1
Q
How many lobes does the right lung have?
A. One
B. Two
C. Three
D. Four
A
C. Three
Slide 4
2
Q
How many lobes does the left lung have?
A. One
B. Two
C. Three
D. Four
A
B. Two
4
3
Q
There are a total of _______ segments in both lungs combined.
A. 20
B. 24
C. 40
D. 42
A
D. 42
(22 on the right, 20 on the left)
Slide 4
4
Q
FEV₁ measures which of the following?
A. The total air inhaled during a deep breath for one minute
B. The volume of air expired in the first second after full inspiration
C. The total volume of air exhaled after one full breath
D. The average breathing rate per minute
A
B. The volume of air expired in the first second after full inspiration
“Forced expiratory volume in 1 second”
5
5
Q
The forced vital capacity (FVC) represents:
A. Air expelled during the first second of exhalation
B. The amount of residual air left in the lungs
C. The total air inhaled during quiet breathing
D. The total air exhaled after a deep inhalation
A
D. The total air exhaled after a deep inhalation
5
6
Q
The FEV₁% predicted compares a patient’s result to the actual total volume breathed out to an average normal for a person of the same __________.
A. Weight, age, height
B. Gender, height, and age
C. Height, age, family history
D. Lung volume, weight, age
A
B. Gender, height, and age
The FEV-1 itself as a number is not super helpful. We have to take that FEV-1 and we have to compare it to an average normal for a person of the same gender, height, and age.
So the FEV-1 percent predicted-is a derived value. It’s an estimation and it helps us understand how healthy or how unhealthy this person’s lungs are.
5
7
Q
The normal range for FEV₁% predicted is:
A. 80–120%
B. 70–90%
C. 60–100%
D. 120–150%
A
A. 80–120%
5
8
Q
A higher FEV₁% predicted value indicates:
A. Poor lung function
B. Airway obstruction
C. Healthier lungs
D. Restrictive disease
A
C. Healthier lungs and better post-op outcomes
Strong correlation with post-op outcomes
5
9
Q
The Postoperative FEV₁% (PPO FEV₁) is calculated using which formula?
A. Preop FEV₁ × (1 + % of lung tissue removed x 100)
B. Preop FEV₁% × [1 − (% of lung tissue removed / 100)]
C. Preop FEV₁ − % of lung tissue removed [(100)]
D. Preop FEV₁% × % of predicted lung tissue removed/100
A
B. Preop FEV₁% × [1 − (% of lung tissue removed / 100)]
Remember PEMDAS
6
10
Q
If a patient has a preoperative FEV₁ of 70% and 25% of lung tissue is removed, what is the predicted postoperative FEV₁ (PPO FEV₁)?
A. 52%
B. 68%
C. 72%
D. 32%
A
A. 52%
If FEV1=70% and 25% of lung tissue is surgically removed,
Then, 70% x [1-(25/100)] = 52% PPO FEV1
REMEMBER 42 segments of the lung, if removing 10 segments thats 10/42= ~25% removed!
6
11
Q
If PPO FEV₁% is < 30 the __________ the patient’s pulmonary complications.
A. Unchanged
B. Insignificant
C. Lower
D. Higher
A
D. Higher
6
12
Q
A PPO FEV₁ < ______ indicates increased risk of pulmonary complications:
A. 10%
B. 20%
C. 40%
D. 60%
A
C. 40%
6
13
Q
True or False
The ablility of the lung to exchange O2 and CO2 occurs primarily between the bronchioles and alveolus
A
False
Ability of lung to exchange O2 and CO2between the pulmonary capillary bed and alveoli
7
14
Q
In gas exchange, V represents ________, and Q represents ________.
A. Ventilation; perfusion
B. Volume; quantity
C. Venous pressure; quantity
D. Velocity; quality
A
A. Ventilation; perfusion
7
15
Q
A PaO₂ < 60 mmHg indicates:
A. Excellent oxygenation
B. Poor gas exchange
C. Normal alveolar function
D. Metabolic alkalosis
A
B. Poor gas exchange and likely hypoxemia
Poor surgical outcomes
7
16
Q
A patient with a PCO₂ > 45 mmHg is likely experiencing:
A. Hypercapnia
B. Alkalosis
C. Hypocapnia
D. Normal ventilation
A
A. Hypercapnia
7
17
Q
Which of the following are true about the DLCO test?
Select 2
A. It measures the ability of gases to diffuse across the alveolar membrane.
B. It is performed by inhaling CO2
C. A lower DLCO indicates better lung compliance.
D. It helps predict postoperative outcomes for thoracic surgery.
E. It directly measures blood pH.
A
A. It measures the ability of gases to diffuse across the alveolar membrane.
D. It helps predict postoperative outcomes for thoracic surgery.
From Miller
8
18
Q
In the DLCO test, exhaled gas is analyzed to determine how much of the inhaled __________ was taken up by hemoglobin.
A. Carbon dioxide
B. Carbon monoxide
C. Helium
D. Methane
A
B. Carbon monoxide (CO)
HIGH affinity for binding to Hgb
8
19
Q
In addition to carbon monoxide, which tracer gases are commonly added during a DLCO test to measure alveolar volume and diffusion?
A. Helium or methane
B. Methane or oxygen
C. Nitrous oxide or Helium
D. Methane or argon
A
A. Helium or methane
8
20
Q
True or False
DLCO correlates directly with the total functioning alveolar surface area available for gas exchange.
A
True
the more of that carbon monoxide that was picked up, the more that tells us that we have effective gas exchange taking place.
8
21
Q
DLCO is affected by ________, whereas FEV₁ is not.
A. Chemotherapy
B. Radiation therapy
C. Anemia
D. Pneumothorax
A
A. Chemotherapy
8
22
Q
A DLCO less than ____% represents the minimum threshold compatible with survival in thoracic surgery.
A. 20
B. 30
C. 40
D. 50
A
A. 20
<20% is a no go for surgery
8
23
Q
The typical V/Q ratio in a healthy lung is approximately:
A. 0.6
B. 0.8
C. 1.0
D. 1.2
A
B. 0.8
The ideal V/Q ratio in a perfect world is 100%, 1.0
9
24
Q
Factors that influence the V/Q ratio include:
Select 3
A. Gravity
B. Momentum
C. Pathology
D. Cardiac rhythm
E. Situation
A
A. Gravity (positioning)
C. Pathology (atelectasis, PE)
E. Situation
9
25
Which statement about pulmonary **blood flow** is true?
A. It is evenly distributed throughout the lung.
B. It is greatest at the apex in the upright position.
C. It is independent of patient position.
D. It is gravity dependent
D. It is gravity dependent, **with greater flow to the dependent portions.**
## Footnote
10
26
Pulmonary arterial pressure is abbreviated as ________, and pulmonary alveolar pressure as ________.
A. Pa; Pv
B. PA; Pa
C. Pa; PA
D. Pv; PA
C. Pa; PA
## Footnote
10
27
Pulmonary arterial pressure (Pa) is always:
A. Less than pulmonary venous pressure (Pv)
B. Equal to alveolar pressure (PA)
C. Greater than systemic arterial pressure
D. Greater than pulmonary venous pressure (Pv)
D. Greater than pulmonary venous pressure (Pv)
## Footnote
10
28
Absolute pressure of Pa and Pv is greater in the dependent portion of the lung due to gravity and __________ gradients.
A. Temperature
B. Hydrostatic
C. Oxygen concentration
D. Pulmonary compliance
B. Hydrostatic
## Footnote
10
29
# Matching
Match each zone to the correct pressure relationship:
Zone
1. Zone 1
2. Zone 2
3. Zone 3
Pressure
A. Pa > Pv > PA
B. PA > Pa > Pv
C. Pa > PA > Pv
Zone 1 → B (PA > Pa > Pv)
Alveolar pressure exceeds both arterial and venous pressures → little to no blood flow (“dead space”).
Zone 2 → C (Pa > PA > Pv)
Arterial pressure exceeds alveolar pressure, but venous pressure is still lower → intermittent blood flow.
Zone 3 → A (Pa > Pv > PA)
Both arterial and venous pressures exceed alveolar pressure → continuous blood flow, best perfusion.
## Footnote
10
30
What do West’s lung zones describe?
A. Regions of the lung with equal ventilation and perfusion
B. The effects of alveolar pressure on pulmonary blood flow
C. Oxygen diffusion between alveoli and capillaries
D. The flow of lymphatic drainage in the lungs
B. The effects of alveolar pressure on pulmonary blood flow
## Footnote
11
31
In an upright person, which part of the lung has the greatest blood flow?
A. Apex
B. Middle zone
C. Base
D. Equal throughout
C. Base
## Footnote
11
32
In an upright person, the increase in blood flow at the base of the lung compared to the apex is approximately:
A. 5 mmHg
B. 10 mmHg
C. 15 mmHg
D. 20 mmHg
D. ~20 mmHg
"that's what we're talking about with that increase in hydrostatic pressure that's based on gravity. So about 20mmHg, it's a fairly significant difference."
