A 15-year-old male presented with a bronchopleural fistula (BPF) following a chest injury. He underwent thoracotomy for a pneumonectomy due to an unrepairable transected right main bronchus. Anesthesia management focused on limiting ventilation to prevent worsening the BPF while maintaining oxygenation. Post-operatively, the patient required re-intubation due to a displaced double lumen tube causing a leak, then was successfully extubated on postoperative day three. Conservative management can also be considered for small BPFs using strategies like one-lung ventilation or high frequency jet ventilation to rest the lung and promote healing.
Negative pressure pulmonary edema (NPPE) or postobstruction pulmonary edema (POPE) is a clinical entity of great relevance in anesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
Trans sternal trans pericardial closure of post pneumonectomy bronchopleural ...Abdulsalam Taha
The occurrence of a broncho-pleural (BPF) after pneumonectomy is an infrequent but severe complication accompanied by a high morbidity and mortality. Small BPFs may heal either spontaneously or with drainage only. However, the majority of patients with persistent BPFs require operative intervention. There is no standard treatment to this complication and the successful management is a challenge to the thoracic surgeon. While most of the treatment options are staged operations, the trans-sternal trans-pericardial (TSTP) closure is attractive as it is a one stage operation that avoids the infected pneumonectomy space and does not result in patient’s disfigurement. The technique was first used in Italy and then used extensively in the former Soviet Union. Herein, we report a case of chronic BPF after pneumoectomy successfully closed via the TSTP approach. The relevant literature is reviewed to throw light on the indications and the results of this operation.
Key Words: BPF, Pneumonectomy, Empyaema and TSTP Approach.
Publication Date: Mar 2010
Publication Name: Basra Journal of Surgery
view on iasj.net
Negative pressure pulmonary edema (NPPE) or postobstruction pulmonary edema (POPE) is a clinical entity of great relevance in anesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
Trans sternal trans pericardial closure of post pneumonectomy bronchopleural ...Abdulsalam Taha
The occurrence of a broncho-pleural (BPF) after pneumonectomy is an infrequent but severe complication accompanied by a high morbidity and mortality. Small BPFs may heal either spontaneously or with drainage only. However, the majority of patients with persistent BPFs require operative intervention. There is no standard treatment to this complication and the successful management is a challenge to the thoracic surgeon. While most of the treatment options are staged operations, the trans-sternal trans-pericardial (TSTP) closure is attractive as it is a one stage operation that avoids the infected pneumonectomy space and does not result in patient’s disfigurement. The technique was first used in Italy and then used extensively in the former Soviet Union. Herein, we report a case of chronic BPF after pneumoectomy successfully closed via the TSTP approach. The relevant literature is reviewed to throw light on the indications and the results of this operation.
Key Words: BPF, Pneumonectomy, Empyaema and TSTP Approach.
Publication Date: Mar 2010
Publication Name: Basra Journal of Surgery
view on iasj.net
Despite modern anti-tuberculous chemotherapy, approximately 2% of all cases of pulmonary mycobacterial infection require surgical treatment.Therefore, surgical treatment of pulmonary mycobacterial disease is rarely necessary.Types of surgical procedures for PTB include: Collapse therapy, pulmonary resection, lung decortication, drainage procedures such as closed tube thoracostomy, rib resection and open window thoracotomy beside pulmonary resection+ collapse therapy (thoracoplasty). The decreasing morbidity and mortality of pulmonary resection for PTB is due to careful patient selection ( failure of chemotherapy, massive haemoptysis, BPF), improved anaesthetic techniques, stapling devices and better chemotherapy.The prognosis after successful resection is excellent ( 90% survive and remain disease free).
Transsternsl transpericardial closure of postpneumonectomy bronchopleural fis...Abdulsalam Taha
There is no standard treatment for post-pneumonectomy bronchopleural fistula and the successful management is a challenge to the thoracic surgeon. Most of the treatment options are staged procedures.Transsternal transpericardial closure (TSTP) is attractive as it is a one stage operation, that avoids the infected pneumonectomy space and does not result in patients disfigurement. The single disadvantage of TSTP closure is that it does not address the problem of the pneumonectomy space.Herein, we report a case of chronic BPF after pneumonectomy successfully closed via the transsternal transpericardial approach.The relevant literature is reviewed to throw light on the indications and the results of this operation.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. Presenter : DR. M.MADHU CHAITANYA
Moderator : DR. PRADEEP KUMAR DAS (assistant professor)
Great eastern medical school and hospital
ANESTHESIA CONSIDERATIONS
IN BRONCHO-PLEURAL FISTULA
2. Case report
•A 15-year-old male, weighing 49 kg was brought to emergency department ,9 days after
an injury to the right side of his chest by the steering wheel of a tractor.
•Patient had complaints of pain over the right side of chest and breathlessness soon after
the injury.
• He had no upper airway obstruction and there was no other associated injury.
• He was initially treated at a peripheral hospital, where intercostal drainage (ICD) was
placed.
•He was then referred to a centre of specialized facilities, where on fiberoptic
bronchoscopy near complete transaction of right main bronchus with bronchopleural fistula
was diagnosed.
• The right lung was collapsed.
•After further investigation and treatment, he was referred to tertiary centre for further
management.
3. •The patient was conscious and co-operative with stable heart rate and blood pressure
(Pulse rate = 92 beats/min, BP = 120/76 mmHg).
• Respiratory rate was 19 breaths per minute and peripheral
oxygen saturation was 92–97% on room air.
• On auscultation, air entry was absent on the right side of the chest.
• There was collection of 250 ml of straw colored fluid in the right ICD.
• Chest compression test was negative.
• There were no other associated injuries.
• ABG values on room air were within normal limits (pH = 7.46, PCO2 = 37, PO2 = 70
, HCO3- = 26.8, BE = 2.5).
•Chest radiograph and CT Scan showed right sided pneumothorax with collapsed lung,
absent broncho-pulmonary markings with ICD in situ
4. CX Ray showing right side pneumothorax with collapse of right lung.
Broncho-pulmonary marking are present only in the left lung field (white arrow)
not seen on the right side. Grey arrow shows the ICD in situ on the right side.
5. PLAN OF MANAGEMENT
Patient was planned for elective Thoracotomy under General anesthesia with
epidural anesthesia because of massive air leak through bronchopleural fistula.
6. PROCEDURE
In the operating room, routine monitors were attached and an epidural catheter was
placed at T10-T11 level in the sitting position.
Epidural infusion of Bupivacaine 0.25 % was started.
Anesthesia induction with Fentanyl , Propofol and Rocuronium was done.
Trachea was intubated using 32 Fr left-sided DLT.
The position of the tube was confirmed by fiberoptic bronchoscopy.
Anesthesia was maintained with isoflurane in a mixture of Oxygen and Air
(1:2), fentanyl and vecuronium.
Patient was positioned in left lateral position and ICD was removed.
Thoracotomy was done using a J-shaped incision in the 5th intercostals space.
7. Intraoperative, decision for pneumonectomy was taken as there was severe
contusion and collapse of right lung and the margin of the transected right main
bronchus was sloughed and un repairable.
Pulmonary vein and artery were clamped and tied separately and right bronchus was
cut and sutured.
The absence of leak at suture site was confirmed by applying
positive pressure ventilation up to 40 cm H2O.
A new ICD was placed in the 6th intercostal space and wound closed in layers.
Intraoperative course was uneventful.
At the end of surgery, patient was shifted to intensive care unit (ICU).
8. POSTOPERATIVE PERIOD
• Elective ventilation with DLT in situ was planned in the Postoperative Period
•In the ICU, patient received sedation and analgesia with midazolam and fentanyl along
with epidural analgesia .
• Patient was mechanically ventilated using pressure controlled mode (PCV) with following
ventilatory settings:
1. Peak inspiratory pressure of 20 cm H2O,
2. Respiratory rate 20 breaths/min,
3. I:E ratio 1:2
4. positive end expiratory pressure (PEEP) of 3 cm H2O.
9. Four hours later in the ICU, the stump leaked due to malposition of the
DLT, leading to difficulty in ventilation.
The tube was repositioned with fiberoptic bronchoscope in ICU and the
patient re-operated to repair the site of leak.
Right thorax was opened through the same incision and major air leak
was detected from right main bronchus, which was then secured.
After the surgery, patient was again shifted to ICU with DLT in situ and
this time patient was kept paralyzed with vecuronium infusion at 3 mg/h
for next 48 h.
10. The displaced left DLT into the stump of the right main bronchus (black arrow)
causing injury to the suture line. Right side of the thorax having ICD in situ
(white arrow).
11. After two days, DLT was changed with 6 mm portex endo-tracheal tube using
fiberoptic bronchoscope with due care not to injure the stump.
The patient was electively ventilated for the next one day.
On the third postoperative day, patient was weaned off the ventilator and
later tracheally extubated.
Further course in the hospital was uneventful and patient was discharged
home on 14th day
12. Definition
A bronchopleural fistula is a connection from the bronchial tree to the pleural space.
