thorax surgery

1. Thoracis anaesthesia
zikrullah

2. • Thoracis surgery presents with
what unique set of physiologic
problems??

3. THORACIC ANAESTHESIA
• 1)Lateral decubitus position
2)The open pneumothorax
3)One lung ventilation

4. • What happens to lung mechanics during
lateral decubitus position?
• Awake state?
• After induction of anesthesia?

6. AWAKE STATE:
V/Q: Preserved
Dependent lung:
More perfused
Receives more ventilation
Contraction of hemidiaphragm more
efficient
More favourable part of compliance curve

7. • V/Q : mismatch and hypoxia
• Induction of G.A: FRC & moves lower
lung( perfused) to less compliant part of
the compliance curve
• PPV favors the upper lung (Compliant)
• Neuromuscular blockade: abdominal
contents rise up against dependent
hemidiaphragm
• Rigid bean bag
INDUCTION AND PPV

8. What happens during open
pneumothorax?

9. . The Open Pneumothorax :
• The lungs are kept expanded by the
negative pleural pressure .When chest is
opened the –ve pleural pressure is lost
and the lung is collapsed
• Spontaneous ventilation with open
pneumothorax in the lateral position
results in paradoxical respiration &
mediastinal shift

10. Paradoxical respiration:
• During spont ventilation
• To and fro gas flow between dependent
and non dependent lung

12. Mediastinal shift:
• During spont ventilation
• Downward shift of mediastinum during
inspiration
• Upward shift during expiration

14. • Concerns during one lung
ventilation?

15. 3. One Lung Ventilation:
• Intentional collapse of the lung on the
operative side greatly facilitates most
thoracic procedures but complicates
anesthetic management
• The collapsed lung continues to be perfused
and no longer ventilated

16. • So the patient develops RT to LT
intrapulmonary shunt hypoxia
• Widens alveolar to arterial gradient
hypoxia

17. • Protective mechanism?

18. Hypoxic pulmonary vasoconstriction
Factors inhibiting:
• Pulmonary artery pressure: very high or
low
• Hypocapnia
• Mixed venous oxygen : very high or low
• Vasodilators
• Pulmonary infection
• Inhalational anesthetic

19. • Technique of one lung
ventilation?

20. • Techniques for one lung ventilation:
1. Use of double lumen BT
2. Use of single lumen ET + bronchial blocker
3. Use of single lumen EBT
• Double lumen endobronchial tube is often
used

21. Indication of lung ventilation?

22. • Indications for one lung ventilation:
-CONFINED INFECTION TO ONE LUNG
-CONFINED BLEEDING TO ONE LUNG
-SEPARATE LUNG VENTILATION:
*large cyst or bulla *BPF *tracheobron. disruption
PATIENT
RELATED:
-LUNG RESECTION:
*pneumonectomy *lobectomy *segmental resection
-THORACOSCOPY
-ANT. APPROACH TO THORACIC SPINE
-ESOPHAGEAL SURGERY -B.A. LAVAGE
PROCEDURE
RELATED:

23. Absolute indication for OLV
– Isolation of one lung from the other to avoid
spillage or contamination
• Infection
• Massive hemorrhage
– Control of the distribution of ventilation
• Bronchopleural / - cutaneous fistula
• Surgical opening of a major conducting airway
• giant unilateral lung cyst or bulla
• Tracheobronchial tree disruption
• Life-threatening hypoxemia due to unilateral lung
disease

24. – Unilateral bronchopulmonary lavage
– VAT

25. Relative indication
– Surgical exposure ( high priority)
• Thoracic aortic aneurysm
• Pneumonectomy
• Upper lobectomy
• Mediastinal exposure
• Thoracoscopy
– Surgical exposure (Intermediate priority)
• Middle and lower lobectomies and subsegmental
resections
• Esophageal surgery
• Thoracic spine procedure
• Minimal invasive cardiac surgery .

26. • Postcardiopulmonary bypass status after
removal of totally occluding chronic unilateral
pulmonary emboli (Low priority)

27. • Types of DLT?
• Advantage/disadvantage?

28. THORACIC ANESTHESIA
• Double lumen endobronchial tubes:
Carinal hookBronchusName
YESLEFTCARLENS
NOLEFT -RIGHTROBERT-SHAW
YESRIGHTWHITE

29. • Advantage:
– Can suction lungs independently
– Quality of suctioning better
– Can apply CPAP to nonventilated lung
• Disadvantage:
– Difficult to insert.
– Needs change of tube if postoperative
ventilation is considered
– Needs determination of appropriate size
– Potential for tracheobronchial injury

30. How is the size of the DLT
determined for each patient?

31. • An ideally placed DLT should pass easily
through the glottis and should enter the
intended main bronchus without causing
trauma
• Single-use PVC DLTs : 26 F, 28 F, 32 F,
35 F, 37 F, 39 F, 41 F
• 35 F and 37 F - small and large females
• 39 F and 41 F for small and large males

33. Why are left sided DLTs
preferred over right?

34. • The right upper lobe bronchus takes off
from the right main bronchus 0.5 to 1 cm
below the carina
• When right sided DLT is placed, there
are high chances that the right upper
lobe bronchus may be occluded
• Left mainstem bronchus is much longer
than the right one (50 mm as compared
to 20 mm)
• Margin of safety while positioning a left
sided DLT is more

36. Describe the pre-anaesthetic
evaluation of a patient posted
for lung resection surgery ?

37. • ƒDetailed medical history : coexisting disease
• Optimal treatment and control of associated
medical conditions
• Patient’s functional capacity should be assessed
• History of smoking, symptoms suggestive of COPD
elicited
• Preoperative cardiologic evaluation
• Airway evaluation
• Patients may receive chemotherapy
preoperatively, and should be evaluated for
chemotherapy related toxicity

38. Investigations?

39. Investigations
• CBC : Polycythemia - COPD or leucocytosis -
active pulmonary infection
• Sputum cultures and sensitivity to guide
appropriate antibiotic therapy
• Renal function test
• Liver function test
• X-ray Chest : tracheal deviation or
obstruction, mediastinal mass, superior vena
cava syndrome, pleural effusions,
consolidation

40. • Pulmonary function tests : obstructive or
restrictive abnormalities, to assess
responsiveness to bronchodilators and to
confirm suitability for resection
• ECG : For signs of left or right heart
dysfunction
• TTE : to rule out pulmonary hypertension
• Further cardiopulmonary testing may be
indicate if warranted by the history/above
investigations

41. Describe the 3 legged stool
test of prethoracotomy
respiratory assessment ?

43. Predicted post operative FEV1?
Importance?

45. Preoperative optimization?

46. THORACIC ANESTHESIA
• Preoperative management
ResultMeasures
HbCO2 decreases in 12-24h
so more O2 is available
Cessation of smoking
Select antibiotics according
to culture and sensitivity
Treat pulmonary infections
Beta-2 agonistsTreat bronchospasm
Hydration and chest
percussion
Thin and mobilize secretions

47. Preparation?
Monitoring?

48. THORACIC ANESTHESIA
1) Preparation:
• Apart from basic airway management
• Multiple single and double tubes should be
available
• fiberoptic bronchoscope should be available
• Tube exchanger
• Cpap delivery system,bronchodilator
• Thoracic epidural catheter

49. THORACIC ANESTHESIA
2) Venous access:
• At least 2 large iv canula( 14-16 g) is
mandatory
• CV catheter, blood warmer ,rapid infusion
device are desired if blood loss is
anticipated

50. 3) Monitoring:
• ECG
• pulse oximetry
• Capnography
• NIBP
• Temperature
• Urinary catheterization
• Arterial cannula
• CVP monitoring
• PAC is indicated in LT ventricle dysfunction
• Periodic ABG