## Footnote
11
33
Which of the following are characteristics of **Zone 1**?
Select 3
A. Alveoli are maximally distended
B. Blood flow is continuous and unaffected by the cardiac cycle
C. Alveolar pressure (PA) > arterial pressure (Pa) > venous pressure (Pv)
D. Ventilated but not perfused — creates dead space
E. Weight of lung compresses flow on arterial side
F. Arterial pressure (Pa) > alveolar pressure (PA)> venous pressure (Pv)
A. Alveoli are maximally distended
C. Alveolar pressure (PA) > arterial pressure (Pa) > venous pressure (Pv)
D. Ventilated but not perfused — **creates dead space**
## Footnote
12
34
Which of the following best describes blood flow in **Zone 2**?
Select 2
A. Constant and unaffected by cardiac cycle
B. Absent due to capillary collapse
C. Pulsatile and varies with systole and diastole
D. Completely dependent on pleural pressure
E. Weight of lung compresses flow on venous side
C. Pulsatile and varies with systole and diastole
E. Weight of lung compresses flow on venous side
## Footnote
12
35
Which statements correctly describe **Zone 2** of the lung?
Select 3
A. Intrapleural pressure is greatest
B. Flow varies with venous pressure
C. Systolic arterial pressure > PA
D. Diastolic art pressure < PA
E. Flow varies with cardiac cycle
F. Vasculature is more distended
C. Systolic arterial pressure > PA
D. Diastolic art pressure < PA
E. Flow varies with cardiac cycle **and respirations**
"And so that is why I have drawn this red arrow a little bigger, because every time systole is taking place, that arterial flow is able to overcome that alveolar pressure and it's pushing- that through.
There's still a little bit of compression here, because diastolic arterial pressure is less than alveolar pressure. So the flow of the capillary blood flow, it's gonna vary with the cardiac cycle and with respirations as well."
## Footnote
12
36
Which statements apply to **Zone 3**?
Select 3
A. Alveoli are more distended
B. Intrapleural pressure is greater
C. Blood flow is continuous
D. Ventilation is greater
B. Intrapleural pressure is greater **→ alveoli more compliant and LESS distended**
C. Continuous blood flow **not affected by the cardiac cycle**
D. Ventilation is greater
Alveoli less distended, but intrapleural pressure is greater = alveoli are more COMPLIANT and VENTILATION is greater
## Footnote
12
37
Zone 1 is most likely to appear during which condition?
A. Spontaneous breathing at rest
B. Deep sleep
C. Positive pressure ventilation with high PEEP
D. Mild exercise
C. Positive pressure ventilation with high PEEP
Positive pressure increases alveolar pressure, compressing pulmonary capillaries, poor to no perfusion. **More dead space**
| PA > Pa > Pv
## Footnote
13
38
Which factor most contributes to Zone 1 formation in extreme hypovolemia or hemorrhagic shock?
A. Increased venous return
B. Decreased arterial pressure
C. Increased alveolar compliance
D. Increased pulmonary capillary recruitment
B. Decreased arterial pressure
Low arterial pressure prevents blood from overcoming alveolar pressure.
| PA > Pa > Pv
## Footnote
13
39
Why does blood flow in Zone 2 occur in pulses rather than continuously?
A. It depends on cardiac cycle changes in arterial pressure
B. It is controlled by alveolar compliance
C. It is restricted by venous valves
D. It depends on gravity-independent factors
A. It depends on cardiac cycle changes in arterial pressure
Flow **occurs** only when Pa > PA (systole) - follows a gradient.
Flow **ceases** when Pa < PA (diastole), Pa falls below PA
## Footnote
14
40
Why is pulmonary blood flow continuous in Zone 3?
A. Arterial pressure intermittently exceeds alveolar pressure
B. Alveolar pressure exceeds venous pressure
C. There is no external resistance
D. The alveoli are maximally distended
C. There is no external resistance
Because both Pa and Pv exceed PA, flow is unimpeded throughout the cardiac cycle, there is no external resistance - **vasculature is more distended**
## Footnote
15
41
Zone 3 is the area with the __________ hydrostatic pressure, aka gravity's push on blood and most well-perfused.
A. moderate
B. variable
C. lowest
D. highest
D. highest
## Footnote
15
42
# True or False
For an accurate measurement of pulmonary capillary wedge pressure (PCWP), the pulmonary artery catheter must be placed in Zone 3, where there is a continuous column of blood connecting the catheter to the left atrium.
True
## Footnote
15
43
During thoracic surgery with the patient in the lateral position, which lung receives more perfusion?
A. The nondependent lung
B. The dependent lung
C. Both equally
D. Depends only on heart position
B. The dependent lung
## Footnote
16
44
In the anesthetized patient in the lateral position, which physiological change commonly occurs?
A. The dependent lung receives most ventilation
B. The nondependent lung receives most perfusion
C. The nondependent lung becomes better ventilated than perfused
D. V/Q matching improves compared to the awake state
C. The nondependent lung becomes better ventilated than perfused
## Footnote
16
45
A patient is positioned in the right lateral decubitus position for a left thoracotomy.
Which lung is dependent, and which receives the most perfusion?
A. Right lung is dependent; receives most perfusion
B. Left lung is dependent; receives most perfusion
C. Right lung is nondependent; receives most perfusion
D. Perfusion is equal in both lungs
A. Right lung is dependent; receives most perfusion
## Footnote
16
46
The FEV₁/FVC ratio is primarily used to determine if lung disease is __________ or __________.
A. Obstructive; restrictive
B. Acute; chronic
C. Diffusion; perfusion
D. Upper airway; lower airway
A. Obstructive; restrictive
## Footnote
19
47
A normal FEV₁/FVC ratio for a healthy adult is approximately:
A. 40–55%
B. 60–70%
C. 70–85%
D. >90%
C. 70–85%
*"...pulmonologists use this to determine if the breathing pattern is obstructive, if it's restrictive, or if it's normal.
And if this ratio is 70 to 85%, that is normal for healthy adults"*
## Footnote
19
48
Which of the following are characteristics of restrictive lung disease?
Select 3
A. Decreased FVC
B. Decreased TLC
C. Increased FVC
D. Normal FEV₁/FVC ratio
E. Decreased or normal FEV₁/FVC ratio
A. Decreased FVC
B. **Decreased TLC**
D. Normal FEV₁/FVC ratio
**Decreased or normal FEV₁**
## Footnote
19
49
Which of the following are characteristics of obstructive lung disease?
Select 4
A. Increased FEV₁
B. Decreased FEV₁
C. Increased total lung capacity (TLC)
D. Decreased FEV₁/FVC ratio
E. Increased diffusion capacity
F. Decreaed FVC
B. Decreased FEV₁
C. **Normal** or Increased total lung capacity (TLC)
D. Decreased FEV₁/FVC ratio
F. **Normal** or Decreased FVC
**Air Trapping**
*"...total lung capacity for someone with an obstructive disease is going to be either normal or increased, and that's because someone with an obstructive disease, they air trap, they can't exhale all of their air, so that causes their total lung capacity to be increased.*
## Footnote
19
50
Obstructive lung disease is primarily characterized by:
A. Increased lung compliance and decreased airflow
B. Difficulty exhaling air due to narrowed airways
C. Reduced alveolar diffusion
D. Decreased total lung capacity
B. Difficulty exhaling air due to narrowed airways
| Air trapping - hyperinflation of the lungs
## Footnote
20
51
Which of the following are considered obstructive lung diseases?
Select 3
A. COPD
B. Interstitial lung disease
C. Asthma
D. Cystic fibrosis
E. Pulmonary fibrosis
A. COPD
* Chronic bronchitis -*has mucus and inflammation.*
* Emphysema - *from smoking*
D. Asthma
E. Cystic fibrosis - *mechanical narrowing with mucous*
## Footnote
20
52
COPD is the most common comorbid condition in which surgical population?
A. Thoracic
B. Cardiac
C. Orthopedic
D. Neurosurgical
A. Thoracic
**Progressive & debilitating**
## Footnote
21
53
# True or False
COPD is the second leading cause of death in the United States.
False
COPD is the **third** leading cause of death in the United States.
## Footnote
21
54
COPD involves abnormal, **permanent** __________ of the airspaces and destruction of the __________.
A. Collapse; bronchi
B. Fibrosis; capillaries
C. Narrowing; trachea
D. Enlargement; alveoli
D. Enlargement; alveoli
## Footnote
21
55
Which of the following best explains why COPD patients develop hypercapnia?
select 2
A. Loss of surfactant production
B. Air trapping
C. Decreased pulmonary perfusion
D. Decreased alveolar ventilation
B. Air trapping
D. Decreased alveolar ventilation
**Hyperinflation of the lungs**
## Footnote
21
56
Which of the following are common clinical features of COPD? (Select 3)
A. Dyspnea
B. Hypercapnia
C. Decreased airway resistance
D. Hypoxia
E. Obesity
A. Dyspnea
B. Hypercapnia
D. Hypoxia
Compromised pulmonary mechanics
## Footnote
22
57
Which of the following is an important preoperative assessment question for COPD patients?
A. “Do you use oxygen therapy at home?”
B. “Do you experience orthopnea?”
C. “Do you snore at night?”
D. “Do you have a family history of asthma?”
A. “Do you use oxygen therapy at home?”
*"... that can kind of give you a good- idea of-of how, um, severe their diseases.*
## Footnote
22
58
Restrictive lung diseases are characterized by decreased ____ and limited lung ____.
A. Compliance; expansion
B. Elasticity; obstruction
C. Resistance; pressure
D. Flow; recoil
A. Compliance; expansion
*Stiffness in lung tissue, chest wall, or weak muscles/nerves*
## Footnote
23
59
Which of the following are classified as restrictive lung diseases? (Select 4)
A. Pulmonary fibrosis
B. Interstitial lung disease
C. Chronic bronchitis
D. Sarcoidosis
E. Obesity syndrome
F. Asthma
A. Pulmonary fibrosis
B. Interstitial lung disease
D. Sarcoidosis
E. Obesity syndrome- *hypoventilation*
## Footnote
23
60
# True or False
Restrictive lung diseases related to neurological disorders occur because of weakened respiratory muscles that limit lung expansion.
True
## Footnote
23
61
The most significant risk factor for lung cancer is ______.
A. Air pollution
B. Smoking
C. Alcohol use
D. Radiation exposure
B. Smoking
## Footnote
24
62
Which of the following environmental factors are associated with lung cancer? (Select 4)
A. Microchips
B. Radon gas
C. Diesel exhaust
D. Yogurt
E. Asbestos
F. Metals
B. Radon gas
C. Diesel exhaust
E. Asbestos - **Mesothelioma**
F. Metals
## Footnote
24
63
Which factor does **NOT** contribute to the decline in lung cancer mortality?
A. Smoking cessation
B. Earlier diagnosis through screening
C. Advances in thoracic surgery
D. Increased vaping in young adults
D. Increased vaping in young adults
(the jury is still out on this one, but just heads up she mentioned it)
## Footnote
24
64
Lung cancer most commonly forms in which part of the respiratory system?
A. Alveoli
B. Pleural space
C. Cells lining the airway
D. Pulmonary arteries
C. Cells lining the airway
## Footnote
25
65
The two main types of lung cancer are classified based on:
A. Location within the lung
B. How the cells appear under a microscope
C. Rate of metastasis
D. Presence of environmental exposure
B. How the cells appear under a microscope
## Footnote
25
66
Small cell lung cancer most commonly originates in which part of the respiratory tract?
A. Alveoli
B. Pleura
C. Bronchi
D. Trachea
C. Bronchi
## Footnote
26
67
Which of the following statements best describes small cell lung cancer?
A. Slow-growing and rarely metastasizes
B. Fast-growing and aggressive
C. Typically unrelated to smoking
D. Less aggresive and more common
B. Fast-growing and aggressive
## Footnote
26
68
Small cell lung cancer is most commonly associated with ______.
A. Smoking
B. Air pollution
C. Asbestos exposure
D. Viral infection
A. Smoking
## Footnote
26
69
Which of the following statements about small cell lung cancer metastasis is true?
A. It rarely spreads beyond the lungs
B. It frequently metastasizes
C. It only metastasizes in late-stage disease
D. Better prognosis over long term
B. It frequently metastasizes
## Footnote
26
70
Which of the following best describes non-small cell lung cancer?
A. Fast growing and highly aggressive
B. Rare and seen only in smokers
C. Always associated with asbestos exposure
D. Less aggressive and more common
D. Less aggressive and more common
Better prognosis
## Footnote
27
71
Non-small cell lung cancer affects ______.
A. Both smokers and non-smokers
B. Only non-smokers
C. Only smokers
D. Neither group
A. Both smokers and non-smokers
## Footnote
27
72
Signs and sympotoms of lung cancer are related to
A. treatment regimen
B.years since diagnosis
C. treatment compliance
D. extent of the disease
D. extent of the disease
## Footnote
slide 28
73
Signs and symptoms of lung cancer include all the following except
A. cough
B. hemoptysis
C. wheezing
D. stridor
E. dyspnea
F. airway restriction
G. hoarseness
H. superior vena cava syndrome
I. pleural effusion
J. congestive heart failure
F. airway restriction
airway OBSTRUCTION
## Footnote
slide 28
74
How is lung cancer diagnosis made for central/endo-bronichial lesions (select 2)
A. percutaneous fine needle aspirate
B. cytology analysis os sputum
C. flexible fiberoptic bronchoscopy
D. VATS
E. CT scan
B. cytology analysis of sputum
C. flexible fiberoptic bronchoscopy
## Footnote
slide 29
75
How is lung cancer diagnosis made for peripheral/pleural lesions (select 3)
A. percutaneous fine needle aspirate
B. cytology analysis os sputum
C. flexible fiberoptic bronchoscopy
D. VATS
E. CT scan
A. percutaneous fine needle aspirate
D. VATS
E. CT scan
## Footnote
slide 29
76
# true or false
During radiation treatmemt for lung cancer, small cell is very radiosensitive
true
## Footnote
slide 30
77
Which of the following statements about lung cancer treatment are true (select 3)
A. chemotherapy can be with or without radiation
B. surgical resection always improves survival
C. surgical resection can be palliative
D. surgical resection has little effect on survival if spread to lymph nodes
A. chemotherapy can be with or without radiation
C. surgical resection can be palliative
D. surgical resection has little effect on survival if spread to lymph nodes
## Footnote
slide 30
78
All of the following are components of mediastinum except
A. trachea
B. thymus
C. lymph nodes
D. thyroid
E. esophagus
D. thyroid
s
## Footnote
slide 31
79
What are 2 improvements for thoracic surgery that have been made overtime?
A. minimally invasive
B. older population has no benefit
C. all robotic
D. one lung ventilation
A. minimally invasive
D. one lung ventilation
many more patients (sicker, older, ect) can undergo thoracic surgery and have a positive outcome these days
## Footnote
slide 33
80
A pneumonectomy is when
A. partial lung is removed
B. a segment resection
C. a wedge resection
D. entire lung removed
D. entire lung removed
## Footnote
slide 35
81
A lobectomy is when
A. a whole lobe is removed
B. a segment resection
C. a wedge resection
D. entire lung removed
A. a whole lobe is removed
## Footnote
slide 35
82
A resection or lung sparing partial lobe removal includes (select 3)
A. sleeve
B. wedge
C. segment
D. full
A. sleeve
B. wedge
C. segment
## Footnote
slide 35
83
How can a hemothorax be treated?
A. needle decompression
B. chest tube
C. wedge resection
D. obliteration
B. chest tube
extent of trauma, control bleeding
## Footnote
slide 36
84
An obliteration of pleural space to prevent recurrence of fluid, pus, or blood build up is know as
A. empyema
B. abcess drainage
C. hemothorax
D. pleurodesis
D. pleurodesis
## Footnote
slide 36
85
Thoracotomy indications include (select 4)
A. CABG
B. pneumonectomy
C. lobectomy
D. advanced malignancy
E. hemorrhagic complications
B. pneumonectomy
C. lobectomy
D. advanced malignancy
E. hemorrhagic complications
## Footnote
slide 37
86
What is the most common method of thoractomy
A. anterolateral
B. sternotomy
C. posterolateral
D. posterior
A. anterolateral
## Footnote
slide 37
87
What is an important anesthetic consideration to a thoracotomy?
A. always 100% oxygen
B. double lung ventilation
C. no volatile anesthetic
D. very painful
D. very painful
## Footnote
slide 37
88
What are indications for VATS (select 4)
A. pleural surgery
B. undiagnosed nodules
C. pneumonectomy
D. interstital disease
E. lobectomy
A. pleural surgery
B. undiagnosed nodules
D. interstital disease
E. lobectomy (not always)
surgery done through ports
## Footnote
slide 38
89
How many ports are there for a VATS typically
A. 2-4
B. 5-6
C. 1-3
D. 1-5
C. 1-3
## Footnote
slide 38
90
Benefits of VATS procedure include all the following except
A. reduced hospital stay
B. less blood loss
C. more pain
D. better post op pulm function
E. can be done robotically
C. more pain
less pain b/c ribs are not separated and retracted
## Footnote
slide 39
91
# true or false
One lung ventilation allows immobile surgical field access/ visibility, prevent pus, blood, secretions from contaminating non operative lung ``
true
## Footnote
slide 41
92
Match the following
A. separation
B. isolation
1: complete deflation
2: adequate deflation
A: 2
B:1
## Footnote
slide 41
93
How does DLT work?