Miller cites three ways this can occur:
1. Rupture of a bronchus, bulla, cyst, or abscess
2. Erosion due to carcinoma or inflammatory disease
3. Stump dehiscence status post pneumonectomy
Incidence:
2-11% after pulmonary resection
Mortality of 5-70%
13. Etiology
I. Most commonly occurs due to giving away of bronchial suture after
pneumonectomy
II. Erosion of bronchus by carcinoma or chronic inflammation
III. Spontaneous drainage of lug abscess/ empyema cavity into bronchial
tree
IV. Traumatic rupture of bronchus/bulla/cyst{ by barotrauma/PEEP}
V. Penetrating chest wound
14. CLINICAL PRESENTATION
Usually 7-15 days following a lung resection
Early (1-7days ),
Intermediate ( 8-30 days ) and
Late ( more than 30 days ) As complication of pleuro-pulmonary infection
- any time during the course of the illness
Early indicators: Reappearance of fever, increased cough with purulent/
serosanguinous sputum Persistent bubbling from the chest drain.
15. CLINICAL PRESENTATION
1. ACUTE: Sudden onset of dyspnea, cough, expectoration of purulent material,
hypotension, subcutn.emphysema,shifting of trachea and mediastinum.
2. SUBACUTE: Insidious onset of fever, malaise, wasting,minimally productive cough
3. CHRONIC: Associated with infectious disease, minimal mediastinal shift due to
pleural and mediastinal fibrosis, not life threatening, adequate gas exchange in
healthy lung Systemic features of sepsis.
16. Anesthesia Considerations
Inability to effectively ventilate these patients may be encountered due to
large air leak
Also positive pressure ventilation might increase air leak across BPF
causing tension pneumothorax and delayed healing of fistula.
Reduced alveolar ventilation on the other hand causes CO2 retention and
increased acidosis.
Reducing risk of contaminating healthy lung is important if empyema is
present
.
17. GOALS
Need for resuscitation & stabilization prior to OR:
– Fluids, vasopressors, antibiotics, chest tube placement
– If no chest tube in place prior to OR, thoracic surgeon must be
immediately available to place a chest tube
Intra operative goals:
– Lung protective ventilation
– Restrictive fluid strategy
– Maintenance of normothermia & normal metabolics
Optimization to facilitate postoperative extubation:
– Resuscitation
– Bronchial suctioning
– Bronchodilators
– Extubation to BiPAP
18. PRE-OPERATIVE ASSESSMENT
An assessment of the patient’s cardio-respiratory function.
Preoperative optimization - the presence of active infection / wheeze
should be identified and treated if possible.
19. Preoperative preparation and Premedication
1. Drainage of empyema
Empyema if present, should be drained before any surgery is done, to close the
BPF
This is done to avoid risk of tension pneumothorax during PPV
Drainage is done with person sitting up and leaning towards affected side
A drain to underwater seal system is left In the pleural cavity before anesthesia
Chest x ray should be take to determine efficacy of procedure
20. Estimation of size of BPF
Important as it determines the amount of air leak from the tidal volume administered
Two methods
1. Amount of ICD drain:
- After pneumonectomy if continuous drainage occurs , it implies that BPF is large
- If drainage is intermittent, it implies small size of BPF
2. Loss of tidal volume:
• Estimate loss of tidal volume between inspired and expired tidal volume
• Smaller difference between inspired and expired tidal volume implies smaller sized BPF
This is done by connecting spirometer to
A tightly fitting face mask in non intubated patients
To ETT In intubated patiets
21. Investigations
1. CBP, bleeding time, clotting time, Creatinine, Urea, LFT, ECG
2. Neutrophilia, Raised total counts
3. ABG: hypoxia, hypercarbia, metabolic acidosis
Chest x ray, CT Scan
I. Air filled pleural space, new air fluid level
II. Shifting of trachea, collapse of lung
III. Reducing fluid level o serial chest x ray following pneumonectomy
a) Brochography, sinogram: confirmatory test
b) Bronchoscopy
c) Accumulation of radionuclide In pleural space after inhalation of xenon or O2-N2O
mixture.
d) Methylene blue injection into pleural space and recovering it In sputum.
22. PREMEDICATION
1. Informed consent.
2. Npo orders.
3. Premedication is not required in emergency surgery.
4. Diazepam 5mg per oral, Midazolam can be used.
5. Inj Glycopyrrolate 10mcg/kg IV .
6. Anti aspiration prophylaxis if awake intubation is planned.
25. Induction and Intubation
100% oxygen with facemask of appropriate size
Sitting up position is preferred pre induction to prevent spill over
Priority is to isolate affected site in terms of contamination and ventilation
Endobronchial tube placed before PPV initiated
Care of ICD :
Chest tube position in infected area confirmed
Chest tube has to be left unclamped to :
1 . Avoid any bouts of coughing
2. Prevent build up of tension pneumothorax in case a pre existing valve
mechanism exists
During induction,suction from chest tube is avoided to prevent loss of tidal volume
.
