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Anaesthesiology
Anesthesia for Thoracic Surgery
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
15 sections · 199 slides
Overview
- Scope of this topic
- Route through the topic
Lung cancer and the thoracic workload
- Burden of lung cancer
- Who develops lung cancer
- Two-year survival for lung cancer by subtype and stage
- Reading the survival figure
Preoperative evaluation
- Purposes of preoperative assessment
- Common complications after thoracic surgery
- Age and exercise tolerance
- Dyspnoea, cough and sputum
- Cigarette smoking and lung cancer
- Smoking and surgical outcome
- Chronic obstructive pulmonary disease
- Risk factors for acute lung injury
- Cyanosis and clubbing
- Respiratory pattern and breath sounds
- Cardiac risk in thoracic surgery
- Pulmonary vascular resistance and pulmonary hypertension
- Consequence chain in COPD
- Electrocardiogram and chest radiograph in COPD
- What a mediastinal mass on imaging predicts
- Arterial blood gases in COPD
Pulmonary function testing and resectability
- Three goals of pulmonary function testing
- Effect of anaesthesia and surgery on lung volumes
- Spirometry values that predict outcome
- Two families of abnormal spirometry
- Predicted postoperative FEV1
- Flow-volume loop in a normal subject
- What a flow-volume loop shows
- Flow-volume loops in obstruction, fixed obstruction and restriction
- Flow-volume findings in obstruction and restriction
- Testing bronchodilator reversibility
- Split-lung function tests
- Computed tomography and positron emission tomography
- Diffusing capacity for carbon monoxide
- Cardiopulmonary exercise testing
- Risk strata by peak oxygen consumption
- Simpler field tests of fitness
- Putting the assessment together
- Sequence of tests for cardiopulmonary status and resectability
- Reading the resectability algorithm
Preoperative preparation
- Prehabilitation and what to treat first
- Smoking cessation before surgery
- Nutrition as a modifiable risk
- Perioperative nutrition screen
- What the nutrition screen asks
- Infection and antibiotic prophylaxis
- Hydration and clearing secretions
- Wheezing before surgery
- Sympathomimetics and phosphodiesterase inhibitors
- Steroids, cromolyn and parasympatholytics
- Pulmonary rehabilitation
Intraoperative monitoring
- Standard monitoring in thoracic anaesthesia
- Arrhythmias and lead choice
- Arterial catheterisation
- Fluid responsiveness rather than filling pressure
- Central venous pressure monitoring
- Pulmonary artery catheterisation and its limits
- Interdependence and catheter tip position
- Transoesophageal echocardiography
- Reported findings from intraoperative echocardiography
- Cerebral oximetry and non-invasive cardiac output
- Monitoring oxygenation
- Monitoring ventilation and capnography
- Why hypoxaemia beats hypercarbia as the problem
Physiology of the lateral decubitus position
- The six situations to work through
- Progression through the six situations
- Effect of gravity on lung blood flow in the lateral position
- Awake, breathing, chest closed
- Mediastinal shift in the open-chested spontaneously breathing patient
- Mediastinal shift and paradoxical breathing
- Paradoxical respiration in the open-chested spontaneously breathing patient
- Distribution of ventilation awake versus anaesthetised in the lateral position
- Anaesthetised, breathing, chest closed
- Closed chest compared with open chest and paralysis in the lateral position
- Effect of opening the chest and of paralysis
- Two-lung ventilation compared with one-lung ventilation
- Blood flow split during two-lung ventilation
- The obligatory shunt of one-lung ventilation
- Arithmetic of the one-lung shunt
- Why the dependent lung has a low residual capacity
Lung isolation and lung separation
- Separation versus isolation
- Two purposes of one-lung ventilation
- When lung isolation is life-saving
- Bullae, cysts, airway disruption and lavage
- What lung separation achieves
- Indications for one-lung ventilation
- Reading the indications table
Double-lumen endobronchial tubes
- Design of a double-lumen tube
- Carlens tube and a left-sided Robertshaw double-lumen tube