A. two parallell lumens
B. one terminates in trachea
C. one terminates in bronchus
all of the above
sorry...
## Footnote
slide 42
94
What is most common side for DLT
A. right
B. left
B. left
so theat right main bronchus doesnt get blocked off
## Footnote
slide 42
95
When would we use a right double lumen tube? (select 3)
A. Left pneumonectomy
B. Distorted anatomy of left main bronchus
C. Abdominal Aortic aneurysm
D. Tumor compressing left main bronchus
E. Right Pneumonectomy
A. Left pneumonectomy
B. Distorted anatomy of left main bronchus
D. Tumor compressing left main bronchus
Thoracic aortic aneuysm
## Footnote
slide 43
96
# True or false
right sided tubes have an extra port to ventilate RUL
true
## Footnote
slide 43
97
Which of the following match the height of <1.5m for women?
A. 37
B. 35
C. 39
D. 32
E. 41
D. 32
## Footnote
slide 44
98
Which of the following match the height of 1.5-1.6m for women?
A. 37
B. 35
C. 39
D. 32
E. 41
B. 35
## Footnote
slide 44
99
Which of the following match the height of >1.6m for women?
A. 37
B. 35
C. 39
D. 32
E. 41
A. 37
## Footnote
slide 44
100
Which of the following match the height of <1.6m for men?
A. 37
B. 35
C. 39
D. 32
E. 41
A. 37
101
Which of the following match the height of 1.6-1.7m for men?
A. 37
B. 35
C. 39
D. 32
E. 41
C. 39
## Footnote
slide 44
102
Which of the following match the height of >1.7m for men?
A. 37
B. 35
C. 39
D. 32
E. 41
E. 41
## Footnote
slide 44
103
Patient that just had a right pneumonectomy is requiring post op ventilaiton. What is the correct next step?
A. leave the double lumen tube
B. place a LMA
C. exchange for a single lumen tube
D. place a bronchial blocker
C. exchange for a single lumen tube
## Footnote
slide 44
104
When positioning a double-lumen tube for insertion, the bronchial (blue) lumen should face which direction?
A. Toward the patient’s head
B. Toward the patient’s right side
C. Toward the patient’s toes
D. Straight anterior toward the sternum
C. Toward the patient’s toes
## Footnote
slide 45
105
After passing the vocal cords during DLT placement, what is the next key maneuver?
A. Inflate both cuffs
B. Rotate the tube 90° toward the target bronchus
C. Remove the stylet and immediately ventilate
D. Advance until resistance is met, then withdraw 2 cm
B. Rotate the tube 90° toward the target bronchus
remove stylet
advance into trachea
## Footnote
slide 45
106
What is the recommended volume to inflate the bronchial cuff during DLT placement?
A. 10–12 mL
B. 7–10 mL
C. 5–7 mL
D. 2–3 mL
D. 2–3 mL
## Footnote
slide 45
107
The tracheal cuff on a DLT is generally inflated with:
A. 5–7 mL
B. 2–3 mL
C. 1–2 mL
D. 8–10 mL
A. 5–7 mL
## Footnote
slide 45
108
Which statement best describes confirmation of correct DLT placement?
A. High peak pressures confirm proper bronchial seating.
B. The ability to isolate each lung once connected via the adapter.
C. Only right breath sounds should be heard.
D. Visualization of the blue cuff above the cords confirms placement.
B. The ability to isolate each lung once connected via the adapter.
## Footnote
slide 45
109
When confirming proper DLT placement with fiberoptic bronchoscopy, the first step is to insert the scope through which lumen?
A. Bronchial lumen
B. Pilot balloon port
C. Suction port
D. Tracheal lumen
D. Tracheal lumen
## Footnote
slide 46
110
Which structure should be visualized to confirm the bronchial cuff is properly seated when viewing through the tracheal lumen?
A. Epiglottis
B. Fully inflated bronchial cuff
C. Arytenoids
D. Vocal cords
B. Fully inflated bronchial cuff
## Footnote
slide 46
111
While viewing through the tracheal lumen, a correctly positioned left-sided DLT will show the bronchial cuff located where?
A. Just above the vocal cords
B. At the level of the carina
C. 5–10 mm below the carina inside the left mainstem bronchus
D. Within the right mainstem bronchus
C. 5–10 mm below the carina inside the left mainstem bronchus
## Footnote
slide 46
112
After evaluating through the tracheal lumen, confirmation continues by inserting the bronchoscope through the bronchial lumen. What should be seen?
A. Entrance to left upper and left lower lobe bronchi
B. Entrance to right upper and right middle lobe bronchi
C. Only tracheal rings
D. Carina only
A. Entrance to left upper and left lower lobe bronchi
## Footnote
slide 46
113
What is the mechanism by which a bronchial blocker collapses the lung?
A. Sucking air out of the bronchus through continuous suction
B. Inflating a balloon to occlude the mainstem bronchus
C. Delivering high-pressure oxygen distally
D. Applying high PEEP to the intact lung
B. Inflating a balloon to occlude the mainstem bronchus
## Footnote
slide 47
114
Compared with a double-lumen tube, a bronchial blocker may be preferable because it can:
A. Be positioned more distally to collapse a specific lobe
B. Collapse only the right upper lobe
C. Ventilate both lungs simultaneously
D. Avoid need for fiberoptic bronchoscopy
A. Be positioned more distally to collapse a specific lobe
## Footnote
slide 47
115
Placement of a bronchial blocker requires what for proper confirmation and positioning?
A. CXR only
B. Capnography
C. Fiberoptic bronchoscopy
D. Fluoroscopy
C. Fiberoptic bronchoscopy
## Footnote
slide 47
116
Which of the following is a known limitation of bronchial blockers?
A. They cannot be used in pediatrics
B. They routinely damage the carina
C. They cannot achieve lung collapse
D. They often become dislodged and require repositioning
D. They often become dislodged and require repositioning
## Footnote
slide 47
117
Bronchial blockers work by occluding which airway structure?
A. Trachea at the level of the cords
B. Mainstem bronchus
C. Nasal passage
D. Segmental bronchiole only
B. Mainstem bronchus
## Footnote
slide 47
118
Which of the following is an indication for using a bronchial blocker instead of a double-lumen tube for one-lung ventilation (OLV)?
A. Routine thoracotomy without airway concerns
B. Anticipated difficult airway
C. Need for rapid lung isolation in trauma
D. Patient request
B. Anticipated difficult airway
## Footnote
slide 48
119
A bronchial blocker is particularly useful when OLV is required and which of the following is true?
A. The procedure requires neuromonitoring
B. The patient is allergic to latex
C. The patient has a history of smoking
D. The patient requires nasal intubation
D. The patient requires nasal intubation
## Footnote
slide 48
120
Which statement best describes a scenario where a bronchial blocker is preferred?
A. OLV is needed, and the patient will not require postoperative ventilation
B. OLV is needed in a pediatric patient with no airway concerns
C. OLV is needed, and postoperative mechanical ventilation is anticipated
D. The patient has no airway access
C. OLV is needed, and postoperative mechanical ventilation is anticipated
## Footnote
slide 48
121
One advantage of bronchial blocker use is its suitability for:
A. Patients who already have an ETT in place and now require OLV
B. Patients who refuse bronchoscopy
C. Patients requiring routine oral DLT placement
D. Patients who require lung isolation without anesthesia
A. Patients who already have an ETT in place and now require OLV
## Footnote
slide 48
122
Which of the following are recommended after placing a double-lumen tube (DLT)? (select 3)
A. Confirm placement immediately after insertion
B. Confirm placement again after patient positioning
C. Confirm placement only if oxygen saturation drops
D. Confirm placement only if the surgeon requests
E. Keep FOB available for repositioning
A. Confirm placement immediately after insertion
B. Confirm placement again after patient positioning
E. Keep FOB available for repositioning
## Footnote
slide 49
123
When isolating a lung with a DLT, which structure should be clamped?
A. The bronchial limb of the tube itself
B. The tracheal limb of the tube itself
C. The adaptor
D. The pilot balloon
C. The adaptor
## Footnote
slide 49
124
Which strategies help maintain normocapnia during one-lung ventilation? (select 2)
A. Increase tidal volume to 8–10 mL/kg
B. Decrease tidal volume to ~4–6 mL/kg
C. Increase respiratory rate
D. Use CPAP on the operated lung routinely
E. Reduce respiratory rate
B. Decrease tidal volume to ~4–6 mL/kg
C. Increase respiratory rate
## Footnote
slide 49
125
What is the main advantage of using the included suction catheter with a DLT during lung isolation?