26. Choice of ETT:
Single lumen ET tube can be used for small sized BPF
Double lumen tube for larger size BPF
Intubation techniques:
1. Awake intubation off an anesthetized airway:
- Done with help of fibreoptic bronchoscopy and DLT
- Is safe and most ideal technique
- Neuroleptanalgesia with topical airway anesthesia may be required
2. Intubation after deep anesthetic plane:
- Done with patient breathing spontaneously
- Using IV Propofol 2mg/kg or Thiopentone 5mg/kg
27. Ventilator management is difficult because
• Positive pressure ventilation may lead to tension pneumothorax
• Air leak from the fistula can lead to inadequate oxygenation and ventilation
•A chest drain can reduce the chance of tension pneumothorax with PPV.
• High frequency jet ventilation with permissive hypercapnia avoids the need for a
DLT or SLT with blocker. HFJV avoids barotrauma to the other lung and
decreases the air leak.
• If high frequency jet ventilation is not available, BP fistula is one of the strict
indications for split lung (i.e. DLT) ventilation.
28. 3.Rapid sequence intubation:
- Done with IV succinyl choline
- Has increased risk of tension pneumothorax and contamination
4.Once tube is adequately positioned in trachea, there may be outpouring of pus
from tracheal lumen
5.Thus ,this lumen should be immediately suctioned with a large bore catheter
6. Fibre optic intubation of double lumen tube / SLT is preferred in post
pneumonectomy patients, with tip of endobronchial lumen placed in existing lung
29. Maintenance
1. Nitrous oxide avoided
2. Oxygen + Air + Isoflurane / Sevoflurane used
3. Fentanyl + Vecuronium intermittent boluses
4. High frequency oscillatory ventilation
- May be used along with Permissive hypercapnia
- Minimizes air leak and also stabilizes hemodynamic
- Especially used in patients with multiple BPF
5. After chest is opened, if excessive air leak is encountered, when using SLT,
ventilation can be improved by lung packing and Manual control of air leak
30. Extubation
Early extubation is preferred
This is to avoid barotrauma to surgical stump from PPV
Extubated fully awake, warm and fully reversed
Post operative management
Change DLT to SLT
Shifted to ICU in sitting position after establishment of spontaneous ventilation
Respiratory failure is common post operatively in these patients
32. Postoperative Analgesia
Thoracotomy is among the most painful of all operative procedures.
1. Systemic opioids
2. NSAIDS
3. Epidural analgesia
4. Intercostal nerve blocks
5. Inter pleural analgesia
6. Cryo-analgesia
33. Conservative management of BPF
BPF can be conservatively managed if small, adequately ventilating them and giving
antibiotics
Ventilatory strategies:
- One lung ventilation:
Bronchus of normal lung intubated and ventilated
This allows BPF to rest and heal with the help of antibiotics
This may lead to an intolerable intra pulmonary shunt
PEEP may be needed to maintain PO2
- Differential lung ventilation:
Each lung is managed with different types of ventilation
Done through DLT and two synchronized ventilators
34. Healthy lung is ventilated with normal ventilator
Affected lung is exposed to smaller tidal volumes or HFJV
CPAP with oxygen at pressures below the critical opening pressure of the BPF
can be used
Critical opening pressure is determined by assessing lowest level of CPAP
which must be applied to the bronchus on affected side to produce continuous
bubbling through the underwater seal.
High frequency jet ventilation:
Used for larger BPF or multiple BPF
This causes minimal gas loss through fistula as VT is low
Thus ,BPF may heal more quickly
Also ,hemodynamic affects are usually minimal
35. Unidirectional Chest Tube Valve:
Usually ,inspiratory cycle of ventilator triggers closure of chest tube valve
Valve again opens during expiration
This reduces gas flow across BPF during PPV
Flow across fistula is reduced by increasing pleural pressure during positive pr
essure breaths
This reduces the pressure gradient across BPF
Other strategies:
PEEP to pleural cavity equalising with intrathoracic PEEP
If disruption occurs early in the post pneumonectomy patients, re-suture stump
Small fistulas can be closed by bronchoscopy or fibrin glue
36. Spirometry
Spirometry should be performed on all patients undergoing lung resection. Provided
the patient effort is adequate, the presence and severity of obstructive and restrictive
lung disease can be reliably identified.
The following parameters have been associated with an increased risk of pulmonary
complications following pneumonectomy:
FVC <50% of predicted or <1.75-2L
FEV1>2L, mortality = 10%, <2L, mortality = 20-45%
MBC <50-60% of predicted, mortality = 5-32%
An FEV1 of less than 800ml generally precludes thoracic resection apart from lung
volume reduction surgery
The response to bronchodilators should be assessed in patients with obstructive
airways disease.