Thoracic anesthesia

1. THORACIC
ANAESTHESIA
DR. ANKIT GAJJAR

2. PRE OPERATIVE EVALUATION
• Most of the cases presenting for thoracic surgery have
bronchial carcinoma, mediastinal masses or esophageal
disease. In order to assess patients for thoracic anesthesia it is
necessary to have an understanding of the risks specific to this
type of surgery. Respiratory complications are the major cause
of peri-operative morbidity and mortality in thoracic surgery
patients.
• History
• detailed h/o smoking and symptoms suggestive of COPD and
ischemic heart diease should be elicited.
• h/o of chemotherapy taken pre op.
• h/o of lethargy, weight loss, anorexia…etc….

3. BRONCHO PULMONARY
SYMPTOMS
• Cough with expectoration - mc
• Dyspnea
• Chest pain
• Wheezing
• Look for any metastasis and involvement of other
systems as in paraneoplastic syndrom

4. • Detailed medical history for any co-existing diease
• Physical examination:
Inspection: look for respiratory rate
if any use of acessory muscle
Palpation : see for mediastinal shift
Auscultation : presence of any foreign sounds like rhonchi
or
creps present, in which zone of lungs
-Air entry in each area of lung
Percussion: assess the overall severity
of chronic lung disease and indicate the presence of
consolidation, atelectasis or pleural effusion.

5. INVESTIGATION
• BASELINE INVESTIGATION
• CBC: look for anemia (HB), polycythemia and
leukocytosis
• RBS , Liver and renal function in the view of age,
metastasis and if pt had received CTH
• CXR: - tracheal deviation or obstruction
- signs of pleural effusion
- signs of pulmonary edema, atelectasis and
consolidation

6. INVESTIGATION
ECG : See for any rt or lt side heart dysfunction
- signs of any ischemic changes
_ signs of coronary artery diease
•Sputum culture
•Qualitative index of infection and specific antibiotic
therapy
•Serum protein and s. albumin
=

7. INVESTIGATION
• CT SCAN
• Asses the which part of the lung and up to which
extent lungs are involved
• Helps in staging of the ca lung
• All the CXR findings can be seen in more detail in
CT SCAN
• Which no of DLT, we have to use can be assess by
CT SCAN

8. • BASELINE ABG
COPD pts are CO2 retainers and low PaO2
• ECHOCARDIOGRAPHY
• Rt ventricular dysfunction occur in 50% of COPD
pts and 30-40% pts with post op pneumonectomy.
• Recurrent hypoxemia is main cause of rt
ventricular dysfunction which increase the
pulmonary vascular resistance
INVESTIGATION

9. Noninvasive diagnosis of pulmonary hypertension, increased
pulmonary vascular resistance, right atrial andventricular
hypertrophy and corpulmonale
Auscultatory signs of
increased PAP and PVR
Radiographic signs of
increased PAP and PVR
Electrocardiographic sign
of increased RA and RV
Additional signs of CP
Increased pulmonary
component of second heart
sound
Dilation of main pulmonary
artery
Increased RV
Clockwise vector rotation
Right axis deviation
Inverted t wav v1-v6
All those of increased PAP,
increased PVR, increased
RA increased RV
Loss of normally present
split In second heart sound
Fullness of apical
pulmonary vessels
Pulmonary diastolic murmur
Presence of fourth heart
sound
Counterclockwise cardiac
rotation, globular shape on
PA film(the RV comprises
the left and right heart
border, aortic knob)
Increased RA
ST depression V2-v6
Increased P wave II and III,
Third heart sound
Presence of high-pitched
early ejection systolic click
Lateral film showing
encroachment of
retrosternal airspace (RV
dilation)
Prominent right sternal
border pulsation plus
retraction over left side of
chest- rocking motion
synchronous with heratbeat.
Chronic dependent edema,
large tender liver, ascitis,
distended neck veins(large
A waves)

10. • In all patients baseline spirometry is
necessary
• Respiratory function assessment includes:
- respiratory mechanics
- gas exchange
- cardio respiratory assesssment