51. Induction?
Maintenance?

52. • GA with controlled ventilation with
thoracic epidural analgesia
• IV induction with propofol or
thiopentone
• Propofol : preferred since many of these
patients will have reactive airways and
use of thiopentone and tracheal
instrumentation in light plane can lead to
bronchospasm
• NDMR can be used

53. • Maintenance : halogenated agent + opiod
• Delivered in an oxygen/air or
oxygen/nitrous oxide mix
• During one-lung ventilation, anaesthesia
can be maintained intravenously with
propofol and an air/oxygen mix

54. What is management of
hypoxemia during one lung
ventilation?

55. • For sudden or severe desaturation:
–Convert to two-lung ventilation
• For gradual desaturation:
1. Increase FiO2 to 1.0
2. The position of DLT should be
rechecked using a fiberoptic
bronchoscope.
3. The hemodynamic status of the patient
should be optimized
4. Recruitment of the ventilated lung

56. 5. PEEP of 5-10 cm H2O: the dependent
lung
6. CPAP of 1-2 cm H2O: to the
nondependent lung, after a recruitment
maneuver
7. Intermittent two-lung ventilation.
8. Partial ventilation of the non-ventilated
lung using either low flow oxygen
insufflations or high frequency ventilation
9. If a pneumonectomy is being
performed, ligation of the pulmonary
artery : completely eliminate the shunt.

57. Fluid management in these
patients?

58. • Fluid restriction is generally advocated in lung
resections.
• The reasons for this are:
– Third spacing is not excessive in lung surgeries
– The dependent lung : high capillary hydrostatic
pressures
– Postoperative pulmonary edema
– Surgery may impair lymphatic drainage. It is
recommended that the total positive fluid
balance in the first 24 hours should not
exceed 20 mL/kg

59. Lower lung syndrome?

60. • Excessive fluid administration may
promote this syndrome i.e gravity
dependent transudation of fluid into the
dependent lung

61. What about mechanical
ventilation post op?

62. • Most patients are extubated early to
reduce the risk of pulmonary
barotrauma, blowout of the bronchial
stump and pulmonary infection
• Pts with marginal reserve: Double lumen
tube is exchanged with regular
tube,extubated when criteria met

63. What are the available
techniques for pain relief in
this patient?

64. • Thoracic epidural analgesia:gold standard for
post-thoracotomy analgesia
– The epidural is most effective when placed at
the vertebral level corresponding with the
dermatomes of the surgical incision.
– Local anaesthetic solutions may be infused
continuously or via a patient controlled device
– Opiods can be added
• Parenteral opioids: Patient-controlled analgesia
(PCA) devices can be used to deliver opioids

65. • Paravertebral blocks
• Intrathecal opioids
• Intercostal nerve blocks

66. Post-op complications of
pneumonectomy?

67. • 1. Cardiovascular:
– a. Arrhythmias
– b. Right ventricular failure
– c. Cardiac herniation
– d. Hemorrhage
• 2. Pulmonary
– a. Pulmonary edema
– b. Respiratory insufficiency
– c. Pulmonary torsion
• 3. Pneumonectomy space
– a. Bronchopleural fistula
– b. Empyema
• 4. Neurological
– Recurrent laryngeal, vagus or phrenic nerve injury

68. Indication of thoracotomy
once ICTD is placed?

69. • > 1.5 L once ICTD is placed.
• > 200ml/hr for consecutive 4 hrs
• Clotted hemothorax
• Persistent pneumothorax

70. What are the indications
of chest tube insertion

71. • Asymptomatic patients with minimal
pneumothorax (< 15–20% of hemithorax) :
conservative management
• Symptomatic or patients with larger
pneumothorax need aspiration or drainage
• ICTD indications :
1. Pneumothorax
a. In mechanically ventilated patient
b. Tension pneumothorax after initial
decompression by inserting a needle
c. Persistent or recurrent pneumothorax
after simple aspiration

72. 2. Large or symptomatic pleural
effusions
3. Other pleural collections
a. Pus (empyema)
b. Blood (hemothorax)
c. Chyle (chylothorax)
4. Postoperative—after thoracotomy
or thoracoscopy