \> 50 * Post-op mechanical ventilation should be to maintain * PaO2 60-100 * PaCO2 - maintain pH 7.35-7.45

Answer 30

* Airway hyper-responsiveness and inflammation * Patho: Eosinophils, mast cells, neutrophils, macrophages, basophils, T lymphocytes have all been implicated as histologic mediators * Other probable mediators of acute bronchoconstriction * include: cytokines, interleukins (3,4,5), arachidonic acid metabolites (leukotrienes and prostaglandins), kinins, histamine, adenosine, and platelet activating factor

Answer 31

* Consider regional techniques * GA → * depress airway reflexes * avoid hyperactivity &bronchoconstriction * Techniques: * B2 Agonists via inhaler q 15-20 min or continuous neb * Intravenous corticosteroids * Cortisol 2 mg/kg followed by 0.5 mg/kg/hr (or) * Methylprednisolone 60-125 mg q6 hr * Supplemental O2 to maintain Sao2 \> 90% * IV magnesium sulfate may improve lung function * Oral leukotriene inhibitor * Tracheal intubation and mechanical ventilation (when Paco2 \> 50 mm Hg) * Bronchodilation via: * VA * Ketamine * High gas flows → permit short inspiration times and longer expiration times. * Expiration time → prolonged to avoid air-trapping and “auto PEEP.” * Permissive hypercarbia to avoid barotrauma. * Empirical broad-spectrum antibiotics * What interventions would you take to meet those requirements? * How do you manage intraoperative bronchospasm?

Answer 32

* Decreased TLC * Vital Capacity \< 70 ml/kg * Expiratory flow rate normal * FEV₁/FVC ratio NORMAL * Rapid, shallow breathing pattern * Increased PaCo2 * Decreased lung compliance * Increased work of breathing * Conditions that interfere with normal lung expansion during inspiration Spirometry → all volumes reduced

Answer 33

* Lung Cancer * 13% cure rate → surgical resection * Population: * older (~70 yo) (\< 2% \< 45 yo) * 1 PPD life smoker → 1 in 14 risk * Surgical resections are responsible for nearly all cures * Leading cause of cancer deaths in both genders * 90% of Lung ca’s are smoking related * Less common: asbestos, radon * Categorized as: (2) * Small Cell Carcinoma * Non-Small Cell Carcinoma

Answer 34

* Majority of patients will have one or more symptoms related to the presence of the tumor * **Symptoms include:** * Cough * Dyspnea * Chest pain * Unilateral wheezing * Nonspecific symptoms include * Weight loss, anemia, lethargy, malaise, vague cold-like * Symptoms from the tumor may occur in one or more category: * Bronchopulmonary * Involvement of the lung: cough, dsypnea, * Extrapulmonary Intrathoracic * Tumor growth beyond the confines of lung: * pleural effusion * chest wall pain * dysphagia * Extrathoracic Metastatic * Tumor spread outside the thorax: brain, skeletal, kidney, lymph nodes, skin * Extrathoracic Nonmetastatic * Paraneoplastic syndrome: endocrine or endocrine-like syndrome * Cushings disease * hypercalcemia, * Nonspecific * Weight loss, anemia, anorexia, malaise, vague cold-like syndrome

Answer 35

* Poor prognosis * Metastatic on presentation * Prognosis: ~3 months after diagnosis due to metastasis * Not usually surgical candidates * Chemo/ radiation * **Neuroendocrine origin (paroneoplastic syndrome)** * **Lambert-Eaton Myasthenic Syndrome** * impaired release of acetylcholine from nerve terminals * → typically presents as proximal lower limb weakness and fatigability that may temporarily improve with exercise. * Diagnosis: * confirmed by electromyography showing increasing amplitude of unusual action potentials with high-frequency stimulation * Considerations: * Similar to true myasthenia gravis → pt’s with myasthenic syndrome are extremely sensitive to nondepolarizing muscle relaxants. However, they respond poorly to acetylcholinesterase inhibitors (neostigmine) * subclinical involvement of the diaphragm and muscles of respiration * \*\* think long term smoker w/o recovery from NMB → prob tumor/LEMS * Thoracic epidurals used w/o complication * NM fx resolved after tumor resection * **SIADH → hyponatremia (most common)** * Inappropriate production of antidiuretic hormone * **Cushings & Hypercortisolism** * through ectopic production of adrenocorticotropic hormone **Carcinoid tumors (SCLC tumors are the most malignant form of carcinoid tumors)**: * severe hypotension that may not respond to the usual vasoconstrictors (Refractory HoTN) * **will require use of specific antagonists** **octreotide or somatostatin.**

Answer 36

* Includes: 75-80% primary lung ca * **squamous cell** * slow growing * late metastases * frequently have sx due to large endobronchial mass * → SVC syndrome; mainstem bronchus involvement * **hypercalcemia** (due to elaboration of paraythroid-like factor and not due to bone mets) * **Adenocarcinoma (most common)** * peripheral tumors * frequently metastasize early to brain, bone, liver, adrenals; extrapulmonary invasion is frequent (chest wall, diaphragm, pericardium) * Prognosis is variable * Surgery is usually _considered_ * 5 year survival is ~40% * Without surgery \<10%

Answer 37

* Signs & Symptoms: * Acute dyspnea, tachypnea, pleuritic chest pain, cough, accentuation of pulmonic 2^nd sound, rales, tachycardia, fever, hemoptysis * Diagnosis: V:Q scan and/or pulmonary arteriography * ABG → Decreased PaO₂ and PaCO₂ * Under anesthesia will see: * arterial hypoxemia * hypotension * tachycardia * bronchospasm * **Management:** monitor cardiac filling pressures, avoid drugs that increase PVR, positive pressure ventilation * **Treatment:** Pulmonary artery embolectomy, IVC filter, anticoagulants, analgesics

Answer 38

* Inflammatory process * Major cause-bacterial; usually gram negative bacilli and staph aureus * S&S: * Fever, chills, productive cough tachypnea Treatment - resolve infection * Elective surgery not advised * Consider regional * Acknowledge potential need for postoperative ventilation

Answer 39

* Airborne mycobacterium tuberculosis * Transmitted by droplets, use special filtration masks (personnel) * Follow institutional policy regarding cleaning of anesthesia equipment especially breathing circuit, CO2 absorbent, airway equipment, etc. * Recommend complete change of breathing circuit equipment!

Answer 40

* Right ventricular enlargement 2**^°** pulmonary hypertension * S & S: * dyspnea, syncope, PA mean pressure \>20, prominent “a” wave on CVP, can be overt right heart failure * Rx: * decrease RV workload → digoxin, diuretics, supplemental O₂, vasodilators, antibiotics, anticoagulants * don’t increase afterload * Anesthesia Considerations? * avoid hypoxemia, hypotension, hypercarbia * minimal positive pressure on BVM during induction

Answer 41

* Viral most often * Usual recommendation: avoid elective procedures that require tracheal intubation * → **airway hyperactivity, bronchospasm and laryngospasm-** are all greater risks during URI * Airway irritability may persist for weeks after * Routine case cancellation controversial especially in the Pediatric ENT population

Answer 42

* Systemic granulomatous disorder * Involves many tissues/organs- liver, spleen, heart, thoracic lymph nodes * Ex: **laryngeal sarcoid may** **interfere with passage of ETT** * Pulmonary Sarcoid = Fibrosis * Cor Pulmonale, heart block, dysrhythmias and restrictive cardiomyopathy may develop * Hypercalcemia occurs (rarely) * ACE activity increased, BP ?? * Frequently treated with corticosteroids * Anesthesia Considerations?

Answer 43

* Presence of blood in pleural cavity can be traumatic or post-surgical erosion of tumor, TB or small blood vessel rupture * **Hallmark Symptoms** * **hypotension** * **hypoxemia** * **tachycardia** * **increased CVP** * Treatment aim –eliminate and correct cause (chest tube) * Anesthetic considerations? * Thoracic sx → most require chest tube * **Drainage of more than 200 mL/hr of blood** * **→ indication for surgical re-exploration for hemorrhage.**

Answer 44

* Disruption of the parietal or visceral pleura- presence of gas within the pleural space * 3 categories simple communication and tension * Treatment = chest tube if PTX \> 20% * Placement → midaxillary line, 5^th intercostal space (CXR comfirms) * Acute tension pneumo → needle decompression, 2^nd intercostal space, midclavicular line, 3^rd rib * Tension PTX: occurs with rib fractures and barotrauma due to mechanical ventilation. Where is chest tube placed? * **Hallmark Symptoms of Tension Pneumothorax** * **hypotension** * **hypoxemia** * **tachycardia** * **increased CVP**

Answer 45

* Accumulation of pus in the pleural cavity, with or without abscess formation * Cause: * Aspiration during alcoholic stupor is a classic cause * Other historic factors: * substance abuse, prior pneumonia, lung carcinoma, steroid-induced immunosuppression, diabetes, COPD and infection at another site * **Lung isolation- absolute requirement** when treatment is surgical/open chest (e.g.lobectomy or segmentectomy) * Anesthetic considerations?

Thoracic I Flashcards

(71 cards)