12. PFT II 12
ObstructiveObstructive
Lung dis.Lung dis.
RLDRLD
InterinsicInterinsic
RLDRLD
ExtrinsicExtrinsic
FEV1FEV1
FVCFVC
FEV1/FVCFEV1/FVC
RVRV
TLCTLC
RV/TLCRV/TLC
VCVC
FRCFRC

13. RESPIRATORY MECHANICS:
• It includes FEV1, FVC, MVV, RV/TLC etc…
• Most valid single test for post-thoracotomy
complications is predicted postoperative FEV1
• PpoFEV1 % = preoperative FEV1 % * (1 - %
functional lung tissue removed/100)
• PpoFEV1 % > 40% - low risk
< 40% - high risk
< 30% - very high risk (10/10 on
venti and 6/10 died)

15. LUNG PARENCHYMAL FUNCTION
• It will evaluate the gas exchange in the distal
airway
• Diffusing capacity of the carbon monoxide (DLco)
is the most useful test
• Useful predictor of perioperative mortality but not
long term survival
• Ppo DLco % <40% - high periop mortality

16. CARDIO RESPIRATORY
ASSESSEMANT• Exercise testing “ gold standard “
• Maximum O2 consumption (VO2max) most useful predictor of
post thoracotomy outcome.
• Stair climbing test is also useful ( NO. OF FLIGHTS)
• 6 meter walk test (6MWT)
• VO2max < 15 ml/kg/min
= climbing less than 3 flights
= 6MWT distance less than 2000ft (610 m)
= fall in Spo2 > 4% during exercise
= high risk for post thoracotomy mortality
VO2max < 10 ml/kg/min or climbing < 2 flights absolute C/I
for pulmonary resection

18. VENTILATION PERFUSION
SCINTTIGTAPHY
• Assess contribution of the part of a lung or
a lobe to be resected, in ventilation and
perfusion
• Should be done in all pts posted for
pneumonectomy and
preop FEV1 or Dlco < 80%.

19. Pulmonar
y function
test
Units and designation
(Preop Value vs postop
prediction)
Normal pneumonect
omy
Lobectomy segmental
Resection
FEV₁ Liters(measured Preop)
%(measured preop)
>4.0 lit
>80%FVC
>2.1-1.7
>50%FVC
>1.2-1.0
>40%FVC
>0.6-0.9
>40%FVC
FEV₂₅₋₇₅% Liters (measured Preop) >2 >1.6 0.6-1.6 >0.6
FVC Liters >5.0 >2.0 - -
MVV Liters/ min (measured
for 1 min preop)
% predicted ( measured
preop)
100
100%
>50
>50%
>40
>40%
>25
25%

20. Minimal preoperative measurements or predictions (of postoperative pulmonary function)
for various sized pulmonary resections.
Pulmonary
function
test
Units and designation
(Preop Value vs postop
prediction)
Normal pneumonecto
my
Lobectom
y
segmental
Resection
DLCO % predicted (measured
preop)
%(predicted postop)
100
NA
>60%
>40%
- -
Exercise
testing
Stair climbing(measured
preop)
VO max (L/min)₂
Oxy-Hb saturation drop
with exercise
>10 flights
2.8
none
>5 flights
>1
<3%
>3 flights
>1
<5%
>2 flights
>1
<5%
Pao₂ mm Hg (whole lung
measured preop)
>90 >80 >70 >60
Paco₂ mm Hg (whole lung
measured preop)
40 <45 <50 <55

22. CARDIOVASCULAR SYSTEM
• 2nd
MC cause of mortality in post op periode
• ISCHEMIA
• Incidence is 5%
• In high risk pts only physical exam and ECG is not enough but
non invasive testing like echocardiography, angiography etc..
Should be done.
• prophylactic use of B-blockers reduce risk of ischemia
• ARRYTHMIAS
• Incidence is 30% to 40% (60 to 70 % are atrial fibrilation)
• prophylaxis
• Diltiazem (most useful) B-blockers,verapemil,amiodarone
• Digoxin not useful
• Thoracic epidural analgesia

24. Anesthetic Considerations in Lung
Cancer Patients (the “4 Ms”)
• Mass effects: Obstructive pneumonia, lung abscess,
superior vena cava syndrome, tracheobronchial
distortion, Pancoast's syndrome, recurrent laryngeal
nerve or phrenic nerve paresis, chest wall or mediastinal
extension
• Metabolic effects: Lambert-Eaton syndrome,
hypercalcemia, hyponatremia, Cushing's syndrome
• Metastases: particularly to brain, bone, liver, and adrenal
• Medications: chemotherapy agents, pulmonary toxicity
(bleomycin, mitomycin C), cardiac toxicity

25. PROBLEMS WITH COPD PTS
• 1) Respiratory drive – in stage 2 and stage 3
• 2) Nocturnal hypoxemia
• 3) Right ventricular dysfunction
• 4) Bullae
• 5) Auto PEEP

26. COPD Ventilation-Perfusion
Matching

27. Preoperative preparation:
• The peri-operative events need to be explained to the patient in
particular and they should be explainedB about the potential
risks and benefits of the post thoracotomy pain management
strategies.
• Premedication should be light especially in those patients who
are prone to develop hypoxia due to respiratory depression.
• The patients undergoing thoracic surgery are prone to develop
postoperative respiratory complications. It is therefore
advisable to do preoperative preparation efforts to optimize
any preexisting pulmonary disease. All these patients should
undergon following steps before subjecting them to surgery:

28. 1. Smoking Cessation:
• There is a decrease in airway secretion and reactivity and
improvement in ciliary function after several weeks of
cessation of smoking . It is therefore suggested to stop
smoking at least 1-2 weeks prior to surgery. This reduces
airway secretions and reactivity. Even stopping smoking for
12-48 hours decreases carboxyhaemoglobin levels and shift
the oxygen hemoglobin dissociation curve to the right
• Smoking in patients with COPD is associated with decline in
FEV1 of 90-150 mL/year
Smoking cessation is (associated with increase in FEV1 for
first year) followed with a decline of only 30 mL/year

29. Helping Surgical Patients Quit Smoking
Warner DO, Anesth Analg 2005; 101: 481-7
Surgical Benefits:
• Decrease ST changes intraop.: 2 days
• Decrease wound complic’s: >4wk.
• Decrease Resp. Complications :
Cardiac: >8wk.
Thoracic: > 4 weeks

30. Benificial effects of smoking cessation and time course
Time course Benificial effects
12-24hr Decreased CO and nicotine levels
48-76 hr COHb levels normalised, ciliary function
improves
1-2 week Decreased sputum production
4-6 week PFTs improve
6-8 week Immune function and metabolism normalizes
8-12 week Decresed overall postoperative morbidty and
mortality

31. 2. Airway dilatation:
• Airway dilatation is needed for patients who have
hyperactive airways such as smokers , Asthmatics ,
or COPD .
• This airway dilatation is done by
1) use of inhaled β2 agonist.
2) Ipratropium bromide – especialy in COPD
3) Steroids (inhaled or iv)
• Effect of bronchodilatation is qualified by
subjective feeling of relief and PFT

34. • 3. Loosening and removing secretion:
• The thick secretions are usually loosened by adequate
hydration using humidifier or ultrasonic nebulization.
• The secretions are than removed by postural drainage,
coughing and chest percussion and vibration for 15-20
minutes several times a day
• CHEST PHYSIOTHERAPY – removes secretion from
peripheral airway to central airway
• FORCED EXPIRATION TECHNIQUE – better clearance
of secretion than cough

35. 4. Control of infection
• Chest infection if present should be treated by
antibiotics according to culture and sensitivity.
5. Measures to increase motivation and
postoperative care:
• These include nutrition improvement, weight
reduction in obese, psychological preparation, and
instructions about incentive spirometry, chest
physiotherapy and postural drainage.

36. PROBLEMS IN COPD PTS THAT
SHOULD BE TREATED PRE-OP
• Problem Method of Diagnosis
• Bronchospasm Auscultation
• Atelectasis Chest radiography
• Infection History, sputum
analysis
• Pulmonary edema Auscultation, CXR

37. 1. All patients: Assess exercise tolerance, estimate
predicted postoperative FEV1%, discuss postoperative
analgesia, discontinue smoking
2. Patients with predicted postoperative FEV1< 40%:
DLCO, scan, VO2 max
3. Cancer patients: consider the “4 Ms”: mass effects,
metabolic effects, metastases,medications
4. COPD patients: Arterial blood gas analysis,
physiotherapy, bronchodilators
5. Increased renal risk: Measure creatinine and blood urea
nitrogen

38. ONE LUNG
VENTILATION

39. Anaesthetic management
• Pre operative epidural catheter placement –
gold standard
• Advantage
1) avoid use of iv narcotics
2) decrease requirment of anaesthetic agent
3) for post op analgesia

40. • Induction agent
• sodium Thiopental
• Ketamine – if the pt has reactive airway
• Etomidate – if pt is moderately hypovolemic or
impaired cardiovascular status
• Muscle relaxant
• Vecuronium - unless and until C/I
• Maintenance
• Sevofurane or isofurane (MAC < 1)
• Propofol infusion may be used

41. Introduction
• One-lung ventilation, (OLV), means separation of
the two lungs and each lung functioning
independently by preparation of the airway
• OLV provides:
– Protection of healthy lung from infected/bleeding one
– Diversion of ventilation from damaged airway or lung
– Improved exposure of surgical field
• OLV causes:
– More manipulation of airway, more damage
– Significant physiologic change and easily development
of hypoxemia

42. Indication• Absolute
– Isolation of one lung from the other to avoid spillage or
contamination
• Infection
• Massive hemorrhage
– Control of the distribution of ventilation
• Bronchopleural fistula
• 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
– Unilateral bronchopulmonary lavage

43. Indication (continued)
• Relative
– Surgical exposure ( high priority)
• Thoracic aortic aneurysm
• Pneumonectomy
• Upper lobectomy
• Mediastinal exposure
• Thoracoscopy
– Surgical exposure (low priority)
• Middle and lower lobectomies and subsegmental
resections
• Esophageal surgery
• Thoracic spine procedure
• Minimal invasive cardiac surgery (MID-CABG)

44. Methods of OLV
• Double-lumen endotracheal tube, DLT
• Single-lumen ET with a built-in bronchial
blocker, Univent Tube
• Single-lumen ET with an isolated bronchial
blocker
– Arndt (wire-guided) endobronchial blocker set
– Balloon-tipped luminal catheters
• Endobronchial intubation of a single-lumen
ET

45. Double Lumen Tube (DLT)
Preferred-Gold Standard
• There are right and left sided DLTs
• Robertshaw tubes are most common.
• Designed with a bronchial lumen that has its own
cuff and extends distal to the carina take 3 c.c. air
• The tracheal lumen has its own cuff that inflates
proximal to carina take 8 c.c. air.
• DLTs come in several sizes: 26, 28, 32, 35, 37, 39,
41 F.R.
• Inflatable bronchial cuffs are bright blue
• Few DLTs has carinal hook to provide proper
placement.

47. MARGIN OF SAFETY
- Depend on length of the lumen into which cuff is
placed and length of the cuff
- if the cuff is short or the mainstem bronchus long,
margin of safety will be more
- outermost acceptable position - bronchial cuff is
just below the carina
- distal acceptable position – bronchial segment tip
is at proximal edge of upper lobe bronchial orifice
- margin of safety for rt sided DLTs are less than lt

48. Sizing DLTs
• Correct size defined as largest DLT that fits
mainstem bronchus and allows leak with cuff
deflated.
• Larger tubes accommodate FOB.
• Larger Tubes offer less resistance to gas flow.
• Larger Tubes less likely to go in too far when
inserted blindly.
• Mainstem diameters vary widely and do not
correlate well with height or age.
• More predictive tests: CT, PA CXR

49. Correct Sized DLT
SEX HEIGHT (cm) SIZE (fr)
Female <152 32
Female <160 35
Female >160 37
Male <160 37
Male <170 39
Male >170 41

50. SIZE OF DLT IN CHILDREN
AGE (years) DLT
8 to 10 26
10 to 12 26 or 28
12 to 14 32
14 to 16 35

51. Mesured tracheal and bronchial diameter
preop on imaging study predict the correct
size of DLT
DLT (fr) Mesured tracheal diameter
(mm)
Mesured bronchial diameter
(mm)
41 >18 >12
39 >16 12
37 >15 11
35 >14 10
32 >12.5 <10
28 >11
26 <10

52. Relationship of fiberoptic bronchoscope
size to adult DLT size
Fiberoptic bronchoscop
size (outside diameter)
(mm)
Adult DLT size (fr) Fit of fiberoptic
bronchoscope inside the
DLT
5.6 All sizes
41
39
Does not fit
Easy passage
Moderately easy passage
4.9 37
35
Tight fit, need lubricate,
hard push
Does not fit
3.6 – 4.2 All sizes Easy passage

53. Double Lumen Tube (DLT)
• Remember:
– We use a left tube if surgery is on the right side
and a right tube if surgery is on the left side
• However!!!!!
– In clinical practice, a left sided tube is used for
almost all cases (except if left sided tube
obstruction of left main stem bronchus)

55. Why Left over Right DLT?
• Right sided DLT are
hard to place because
of short right main
stem bronchus
• Right mainstem
bronchus is ~2.2-2.3
cm v.s. Left mainstem
bronchus is ~5.0-
5.4cm

56. DLT- Why LEFT?
• The cuff has the
potential to move 1cm
or less and block the
RUL take off

57. • Before placing right DLT, CXR and CT
SCAN can be closely examined to identify
rt upper lobe bronchus take off which may
make it difficult to use.
• Size of the main stem bronchus may be
determined from CT SCAN and CXR.

58. Indication for right DLT
• Distorted Anatomy of the Entrance of Left
Mainstem Bronchus
• External or intraluminal tumor compression
• Narrowed lt main bronchus
• Descending thoracic aortic aneurysm
• Site of Surgery Involving the Left Mainstem
Bronchus
• Left lung transplantation
• Left-sided tracheobronchial disruption
• Left-sided pneumonectomy †
• Left-sided sleeve resection

59. Placement of DLT
• When Left sided DLT passed blindly by
experienced practitioner - ~24% end up on right
side.
• 1.6% ultimately fail.
• On average taller people require deeper insertion.
• Many times DLTs appear to be well positioned
and actually aren’t when confirmed with
bronchoscope.
• Average depth of insertion for 170 cm pt is 29 cm
and for each 10 cm increase or decrease in height,
the average depth of placement increase or
decrease by 1 cm..

60. Placement of DLT
• Put together the connectors so that replacing the stylet
requires only one step
• Lubricate the tube
• Have a syringes for the two cuffs- inflate bronchial cuff
with as little air as possible to avoid bronchial cuff
herniation
• Hold the tube with the bronchial curve concave anteriorly
(as with normal ETT)
• As the tip is passed through the larynx, rotate the tube 90
degrees to direct the endobronchial part to the intended
side (R or L) (now proximal curve is concave anteriorly)
• Advance until you feel moderate resistance to further
passage
• Inflate both cuffs
• Connect tube to breathing circuit via a double lumen
catheter mount
• Check for bilateral ventilation

61. Confirmation of Placement
– ETCO2 for confirmation on intubation.
– Auscultation of bilateral Breath Sounds, if not equal,
DLT is in too far.
– Air entry should be equal on both sides and there
should be no leak around the tracheal cuff
– Tracheal side of adapter is now clamped and tracheal
port is opened distal to the clamp. The bronchial cuff is
inflated so as to just eliminate air leak from the tracheal
lumen. Breath sounds should be heard only on the side
of the endobronchial intubation
– The contralateral lung should feel reasonably
compliant. Only the contralateral chest should rise and
fall with ventilation.

62. Confirmation of DLT
– Tracheal limb unclamped, tracheal port closed and the
bronchial limb clamped and opened to air. Breath
Sounds should only be heard on the contralateral side.
– Fiber Optic Bronchoscope down the tracheal lumen
should reveal the carina and the top edge of the blue
bronchial cuff should be just visible in the intended
main stem bronchus.
– Recheck Breath Sounds after patient is positioned,
many will recheck with Fiber Optic Bronchoscope
– Final and most sensitive test of proper placement is
observation of lung when chest is surgically opened.

63. Confirmation of DLT
• Fiberoptic bronchoscopic
view showing anterior
and posterior anatomical
landmarks. Cartilaginous
rings are anterior and
membrane is posterior.
You should identify the
rings only.
• Best landmark in lower
airway to identify right
side is the secondary
carina (bifurcation
between RML and RLL)

64. Hazards associated with DLTs
(1) Difficulty in insertion and positioning
(2) Tube malposition
consenquences
- unsatisfactory lung collapse
- obstruction to lung inflation
- gas trapping
- failure of lung separation
possible malposition
- bronchial lumen in wrong mainstem bronchus
- bronchial lumen in apprpriate bronchus but to deep

65. Hazards associated with DLTs
- bronchial lumen proximal to the airway
- incorrect placement in respect to upper lobe
bronchus
(3) hypoxemia
(4) obstructed ventilation
(5) trauma
large tube: direct injury
small tube: excessive inflation of bronchial cuff
Prevention
• Appropriate size tube
• Avoid over inflation of bronchial cuff

66. Hazards associated with DLTs
- Deflates the cuff when repositioning the pt
- Not to much advance the tube when to much
resistance is encountered
- Bronchial cuff is defleted unless and until its
necessary to inflate
(6) surgical complication
- Bronchial cuff may be puncturad or suture taken
by surgeon
(7) failure to seal
- Due to malposition or improper inflation of cuff

67. OPTIONS ADVANTAGES DISADVANTAGES
DOUBLE LUMEN TUBE
1.DIRECT LARYNGOSCOPE
2.VIA TUBE EXCHANGER
3.FIBREROPTICALLY
-QUICKEST TO PLACE SUCCESSFULLY
-REPOSITIONING RARELY REQUIRED
-BRONCHOSCOPY TO ISOLATED TO
LUNG
-SUCTION TO ISOLATED LUNG
-CPAP EASILY ADDED
-CAN ALTERNATE OLV TO EITHER LUNG
EASILY
-PLACEMENT STILL POSSIBLE IF
BRONCHOSCOPY NOT AVAILABLE
-SIZE SELECTION MORE DIFFICULT
-DIFFICULT TO PLACE IN PATIENTS
WITH DIFFICULT AIRWAY OR
ABNORMAL TRACHEAS
-NOT OPTIMAL FOR POSTOPERATIVE
VENTILATION
-POTENTIAL LARYNX AND BRONCHIAL
TRAUMA
BRONCHIAL BLOCKERS
(BB)
ARNDT
COHEN
FUJI
-SIZE SELECTION RARELY AN ISSSUE
-EASILY ADDED TO REGULAR ETT
-ALLOWS VENTILATION DURING
PLACEMENT
--EASY TO PLACE IN PATIENTS WITH
DIFFICULT AIRWAY AND CHILDREN
-CPAP TO ISOLATE LUNG POSSIBLE
-SELECTIVE LOBAR LUNG ISOLATION
POSSIBLE
-POST OP. TWO LUNG VENTILATION BY
WITHDRAWING BLOCKER
-MORE TIME NEEDED FOR
POSITIONING
-REPOSITIONING NEEDED MORE
OFTEN
-BRONCHOSCOPE NEEDED FOR
POSITIONING
-NONOPTIMAL RIGHT LUNG
ISOLATION DUE TO RUL ANATOMY
-BRONCHOSCOPY TO ISOLATED LUNG
POSSIBLE
-MINIMAL SUCTION TO ISOLATED
LUNG

68. UNIVENT TUBE SAME AS BB
LESS REPOSITIONING CAMPARED
TO BB
SAME AS BB
ETT PORTION HAS HIGHER
AIRFLOW RESISTANCE THAN
REGULAR ETT
-ETT HAS LARGER DIAMETER
THAN REGULAR ETT
ENDOBRONCHIAL
TUBE
EASIER PLACEMENT IN PATIENTS
WITH DIFFICULT AIRWAY
-LONGER THAN REGULAR ETT
-SHORT CUFF DESIGNED FOR LUNG
ISOLATION
-BRONCHOSCOPE NEEDED FOR
POSITIONING
-DOES NOT ALLOW FOR
BRONCHOSCOPY,
SUCTIONING,OR CPAP TO
ISOLATED LUNG
-DIFFICULT RIGHT LUNG OLV
ETT ADVANCED INTO
BRONCHUS
EASIER PLACEMENT IN PATIENTS
WITH DIFFICULT AIRWAY
-DOES NOT ALLOW FOR
BRONCHOSCOPY,
SUCTIONING,OR CPAP TO
ISOLATED LUNG
-CUFF NOT DESIGNED FOR LUNG
ISOLATION
- DIFFICULT RIGHT LUNG OLV

69. • PHYSIOLOGICAL
CONSIDERATIONS OF
LATERAL DECUBITUS
POSITION

70. Lateral Decubitus Position (Awake,
Spontaneous, Closed Chest)
• Simply moving into the lateral position has
several, important effects – ventilation increase in
dependent lung, diaphragm of the dependent lung
push higher and stretch greater
• 60% of blood will flow through the dependent
lung
• 40% flowing through the non-dependent lung.
• Because total shunt (10% of cardiac output) is
roughly equally divided, 55% and 35% of cardiac
output participate in gas exchange, respectively
• So ventilation/ perfusion will be better
• Blood flow increase more rapidly than ventilation,
so V/Q will decrease from nondependent to
dependent lung

71. Lateral Decubitus Position (Awake,
Spontaneous, Open Chest)
- Opening the chest of a patient in the lateral
decubitus position (ex. thorascopy in an awake
patient given extensive local anesthesia) can
cause two additional changes.
First (both of which result from the intact
hemithorax’ ability to generate negative
pressures), the mediastinum may shift towards the
closed hemithorax, possibly resulting in
disastrous hemodynamic changes, (mediastinal
shift)
Second the closed hemithorax lung may remove air
from the open hemithorax lung, leading to
“paradoxical breathing”

72. Lateral Decubitus Position (Anesthetized,
Spontaneous, Closed Chest)
• The main effect of inducing anesthesia is
redistribution of ventilation towards the non-
dependent lung, with a relative increase in VT
entering the non-dependent lung, thereby leading
to a significant V:Q mismatch. Note, however,
that overall there is a reduction in both lung
volumes and FRC
• Dependent lung become less compliant and non-
dependent become more compliant
• Application of PEEP will helpful to increase
ventilation in dependent lung

73. Lateral Decubitus Position (Anesthetized,
Spontaneous, Open Chest)
• Opening the chest of an anesthetized,
spontaneously breathing patient also may
result in a mediastinal shift and/or
paradoxical breathing, but also further
increases the V:Q mismatch that occurs in
anesthetized patients (largely owing to
changes in ventilation, not perfusion)

74. Lateral Decubitus Position (Anesthetized,
Paralyzed, Open Chest)
• Paralysis implies in positive pressure
ventilation, which further worsens V:Q
mismatch as gas moves preferentially into
the non-dependent lung, mostly due to
decreased abdominal resistance but
potentially due to the open chest (if large
enough)

75. Summary of V-Q relationships in the
anesthetized, open-chest and paralyzed patients
in LDP

76. Lateral Decubitus Position (Anesthetized,
Paralyzed, Open Chest, One Lung)
• On first glance, it would appear that ventilating
the dependent lung only would result in loss of
35% of cardiac output that participates in gas
exchange (the non-dependent lung).
• Hypoxic pulmonary vasoconstriction can decrease
non-dependent blood flow by 50% (or 17.5%
globally), thus the amount of cardiac output
available for gas exchange should only fall from
90% to 72.5%. That said, because of abdominal
contents, paralysis, anesthesia, and the weight of
mediastinal structures, the dependent lung has
reduced FRC and is relatively non-compliant