A. It increases oxygenation of the non-ventilated lung
B. It permits faster and more complete lung deflation
C. It allows ventilation of both lungs simultaneously
D. It prevents cuff herniation
B. It permits faster and more complete lung deflation
## Footnote
slide 49
126
Which items reflect good equipment practice during one-lung ventilation? (select 3)
A. Keep equipment clean
B. Keep equipment organized
C. Store equipment in the hallway
D. Keep necessary tools handy in the OR
E. Discard suction catheter after placement
A. Keep equipment clean
B. Keep equipment organized
D. Keep necessary tools handy in the OR
## Footnote
slide 49
127
During one-lung ventilation (OLV), an appropriate SpO₂ target is:
A. 88–95%
B. 95–100%
C. 100%
D. >85% regardless of PaO₂
A. 88–95%
## Footnote
slide 50
128
Hyperoxemia during OLV should be avoided because it can contribute to which of the following?
A. Coronary vasoconstriction
B. Reduced shunt fraction
C. Increased FRC
D. Prevention of atelectasis
A. Coronary vasoconstriction
## Footnote
slide 50
129
Which problem is associated with aggressive oxygen administration during OLV?
A. Pneumothorax
B. Bronchospasm
C. Hypervolemia
D. Absorption atelectasis
D. Absorption atelectasis
## Footnote
slide 50
130
Which therapy may be used on the non-dependent lung to improve oxygenation during OLV?
A. High PEEP
B. CPAP
C. Nitric oxide
D. Prone positioning
B. CPAP
## Footnote
slide 50
131
When using PEEP on the dependent lung during OLV, which level is generally supported by evidence?
A. 0 cm H₂O
B. 2–3 cm H₂O
C. ~5 cm H₂O
D. 12–15 cm H₂O
C. ~5 cm H₂O
## Footnote
slide 50
132
Which of the following PEEP strategies may worsen oxygenation during OLV?
A. Discontinuing PEEP
B. Increasing PEEP to 8–10 cm H₂O
C. Increasing FiO₂
D. Adding CPAP to the dependent lung
B. Increasing PEEP to 8–10 cm H₂O
## Footnote
slide 50
133
Which intervention can be used to reopen collapsed alveoli during OLV?
A. Rapid shallow breathing
B. Trendelenburg positioning
C. Recruitment maneuver
D. Suctioning entire lung continuously
C. Recruitment maneuver
## Footnote
slide 50
134
Under normal two-lung ventilation, which lung regions receive the greatest blood flow?
A. Upper lung regions
B. Nondependent lung regions
C. Dependent (lower) lung regions
D. Right lung only
C. Dependent (lower) lung regions
* **More blood flow** (due to gravity)
* **More ventilation** (due to greater lung compliance)
| *bolded on ppt*
## Footnote
slide 51
135
Which factors explain why dependent lung regions receive more ventilation during normal breathing? (select 2)
A. They have lesser compliance
B. They are exposed to more negative intrapleural pressure
C. Their alveoli begin smaller and more collased
D. They receive less blood flow
E. They completely collapse at end expiration
B. They are exposed to **more negative (higher) intrapleural pressure**
C. Their alveoli begin **smaller and more collased = recruit more during inspiration**
| *bolded on ppt*
## Footnote
slide 51
136
During one-lung ventilation (OLV), the major cause of decreased oxygenation is:
A. Reduced cardiac output
B. Right-to-left shunt
C. Ventilation–perfusion matching
D. Increased physiologic dead space alone
B. **Right-to-left shunt**
| *bolded on ppt*
## Footnote
slide 51
137
Why does right-to-left shunt occur during OLV?
A. Blood flow is redirected exclusively to ventilated lung
B. Collapsed lung becomes hyperinflated
C. Deoxygenated blood from the non-ventilated lung returns to the heart without being oxygenated
D. Hypoxic pulmonary vasoconstriction completely eliminates perfusion to the collapsed lung
C. Deoxygenated blood from the non-ventilated lung returns to the heart without being oxygenated
## Footnote
slide 51
138
These statements correctly describe one-lung ventilation **EXCEPT** ?
A. One lung is not ventilated
B. Right-to-left shunt develops
C. Relative hypoxemia can occur
D. Gas exchange occurs normally in both lungs
E. Venous blood from the collapsed lung bypasses oxygenation
| *bolded on ppt*
D. Gas exchange occurs normally in both lungs
## Footnote
slide 51
139
During one-lung ventilation in the lateral decubitus position, which lung receives MORE perfusion?
A. Non-dependent lung
B. Dependent lung
C. Both receive equal perfusion
D. Perfusion is unpredictable
B. **Dependent lung**
| *bolded on ppt*
## Footnote
slide 53
140
Why is the dependent lung at risk for reduced ventilation during thoracic surgery?
A. It is less compliant than the non-dependent lung
B. It receives less blood flow
C. It is compressed by the table and mediastinal structures
D. It is the operative field
| *bolded on ppt*
C. It is compressed by the table and mediastinal structures
## Footnote
slide 53
141
What type of gas-exchange impairment results when perfusion exceeds ventilation in the dependent lung?
A. V/Q mismatch with shunt component
B. Increased dead space
C. Improved oxygenation
D. Hypocapnia
A. V/Q mismatch with shunt component
| *bolded on ppt*
## Footnote
slide 53
142
Increased risk of atelectasis in the dependent lung during OLV is primarily due to:
A. Excessive alveolar surfactant
B. Increased bronchial diameter
C. Increased FiO₂
D.Mechanical compression and reduced ventilation
| *bolded on ppt*
D.Mechanical compression and reduced ventilation
## Footnote
slidde 53
143
Which factors contribute to reduced ventilation of the dependent lung during lateral decubitus positioning? (select 3)
A. Gas trapping in dependent segments
B. Mediastinal weight
C. Abdominal mass effect
D. Increased surfactant production
E. Hard OR table pressure
| *bolded on ppt*
B. Mediastinal weight
C. Abdominal mass effect
E. Hard OR table pressure
## Footnote
slide 53
144
Which statements correctly describe V/Q physiology of the dependent lung during OLV? (select 3)
A. It receives more perfusion
B. It receives more ventilation than perfusion
C. Perfusion exceeds ventilation
D. It is prone to atelectasis
E. It is the more compliant lung in this situation
| *bolded on ppt*
A. It receives more perfusion
C. Perfusion exceeds ventilation
D. It is prone to atelectasis
## Footnote
slide 53
145
Lateral position and one lung ventilation visual
## Footnote
slide 52
146
What happens to vessels in the collapsed lung during hypoxic pulmonary vasoconstriction (HPV)?
A. Vessels in the collapsed lung dilate in response to low oxygen
B. Vessels in the collapsed lung constrict in response to low oxygen
C. Redirects blood flow to the collapsed lung
D. No change occurs in vessel tone
B. Vessels in the collapsed lung constrict in response to low oxygen
*Protective reflex*
## Footnote
Slide 54
147
HPV **redirects blood flow** to the ventilated lung in order to:
A. Increase shunt
B. Reduce shunt and improve oxygenation
C. Increase airway pressure
D. Collapse the ventilated lung
| *bolded on ppt*
B. Reduce shunt and improve oxygenation
## Footnote
Slid 54
148
Alveolar hypoxia (low O2 tension in the alveoli) results in:
A. Vasodilation of pulmonary vasculature
B. Vasoconstriction of pulmonary vasculature
C. Bronchoconstriction of distal airways
D. Collapse of the most ventilated lung areas
B. **Vasoconstriction** of pulmonary vasculature (increased pulmonary vascular resistance)
| *bolded on ppt*
## Footnote
Slide 55
149
Blood preferentially goes to the most ventilated areas → This leads to:
A. Improved V/Q matching
B. Worsened V/Q matching
C. Increased dead space
D. No change
A. Improved V/Q matching
## Footnote
Slide 55
150
Hypoxic pulmonary vasoconstriction (HPV) __, but it __ to take effect.
A) Redirects blood flow; worsens oxygenation
B) Increases hypoxemia; takes time
C) Attenuates hypoxemia; takes time
D) Improves V/Q matching; occurs immediately
C) Attenuates hypoxemia; takes time
Hypoxic pulmonary vasoconstriction (HPV) **Attenuates hypoxemia**, but it **takes time** to take effect.
## Footnote
Slide 56
151
Put the following in order about Lateral Position + One Lung Ventilation:
A. Activation of HPV
B. More blood shunted to non-ventilated lung
C. If atelectasis occurs in ventilated lung
D. Vasoconstriction
1. C. If atelectasis occurs in ventilated lung
2. A. Activation of HPV
3. D. Vasoconstriction
4. B. More blood shunted to non-ventilated lung
*Dr. F: If atelectasis is also occurring in the ventilated lung, and it likely will be, it's gonna be more easy for atelectasis to now occur in the only lung that we have available to ventilate.