- From the Carlens tube to the disposable Robertshaw
- Advantages of the disposable plastic tube
- Novel double-lumen tube designs
- The Silbroncho, Papworth and VivaSight tubes
- Limits of the camera tube, and the ECOM tube
- Choosing the tube size
- Height and sex criteria for tube size
- Why a larger tube is preferred
- Imaging and ultrasound to guide tube size
- Preparing, inserting and advancing the tube
- Four-step clinical check after intubation
- The four-step check after intubation
- Other ways to confirm placement
- Bronchoscopic views of the main carina and the bronchi
- The fibreoptic bronchoscope
- Malposition of the double-lumen tube
- Bronchoscopic appearance of a tube advanced too far and then withdrawn
- Too deep, and not deep enough
- Blocking an upper lobe orifice
- Cuff herniation and airway laceration
- Laceration of the left main bronchus seen at bronchoscopy
- Airway injury compared with a blocker
Lung separation in the difficult airway
- The patient with a permanent tracheostomy
- What is actually used in tracheostomised patients
- Devices used in long-term tracheostomy stomas
- Recommendations for the tracheostomised patient
- Approach to lung separation in the patient with a difficult airway
- Recognising and managing the difficult airway
- Options once a single-lumen tube is in
Bronchial blockers
- The bronchial blocker principle and its weakness
- Indications for the use of endobronchial blockers
- Indications for the use of endobronchial blockers (continued)
- Where blockers earn their place
- Univent tube with its movable bronchial blocker
- The Univent tube
- Disadvantages of the Univent tube
- Four independent bronchial blockers
- The Arndt blocker
- The Cohen blocker
- The Uniblocker and the EZ-Blocker
- Comparison of the four bronchial blockers
- Reading the blocker comparison
- Comparative trials of isolation devices
- Meta-analysis of blockers versus tubes
- Trade-off between the two devices
- Being versatile with devices
- Choosing between tube and blocker in practice
- Keeping a blocker in place and confirming blockade
Management of one-lung ventilation
- Rechecking the position after turning
- Inspired oxygen fraction
- Continuous positive airway pressure to the upper lung
- Why CPAP is often unavailable today
- Falling hypoxaemia and the intensive care evidence
- Does the intensive care evidence transfer
- Protective ventilation in the lateral position
- Effect of positive end-expiratory pressure on functional residual capacity
- What PEEP does during one-lung ventilation
- Why PEEP does not always improve oxygen
- Four reasons PEEP still matters
- Individualising PEEP
- Titrated versus fixed PEEP at one hour
- Large trials of high versus low PEEP
- Delivering CPAP in practice
- Recruitment manoeuvres and their controversy
- Expert opinion on sustained inflation
- Diminishing returns of a sustained inflation
- Driving pressure
- Driving pressure during one-lung ventilation
- Mechanical power
- Calculating mechanical power in volume-controlled ventilation
- Mechanical power in the lateral position
- Therapeutic hypercarbia
Clinical approach at the bedside
- Starting one-lung ventilation
- Core measures during one-lung ventilation
- Clinical approach to one-lung ventilation management
- Clinical approach to one-lung ventilation management (continued)
- What happens after one-lung ventilation starts
- Stepwise response to hypoxaemia during one-lung ventilation
- Working through hypoxaemia
- What to watch continuously
- Protecting the ventilated lung
- Protective versus conventional ventilation trial
- How strong is the evidence overall
Concluding the surgical procedure
- Planning the postoperative airway
- Other indications for postoperative ventilation
- Decision path at the conclusion of the surgical procedure
- If a blocker was used
- If a double-lumen tube was used
- Exchanging the tube safely
Key points
- Key points on assessment and preparation
- Key points on lung separation
- Key points on ventilating one lung
- Key points on special situations
- Sources for this deck
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition