Educative material

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2. GROUP THREE (3)
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Anesthesia For Thoracic Surgery

3. Anatomical review
 Adult trachea is about 11-14 cm long from cricoid
cartilage at C6 and divided at T5
 Trachea have 16-20 cartilage joined posteriorly by
fibroelastic tissue & trachealis muscle.
 Mainstem bronchus are circular, right main bronchus is
wider & shorter than the left , it gives off its upper lobe
bronchus at 2.5 cm as opposed to 5 cm on the left.
 Right main bronchus arises at 25 degree to vertical
compared with 45 degree on the left.
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4. (bronchial diameter is predicted to be 0.68 of tracheal diameter).
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9. Ventilation and Perfusion
 Awake patient, the dependent lung is better
perfused than the upper lung because of a gravity.
 The ventilation of dependent lung is also better as
contraction of dependent diaphragm is more
efficient and is pushed higher than the upper
during expiration by the weight of abdominal
content.
 The dependent lung is more favourable part of
compliant curve.
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Independent
lung
Dependent
lung

11. In a controlled ventilation
decrease in FRC with induction of anaesthesia move the upper
lung into more favorable part of compliance curve .
Upper lung is ventilated more than dependent
V/Q mismatching occur because the dependent lung continue to
have a greater perfusion and use of muscle relaxant lead to
abdominal content to rise up against the dependent lung and
impede ventilation.
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13. Position of thoracotomy
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14.  When the chest open on one side , the negative pleural
pressure is lost and the lung will collapse.
 Spontaneous ventilation with open pneumothorax in the
lateral position results in paradoxical respiration &
mediastinal shift
 Downward shift of mediastinum during inspiration &
 Upward shift during expiration that causes decrease in
tidal volume.
 All these changes can be overcome by positive pressure
ventilation with double lumen endotracheal tube.
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17. Pulmonary function test associated increase
perioperative mortality in thoracic surgery
PFT THORACOTOMY LOBECTOMY/PNEUMONECTOMY
FVC <70% <50% OR <2L
FEVI <1L <1/2L
FEV1/FVC <50% <50%
FEF25-75 <50%
Paco2 >45-55mmhg >45-55mmhg
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18. The major challenges in anesthesia
for thoracic surgery are :
1. Establishing adequate separation of the lungs.
2. Maintaining gas exchange.
3. Ensuring circulatory stability during one-lung anesthesia.
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19. One-lung anesthesia
Involves lung separation and deliberate ventilation of
the dependent lung by isolating its bronchus from that
of the nondependent lung (the operative site) with
specially designed endotracheal tubes.
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20.  In addition, thoracic surgery often involves thoracotomy
incisions, which are associated with severe pain and
potentially deleterious changes in cardiopulmonary
physiology after surgery.
 Some of these physiologic changes can be minimized by
thoracic epidural analgesia for effective postoperative pain
management .
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21. Preoperative evaluation and
preparation
Patients undergoing thoracic surgery are at high risk
for
postoperative pulmonary complications, particularly if
coexisting chronic pulmonary disease is present.
Risk factors associated with increased perioperative
morbidity and mortality include:
 The extent of lung resection (pneumonectomy >
Lobectomy > wedge resection),
Age older than 70 years,
Inexperience of the operating surgeon 09
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22.  In patients with anatomically resectable lung cancer pulmonary function
testing, lung perfusion scanning, and exercise testing to measure
maximum oxygen consumption may also predict postoperative
pulmonary function, as well as increased mortality .
 A decrease in FEV1, to less than 70% of predicted and a reduction in
diffusing capacity to less than 60% of predicted should prompt further
testing with a quantitative lung perfusion scan.
 If postoperative FEV1, or DLCO are less than 40% as predicted by lung
scan, an exercise study should be obtained. A significant decrease in
oxygen consumption « 10 mL/kg/min) as measured by exercise testing
predicts a postoperative mortality of 25% to 50% and should prompt
discussion of alternatives to surgical resection.
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23. DISCONTINUATION OF SMOKING
Smoking
 Increases airway irritability.
 Increases secretions.
 Decreases mucociliary transport.
 Increases the incidence of postoperative pulmonary
complications.
Cessation of smoking for 12 to 24 hours before surgery
decreases the level of carboxyhemoglobin, shifts the
oxyhemoglobin dissociation curve to the right, and increases
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24.  In contrast to these short-term effects improvement in mucociliary
transport and small airway function and decreases in sputum
production require prolonged abstinence (8 to 12 weeks) from
smoking.
 The incidence of postoperative pulmonary complications decreases
with abstinence from cigarette smoking for more than 8 weeks in
patients undergoing coronary artery bypass surgery and more than
4 weeks in patients undergoing pulmonary surgery.
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26. Management of Anesthesia
The five goals of anesthesia in thoracic surgery are to
(1) produce controlled levels of narcosis and analgesia,
(2) suppress cough and reflex airway activity,
(3) Minimize interference with protective reflexes such as
hypoxic pulmonary vasoconstriction,
(4) maintain satisfactory blood gas exchange and
cardiovascular stability,
(5) permit rapid recovery from anesthesia to avoid
postoperative respiratory depression.
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27. Induction and Maintenance
 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
 Maintenance : halogenated agent + opiod
 Delivered in an oxygen/air or oxygen/nitrous oxide mix
 Depression of airway reflexes and rapid elimination allowing
for rapid recovery are important benefits of volatile
anesthetics
 During one-lung ventilation, anaesthesia can be maintained intravenously with
propofol and an air/oxygen mix
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28. Separation of the Lungs (One-Lung
Anesthesia)
. Separation of the lungs permits intraoperative one-lung
ventilation, which greatly facilitates the surgical procedure.
1. Double-lumen endobronchial tubes (DLTs)
2. bronchial blockers (BBs) with single lumen endotracheal
tubes enable anatomic isolation of the lungs and facilitate
lung separation.
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BBs
DLTs

29. LEFT-SIDED DOUBLE-LUMEN TUBE
Placement of a left-sided DLT
 is the most reliable
 widely used approach for endobronchial intubation in
one-lung ventilation .
Several manufacturers such as Mallinckrodt, Rusch, and Sheridan
produce clear, disposable polyvinyl chloride tubes with high-volume,
low pressure tracheal and bronchial cuffs.
In general, a 35- or 37-French tube can be used for most women
and a 39-French tube for most men.
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31. Insertion Technique for Placement of a Left-Sided
Double-Lumen Tube
1. Endobronchial intubation is usually accomplished by direct
laryngoscopy after induction of general anesthesia and
neuromuscular blockade.
2. The left-sided DLT tube is held so that the distal curve faces
anteriorly while the proximal curve is to the right.
3. The bronchial cuff is inserted through the vocal cords, and the
stylet is removed.
4. Next, the tube is rotated 90 degrees to the left (directing the
bronchial lumen to the left main stem bronchus).
5. The tube is advanced until moderate resistance to further
passage is encountered.
Force should never be used during advancement of the tube;
resistance usually indicates impingemen within the main stem
bronchus. An estimate of the appropriate depth of placement
of the DLT can be based on the patient's height.
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32. The average depth of insertion referenced to
the corner of the mouth is 29 cm for patients
170 cm tall, and for each 10-cm increase or
decrease in height, the average depth of
placement correspondingly changes by 1 cm.
Correct DLT position must be confirmed by
fiberoptic bronchoscopy . 09
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34. Fiberoptic Visualization of a Left-Sided
Double-Lumen Tube
A 3.6-mm fiberscope is initially passed through the tracheal lumen.
Correct position of the DLT is confirmed by visualization of the
carina, a nonobstructed view of the right main stem bronchus, and
the blue bronchial cuff below the carina
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37. RIGHT-SIDED DOUBLE-LUMEN
TUBE
 The short and variable distance of the right upper lobe orifice
from the carina makes the use of a right-sided DLT undesirable
for most procedures requiring lung separation.
 A small change in the position of the tube results in inadequate
lung separation or collapse of the right upper lobe, or both.
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39. Confirmation of correct right-sided DLT position by physical
examination alone results in a 90% chance of malposition, with most
being too deep.
Proper positioning of a right-sided DLT must include fiberoptic
guidance.
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41. Approaches to Improve Oxygenation during
One-Lung Ventilation
 Proper positioning of the DLT should be confirmed with the fiberscope
because dislodgment of the tube is may be occur after positioning of the
patient for surgery and again after surgical manipulation.
 The most effective approach is the application of 5 to 10 cm H20 PEE
(CPAP) to the nondependent lung.
 If the improvement in Pao2 is not sustained, selective application of
PEEP to the dependent lung is then initiated.
 In many circumstances, PEEP applied to the dependent lung may result
in decreased Pao2 because of the increased PVR of the dependent lung,
which then diverts blood flow to the nondependent (atelectatic lung).
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42.  The respiratory rate (R.R) is adjusted to maintain minute
ventilation at the same level as during two-lung
ventilation;
 Paco2 will be maintained at similar or slightly lower levels
than those observed during two-lung ventilation
 In approximately 25% of patients, Pa02 is ≤80 mm Hg,
and in 10% of patients, ≤60 mm Hg.
 The dependent lung should be ventilated with tidal
volumes of 8 to 10 mL/kg. Ventilation with tidal volumes of
5 to 7 mL/kg may promote atelectasis in the dependent
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43. What is management of hypoxemia during
one lung ventilation?
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
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
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44. Fluid management
• 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
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45. CONCLUSION OF SURGERY
 Hyperinflation of the lungs is an important maneuver to remove air
from the pleural space at the end of thoracic surgery .
 Furthermore, alveoli incised during segmental resection of the lungs
continue to leak air into the pleural space, thus necessitating
placement of chest tubes to minimize the air leak and promote
continued expansion of the lung.
 If mechanical ventilation of the lungs must be continued into the
postoperative period, it will be necessary to replace the DLT with a
single-lumen tube.
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46. POSTOPERATIVE PULMONARY
COMPLICATIONS
atelectasis, followed by pneumonia and arterial
hypoxemia.
The severity of these complications parallels the
magnitude of decrease in vital capacity and functional
residual capacity.
Decreases in these lung volumes interfere with the
generation of an effective cough, as well as contribute to
atelectasis.
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47. Pain Management
 Pain decreases respiratory effort, which results in atelectasis,
contributes to development of the stress response with increased
sympathetic nervous system activity, and increases cardiac morbidity.
 Thoracic epidural analgesia offers a unique opportunity to improve
postoperative recovery after thoracotomy.
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48. Thank you
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49. REFERENCES
 Passlick B, Born C, Häussinger K, et al. Efficiency of video-assisted
thoracic surgery for primary and secondary spontaneous
pneumothorax. Ann Thorac Surg 1998;65:324-7.
 Liu HP, Lin PJ, Hsieh MJ, et al. Thoracoscopic surgery as a routine
procedure for spontaneous pneumothorax. Results from 82
patients. Chest 1995;107:559-62.
 https://perioperativemedicinejournal.biomedcentral.com/articles/10
.1186/s13741-020-00159-z
 https://ether.stanford.edu/library/thoracic_anesthesia/Overview/RE
VIEW%20Anesthesia%20for%20Thoracic%20Surgery.pdf
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50. GROUP MEMBERS
 SOAK/2022/R024
 SOAK/2022/R017
 SOAK/2022/R006
 SOAK/2022/R027
 SOAK/2022/R035
 SOAK/2022/R041
 SOAK/2022/R012
 SOAK/2022/R023
 SOAK/2022/R030
 SOAK/2022/R009
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