Because it's being squished between the O.R. table and the mediastinal contents, if atelectasis starts occurring in that ventilated lung, now HPV is gonna be activated in the ventilated lung, and that's gonna result in vasoconstriction in the ventilated lung, and that will shunt blood back to the non-ventilated
lung.*
## Footnote
Slide 56
152
In lateral position with one-lung ventilation, the operative lung is:
A) Ventilated & not perfused
B) Perfused & not ventilated
C) Not perfused & not ventilated
D) Ventilated & perfused
B) **Perfused & not ventilated**
*Dr F: So, this is the lung that we have intentionally collapsed so that the surgeon can operate on it. So, the operative, operative lung is perfused, but it's not ventilated.*
| *bolded on ppt*
## Footnote
Slide 57
153
In lateral position + one-lung ventilation, which statements apply to the operative lung? (Select 2)
A) Perfused & ventilated
B) V/Q Mismatch
C) Don’t want to decrease HPV in the operative lung
D) Ventilated & not perfused
E) Improved V/Q matching
B) V/Q Mismatch
C) Don’t want to decrease HPV in the operative lung
*Dr. F: So, there's an automatic VQ mismatch there. So, we do not want to decrease hypoxic pulmonary vasoconstriction in the operative lung.
We want hypoxic pulmonary vasoconstriction to be happening in the operative lung because it's good. It's a protective mechanism. We want to shunt blood to the ventilated lung, ideally.*
## Footnote
Slide 57
154
HPV is decreased (causing increased shunt, worsening oxygenation) by:
A) Hypoxia
B) Administration of a volatile anesthetic >1 MAC
C) Normal temperature
D) Hypercapnia
B) **Administration of a volatile anesthetic >1 MAC**
| *bolded and highlighted on ppt*
## Footnote
Slide 58
155
ALL VA’s attenuate HPV via their:
A) Depressant effect on the brain
B) Vasodilatory properties
C) Bronchodilatory properties
D) Effect on FiO₂
B) **Vasodilatory properties**
*Dr. F: So, because they're vasodilating, they're preventing that hypoxic pulmonary vasoconstriction from happening*
| *bolded on ppt*
## Footnote
Slide 58
156
Which factors decrease HPV?
Select all that apply.
A) Metabolic and respiratory alkalosis
B) Hypocapnia
C) Hypothermia
D) Hemodilution
E) Vasodilators
F) Sustained High FiO₂
All of the above :)
## Footnote
Slide 58
157
# OLV: Complications
When malpositioning of the tube is suspected during OLV, the appropriate action is to:
A) Increase FiO₂
B) Give a bronchodilator
C) Replace the tube
D) Verify position if in doubt.
D) Verify position if in doubt.
*Dr. F: Always verify the position if you're in doubt. That's why it's important to have that fiber optic available in the room after you position so that you can verify and make sure that everything is how it should be*
## Footnote
Slide 59
158
# OLV: Complications
True or False:
Airway trauma is a complication of OLV
True
*since DLT’s are large and rigid tubes*
## Footnote
Slide 59
159
Which of the following are other complications of OLV? (Select 3)
A) Bronchospasm
B) Hypoventilation
C) Hypoxemia (V/Q mismatch)
D) Alkalosis
E) Atelectasis
A) **Bronchospasm**
*Dr. F: you are putting that tube down into the bronchus, so that can cause a lot of irritation or bronchospasm.*
B) **Hypoventilation**
*Dr. F: just because you are only ventilating one lung*
C) **Hypoxemia (V/Q mismatch)**
*Healthier people may be able to tolerate
*May be very significant in less healthy patients
## Footnote
Slide 59
160
True or False:
When increasing FiO₂ during OLV-induced Hypoxemia, you may give as much as you like without concern.
FALSE!
you can increase your FiO2, but remember, we always want to **consider being pretty judicious with FiO2**
## Footnote
Slide 60
161
100% O₂ should NOT be given to patients who have received ___, due to ___.
A) Bleomycin; cellular oxidative damage/pulmonary toxicity
B) Nitrous oxide; diffusion hypoxia
C) Steroids; immunosuppression
D) Heparin; bleeding risk
A) Bleomycin; cellular oxidative damage/pulmonary toxicity
100% O₂ should NOT be given to patients who have received **Bleomycin**, due to **cellular oxidative damage/pulmonary toxicity**
## Footnote
Slide (50 *bolded on ppt*) 60
162
Which intervention may be used to treat OLV-induced hypoxemia?
A) Increase PEEP only
B) An alveolar recruitment maneuver (ARM)
C) Stop ventilation
D) Decrease FiO₂
B) An alveolar recruitment maneuver (ARM)
## Footnote
Slide 60
163
An alveolar recruitment maneuver (ARM) may cause ___.
A) Transient hemodynamic derangements (high peak pressure)
B) Cellular oxidative damage (pulmonary toxicity)
C) Increased HPV (vasoconstriction)
D) Bronchospasm (airway irritation)
A) Transient hemodynamic derangements (high peak pressure)
*Dr. F: result in transient hemodynamic derangements, because you are increasing intrathoracic pressure.*
## Footnote
Sliee 60
164
Which is an appropriate action for persistent OLV-induced hypoxemia?
A) Increase volatile anesthetic to >1 MAC
B) Communicate with surgeon
C) Clamp the non-operative lung airway
D) Trendelenburg position
B) Communicate with surgeon
## Footnote
Slide 61
165
If hypoxemia persists during OLV, the next step may be to:
A) Resume two-lung ventilation
B) Stop ventilation entirely
C) Reduce FiO₂ to avoid toxicity
D) Place OLV tube deeper
A) **Resume two-lung ventilation**
*Dr. F: if you're having a lot of trouble, that you'll be able to resume two lung ventilation for at least a period of time.*
| *bolded on ppt*
## Footnote
Slide 61
166
Why is it important to *treat hemodynamics* when there is persistent hypoxemia during OLV?
A) Alveoli are over-recruited
B) Perfusion issues
C) HPV is excessive
D) FiO₂ is too high
B) Perfusion issues
*Dr F: always remember, treat your hemodynamics. If you're having persistent hypoxemia, it could be having to do with perfusion issues.*
## Footnote
Slide 61
167
In cases of persistent OLV-induced hypoxemia, which surgical intervention may be required?
A) Bronchial dilation
B) Ligation of pulmonary artery
C) Pleural lavage
D) Lung recruitment only
B) Ligation of pulmonary artery
*Dr. F: if nothing's cutting it, then the surgeon can actually go in and clamp or ligate the pulmonary artery just to cut the perfusion off to the non-ventilated lung. And that would be a pretty extreme*
## Footnote
Slide 61
168
The best predictor of difficult DLT placement is:
A) Mallampati score
B) Thyromental distance
C) Preoperative CXR
D) Neck circumference
C) **Preoperative CXR**
| *bolded on ppt*
## Footnote
Slide 62
169
Which of the following are included in the thoracic surgery preoperative evaluation?
(Select 3)
A) Detailed history
B) Current medications/O₂ therapy
C) Severity of underlying pulmonary disease
D) Daily exercise tolerance
E) Family history only
A) Detailed history
B) Current medications/O₂ therapy
C) Severity of underlying pulmonary disease
* Lung auscultation
* Pulmonary Function Tests/Spirometry
## Footnote
Slide 63
170
Preoperative evaluation includes assessing the presence of comorbid diseases, especially ___.
A) Cardiac disease
B) Dermatologic disease
C) Neurologic disease
D) Endocrine disease
A) Cardiac disease !
## Footnote
Slide 63
171
Exercise testing for thoracic surgery is commonly described in:
A) BPMs
B) METs (Metabolic Equivalent of a Task)
C) VO₂/kg
D) PSI
B) METs (Metabolic Equivalent of a Task)
## Footnote
Slide 64
172
The GOLD STANDARD measure of preoperative cardiopulmonary assessment is and it is defined as...
A) 6-Minute Walk test – distance-based estimation of VO₂max
B) VO₂max – maximum O₂ consumption attainable during physical activity
C) BNP – biomarker associated with heart failure
D) Chest X-ray – plain radiograph of thorax
B) **VO₂max – maximum O₂ consumption attainable during physical activity**
Average healthy male ~30-40ml/kg/min;
female ~27-32ml/kg/min
| *bolded on ppt*
## Footnote
Slide 64
173
Match the VO₂max finding with the corresponding perioperative risk:
VO₂max < 15 ml/kg/min
VO₂max > 20 ml/kg/min
A) Increased risk
B) Unlikely risk
A) **Increased risk if VO₂max is < 15 ml/kg/min**
B) **Unlikely risk if VO₂max is > 20 ml/kg/min**
| *bolded on ppt*
## Footnote
Slide 64
174
The 6-Minute Walk test estimates VO₂max by ___.
A) Distance in meters / 30
B) Distance in meters / 10
C) Distance in meters / 60
D) Distance in meters / 3
A) Distance in meters / 30
## Footnote
Slide 64
175
Which of the following is NOT associated with smoking cessation?
A) Improved surgical outcomes
B) Complications decrease with cessation of 4 weeks
C) Carboxyhemoglobin concentrations decrease after 24 hours
D) Smoking causes prolonged tissue hypoxemia
C) Carboxyhemoglobin concentrations decrease after 24 hours
* Carboxyhemoglobin concentrations decrease after **12 hours**
## Footnote
Slide 65
176
# Pre-op: Cancer-related Assessment
Which of the following are Mass Effects?
Select all that apply.
A) Pneumonia
B) Lung abscess
C) SVC syndrome
D) Laryngeal nerve paresis
E) Mediastinal shift
All of the above
177
# Pre-op: Cancer-related Assessment
Which of the following are Metabolic Effects?
(Select 3)
A) Lambert-Eaton
B) Cushing’s
C) Hypercalcemia
D) Bone involvement due to metastatic spread
A) Lambert-Eaton (associated with Small Cell Lung Cancer = SCLC)
B) Cushing’s (SCLC can cause the body to make too much cortisol)
C) Hypercalcemia (bony mets, release of PTH, calcitriol)
## Footnote
Slide 66
178
# Pre-op: Cancer-related Assessment
Which of the following are listed under Metastases?
Select all that apply.
A) Brain
B) Bone
C) Liver
D) Adrenal
All of the above
## Footnote
Slide 66
179
Which of the following appear under Medications in the pre-op cancer-related assessment?
(Select 4)
A) Bleomycin
B) Mitomycin
C) Doxorubicin
D) Cisplatin
E) Corticosteroid
A) Bleomycin
B) Mitomycin
C) Doxorubicin
D) Cisplatin
## Footnote
Slide 66
180
# Just for your information
The table is quietly telling you that cancer is mischievous:
* it crushes (mass effects),
* it rewires hormones (metabolic effects),
* it wanders (metastases),
* and it poisons (medications).
:)
## Footnote
Slide 66
181
Which of the following characteristics are associated with high-risk patients undergoing thoracic surgery? (Select 5)
A) Advanced age
B) Malnourished
C) Frail
D) Poor general health
E) Concomitant medical conditions
F) Exercise tolerance
A) Advanced age
B) Malnourished
C) Frail
D) Poor general health
E) Concomitant medical conditions
## Footnote
Slide 67
182
Which of the following pulmonary conditions increase risk for thoracic surgery? (Select 3)
A) Chronic Obstructive Pulmonary Disease (COPD)
B) Pulmonary HTN
C) Obesity
D) Interstitial lung disease
E) Bronchitis
A) Chronic Obstructive Pulmonary Disease (COPD)
B) Pulmonary HTN
C) Obesity
## Footnote
Slide 67
183
Which of the following are indicators of increased pulmonary risk prior to thoracic surgery? (Select 3)
A) Low FEV1
B) Low VO₂max / Low exercise tolerance
C) Dyspnea
D) Borderline FEV1 with normal DLCO
E) Good exercise tolerance
A) Low FEV1
B) Low VO₂max / Low exercise tolerance
C) Dyspnea
## Footnote
Slide 67
184
True or False:
A major modifiable risk factor that increases complications in thoracic surgery is smoking.
True
Risk increases with number of pack-years
## Footnote
Slide 67
185
True or False:
You *do not* need to discuss the possibility of postoperative ventilatory support with thoracic surgery patients
FALSE
Dr. F: You always want to **discuss the possibility of post-op ventilatory support for these patients** because if they are high risk for their thoracic surgery, there's a possibility you may not be
able to extubate them at the end.
| *boxed on ppt*
## Footnote
Slide 67
186
Which concurrent medical condition is commonly associated with thoracic surgery patients?
A) Ischemia & CAD
B) Peripheral vascular disease
C) Cerebrovascular disease
D) Carotid artery stenosis
A) Ischemia & CAD
*Many have smoking history*
## Footnote
Slide 68
187
Which of the following may be part of optimization of medical therapy before thoracic surgery? (Select 2)
A) PTCA
B) CABG
C) Carotid endarterectomy
D) Electrophysiology ablation
E) Mitral valve repair
A) PTCA (Percutaneous Transluminal Coronary Angioplasty)
B) CABG
## Footnote
Slide 68
188
Match the type of coronary stent with the recommended delay before thoracic surgery:
1. Bare metal stent
2. Drug-eluting stent
A) 6 months
B) 4–6 weeks
1 → B (Bare metal: 4–6 weeks)
2 → A (Drug-eluting: 6 months)
## Footnote
Slide 68
189
Cardiac Algorithm
*Dr. F: Drive home the point that a lot of these patients, their heart is going to be sick, too.
And hopefully they will have already visited with a cardiologist, but that's not always the case. But it's always the priority.*
## Footnote
Slide 69
190
Which condition is listed as the most common concurrent disease in thoracic surgery patients?
A) RV failure
B) COPD
C) Pulmonary embolism
D) OSA
B) **COPD**
| *bolded on ppt*
## Footnote
Slide 70
191
Which of the following are components of COPD pre-operative assessment?
(Select 2)
A) Assessment of severity made with FEV₁ predicted
B) ABG analysis to monitor hypercapnia
C) CT imaging to assess pleural thickness
D) Pulmonary angiography to evaluate vascular obstruction
E) Serum BNP to trend right-heart strain
A) Assessment of severity made with **FEV₁ predicted**
B) **ABG analysis** to monitor hypercapnia
*Dr. F: they are highly likely to have that CO2 greater than 45, which is associated with poorer outcomes.*
## Footnote
Slide 70
192
Supplemental O₂ should be titrated to maintain PaO₂ ___ in COPD patients undergoing thoracic surgery.
A) 45–50 mmHg
B) 55–60 mmHg
C) 60–65 mmHg
D) 75–85 mmHg
C) 60–65 mmHg
## Footnote
Slide 70
193
A common cardiac complication occurring in about half of COPD patients is:
A) Left ventricular hypertrophy
B) Atrial fibrillation
C) Right ventricular failure
D) Mitral valve stenosis
C) Right ventricular failure
* Intolerant of sudden increases in RV afterload
* i.e. Positive pressure ventilation
## Footnote
Slide 70
194
During thoracic surgery, why does **one-lung ventilation** increase pulmonary vascular resistance (PVR)?
A) It increases alveolar recruitment
B) It triggers hypoxic pulmonary vasoconstriction in the non-dependent lung
C) It improves pulmonary blood flow distribution
D) It reduces right-ventricular afterload
| *bolded on ppt*
B) It triggers hypoxic pulmonary vasoconstriction in the non-dependent lung
## Footnote
Slide 71
195
How does **lung resection** contribute to increased pulmonary vascular resistance (PVR)?
A) Loss of pulmonary vascular bed forces more blood through fewer vessels
B) Expansion of remaining lung decreases perfusion pressure
C) It reduces right-ventricular oxygen demand
D) It eliminates hypoxic pulmonary vasoconstriction
| *bolded on ppt*
A) Loss of pulmonary vascular bed forces more blood through fewer vessels
## Footnote
Slide 71
196
Why do **hypoxia, hypercarbia, or acidosis** increase pulmonary vascular resistance (PVR)?
A) They cause pulmonary vasodilation that increases blood pooling
B) They decrease right-ventricular afterload
C) They cause pulmonary vasoconstriction, increasing RV workload
D) They reduce sympathetic tone
| *bolded on ppt*
C) They cause pulmonary vasoconstriction, increasing RV workload
*Dr. F: And then all of the things that may happen, could happen during thoracic surgery, hypoxia, hypercarbia, acidosis. All the things that we work hard to try to prevent, those things all contribute to that increased pulmonary vascular resistance*
## Footnote
Sllde 71
197
Which complication may occur due to increased pulmonary vascular resistance, particularly in patients with pre-existing pulmonary hypertension?
A) Left ventricular outflow obstruction
B) Right heart strain or failure
C) Improved myocardial oxygen balance
D) Decreased RV workload
B) **Right heart strain or failure**
| *bolded on ppt*
## Footnote
Slide 71
198
Increased pulmonary vascular resistance raises **oxygen demand** primarily because:
A) The right ventricle must work harder
B) The left ventricle compensates by pumping harder
C) Pulmonary vascular dilation reduces perfusion
D) Increased preload reduces myocardial workload
| *bolded on ppt*
A) The right ventricle must work harder to overcome higher afterload
## Footnote
Slide 71
199
What happens when increased PVR lead to **sympathetic overdrive**?
A) It enhances coronary perfusion
B) RV outflow improves, lowering pressure
C) worsens arrhythmia risk and myocardial workload
D) Arterial baroreceptors decrease tone
| *bolded on ppt*
C) worsens arrhythmia risk and myocardial workload
## Footnote
Slide 71
200
Postoperative arrhythmias most commonly occur within what time frame after thoracic surgery?
A) First 24 hours
B) First 7 days
C) First 30 days
D) First 90 days
A) **First 7 days**
Occurs in 30–50% of thoracic surgery patients
| *bolded on ppt*
## Footnote
Slide71
201
Which postoperative arrhythmia accounts for 60–70% of cases after thoracic surgery?
A) Ventricular tachycardia
B) Atrial fibrillation
C) Supraventricular tachycardia
D) Junctional rhythm
B) **Atrial fibrillation**
| *bolded on ppt*
## Footnote
Slide 72
202
Which of the following is NOT a common cause of postoperative arrhythmias after thoracic surgery?
A) Surgical manipulation of the heart, pulmonary hilum, or vagus nerve
B) Inflammation and pericardial irritation
C) Sympathetic stimulation from pain, stress, or hypoxia
D) Fluid shifts and electrolyte disturbances
E) High-dose vitamin C supplementation
F) Hypoxemia and/or transient ischemia during one-lung ventilation (OLV)
| *bolded on ppt*
E) High-dose vitamin C supplementation
## Footnote
Slide 72
203
Postoperative arrhythmias after thoracic surgery may lead to: (Select 3)
A) Hemodynamic instability
B) Increased length of hospital stay
C) Reduced myocardial workload due to parasympathetic suppression
D) Higher postoperative morbidity
E) Improved cardiopulmonary reserve through enhanced stroke volume
A) Hemodynamic instability
B) Increased length of hospital stay
D) Higher postoperative morbidity
## Footnote
Slide 72
204
Which statement best reflects the primary goal when managing thoracic surgery patients according to lecture?
A) Focus solely on intraoperative technique
B) Prioritize postoperative rehabilitation rather than intraoperative care
C) Optimize the patient before and during surgery to improve outcomes
D) Avoid adjusting therapy until complications arise
C) Optimize the patient before and during surgery to improve outcomes
## Footnote
Slide 72
205
Which benefits are associated with arterial line use during thoracic surgery?
(Select 3)
A) Beat-to-beat hemodynamic assessment
B) Serial ABG sampling
C) More accurate CVP readings in lateral position
D) Detection of transient compression of great vessels
E) Reliable cardiac output trending
A) Beat-to-beat hemodynamic assessment
B) Serial ABG sampling
D) Detection of transient compression of great vessels
## Footnote
Slide 73
206
Select 3 that apply regarding central venous catheters in thoracic surgery:
A) They are typically reserved for pneumonectomies or redo thoracotomies
B) They are less accurate for volume measurement in the lateral position with an open chest
C) Optimal placement is on the ipsilateral side of the surgical field
D) They are routinely required for standard lobectomy
E) Placement should be contralateral to avoid surgical interference
A) They are typically reserved for *pneumonectomies or redo thoracotomies*
B) They are *less accurate for volume measurement* in the lateral position with an open chest
C) *Optimal placement is on the ipsilateral side* of the surgical field
## Footnote
Slide 73
207
Which intraoperative consideration helps prevent absorption atelectasis during thoracic surgery?
A) Avoiding nitrous oxide
B) Increasing FiO₂ to 100%
C) Using nitrous oxide early, then discontinuing
D) Maintaining spontaneous ventilation
A) Avoiding nitrous oxide
## Footnote
Slide 74
208
During thoracic surgery, it is recommended to maintain two-lung ventilation for as long as possible. Oxygen saturations of approximately ___ are considered acceptable.
A) 75%
B) 85%
C) 90%
D) 100%
C) 90%
## Footnote
Slide 74
209
During thoracic surgery, careful patient positioning is essential because:
A) Brachial plexus injuries are common
B) Ulnar neuropathy is unavoidable
C) Venous return increases dramatically
D) Cranial nerve palsy frequently occurs
A) Brachial plexus injuries are common
## Footnote
Slide 74
210
To take care of myocardial O₂ supply/demand during thoracic surgery, it is important to:
A) Reduce MAP and increase HR
B) Maintain MAP and avoid increase in HR
C) Increase FiO₂ and decrease tidal volume
D) Avoid IV fluids and hyperventilate
B) Maintain MAP and avoid increase in HR
## Footnote
Slide 74
211
Strategies to prevent ALI intraoperatively during Thoracic Surgery include:
Select 2
A) Avoid fluid overload
B) Avoid hyperinflation
C) Intentionally increase PEEP to high levels
D) Maintain excessive tidal volumes
A) **Avoid fluid overload**
B) **Avoid hyperinflation**
| *bolded on ppt*
## Footnote
Slide 74
212
During lateral positioning for thoracic surgery, providers should perform a comprehensive ____ to assess for neurovascular injury risk.
A) Regional dermatomal survey
B) Head-to-toe survey
C) Upper-extremity neurovascular
D) Position-focused peripheral nerve screen
B) Head-to-toe survey
## Footnote
Slide 75
213
Which intervention is MOST appropriate when positioning a patient in the lateral decubitus position according to lecture?
A. Pulling the dependent ear upward to tighten skin tension
B. Leaving the dependent ear under the edge of the headrest
C. Checking that the dependent ear is straight and free of pressure
D. Applying a warm blanket under the ear to provide cushioning
C. Checking that the dependent ear is straight and free of pressure
## Footnote
Slide 75
214
Which medications may be used for postoperative pain control after thoracic surgery?
A) Nitrous oxide & methadone
B) Ketamine & Precedex
C) Propofol & sevoflurane
D) Furosemide & midazolam
B) Ketamine & Precedex
*Wake up on precedex gtt?*
## Footnote
Slide 76
215
Which of the following 2 anesthetics techniques can be used for postoperative analgesia after thoracic surgery?
A) Paravertebral or intercostal blocks
B) Thoracic epidural
C) Lumbar plexus block
D) Bier block
A) Paravertebral or intercostal blocks
B) Thoracic epidural
## Footnote
Slide 76
216
Which other postoperative strategies help manage pain after thoracic surgery?
A) PCA pump and anti-inflammatories
B) Nitrous oxide inhalation and heparin infusion
C) Dopamine infusion and hyperventilation
D) Magnesium bolus and neuromuscular blockade
A) PCA pump (opioids) and anti-inflammatories
## Footnote
Slide 76
217
After thoracic surgery, which of the following is an appropriate initial postoperative priority?
A) Keep patient intubated until the next morning
B) Extubate if able
C) Begin pulmonary rehab immediately in PACU
D) Hold all pain management orders until postop day 2
B) Extubate if able
*ICU vs PACU*
## Footnote
Slide 77
218
Which postoperative strategy best supports pulmonary recovery after thoracic surgery?
A) Limiting mobilization for the first 48 hours
B) Pulmonary toilet, RT care, and pulmonary rehab
C) Withholding respiratory therapy until symptoms develop
D) Avoiding coughing to protect the incision
B) Pulmonary toilet, RT care, and pulmonary rehab
## Footnote
Slide 77
219
Which of the following are pulmonary complications commonly seen after thoracic surgery?
Select 3
A) Atelectasis
B) Pneumonia
C) Respiratory failure
D) Pleural effusion from thoracic duct injury
E) Acute cholecystitis
A) Atelectasis
B) Pneumonia
C) Respiratory failure
* 15-20% of patients
* Accounts for 3-4% of ALL surgical mortality
## Footnote
Slide 78
220
Which condition after thoracic surgery is closely associated with high ventilatory pressures and excessive fluid administration?
A) Acute Lung Injury
B) Postoperative cholecystitis
C) Volume-depleted shock
D) Acute kidney injury
A) Acute Lung Injury
## Footnote
Slide 78
221
Place the following events in the correct sequence leading to right-ventricular dysfunction during thoracic surgery:
A. V/Q mismatch with hypoxemia + hypercapnia during OLV
B. Increased right-ventricular pressures
C. Increased pulmonary vascular resistance (PVR)
C. Increased pulmonary vascular resistance (PVR) → A. V/Q mismatch with hypoxemia + hypercapnia during OLV → B. Increased right-ventricular pressures
## Footnote
slide 79
222
Which are possible benefits of pressure-controlled ventilation (PCV)? (Select 3)
A) Less inflammation
B) Less barotrauma
C) Lower peak pressures
D) Guarantees fixed minute ventilation
A) Less inflammation
B) Less barotrauma
C) Lower peak pressures
## Footnote
Slide 79
223
Which physiologic effects of a thoracic epidural may worsen right-ventricular output? (Select 3)
A) Loss of vasomotor tone
B) Peripheral venous pooling
C) Increased RV preload
D) Significant decrease in RV preload
A) Loss of vasomotor tone
B) Peripheral venous pooling
D) Significant decrease in RV preload –> worsened RV output
2026 Advanced Principles
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