77. LATERAL DECUBITUS
• ADVANTAGES
– Permits most complete access to hemithorax
– Length of incision can be easily extended
– Pt can be tilted forward/backward easily
– Safest position for hilar dissection
– Permits control of hilar vessels

78. LATERAL DECUBITUS
• Disadvantages
– Opposite hemithorax is inaccessible
– V/Q mismatch
– Contamination of dependent lung
– Decrease FRC, airway closure & atelectasis in
dependent lung
– Injury from positioning

79. Physiology of LDP
Awake Closed chest open chest
.
V Q V Q V Q
ND      
D      

80. INJURIES IN LDP
1. Dependent eye
2. Dependent ear pinna
3. Cervical spine in line with thoracic spine
4. Dependent arm AND Nondependent arm
a. Brachial plexus
b. Circulation
5. Dependent and nondependent suprascapular
nerves
6. Nondependent leg: sciatic nerve
7. Dependent leg:
a. Peroneal nerve
b. Circulation

81. Two-lung Ventilation and OLV

82. Physiology of OLV
• The principle physiologic change of OLV is the redistribution of
lung perfusion between the ventilated (dependent) and blocked
(nondependent) lung
• Many factors contribute to the lung perfusion, the major
determinants of them are hypoxic pulmonary vasoconstriction,
HPV and gravity.

83. Hypoxic pulmonary
vasoconstriction (HPV)
HPV, a local response of pulmonary artery smooth muscle,
(autoregulatory mechanism), decreases blood flow to the
area of lung where a low alveolar oxygen pressure is
sensed and protects the Pao2, by decreasing amount of
shunt flow that can occur through the hypoxic lung.
• The mechanism of HPV is not completely understood.
Vasoactive substances released by hypoxia or hypoxia itself
(K+ channel) cause pulmonary artery smooth muscle
contraction
• HPV aids in keeping a normal V/Q relationship by
diversion of blood flow by 50%, from underventilated areas
• HPV is graded and limited, of greatest benefit when 30% to
70% of the lung is made hypoxic.
• HPV has rapid onset in first 30 mins.

84. Factors Affecting Regional HPV
• HPV is inhibited directly
by 1) distribution of
hypoxia 2) low v/q
3)vasodilators (NTG, SNP,
dobutamine, many ß2-
agonist,CCB), 4)
anaesthetic drugs
5)increased PVR (MS, MI,
PE) and PvO2 hypocapnia
• HPV is indirectly inhibited
by 6) low PvO2 and PVR
7) low FiO2PEEP,
8) vasoconstrictor drugs
(Epi, dopa, NA)

85. Shunt and OLV
• Physiological (postpulmonary) shunt
• About 2-5% CO,
• Accounting for normal PA02-Pa02, 10-15 mmHg
• Including drainages from
– Thebesian veins of the heart
– The pulmonary bronchial veins
– Mediastinal and pleural veins
• Transpulmonary shunt increased due to continued
perfusion of the atelectatic lung and PA02-Pa02 may
increase

86. • Thoracotomy consequences
• Loss of intrapleural negative pressure
• Loss of synchronic walls motion
• Lung collapse
• Alveolar ventilation reduction
• Intraoperatve hypoxemia
• Bronchial mucus stasis and obstruction
• Atelectasis
• Alveoli rupture
• Postoperative pneumothorax

87. Factors that increase risk of
desaturation during OLV
1• High percentage of ventilation or perfusion to
the operative lung on preoperative scan
2• Poor PaO2 during two-lung ventilation,
particularly in the lateral position
intraoperatively
3• Right-sided thoracotomy
4• Normal preoperative spirometry (FEV1 or
FVC) or restrictive lung disease
5• Supine position during one-lung ventilation

88. Strategies to Maintain PaO2
• 1. No N2O
• 2. High FIO2 (.8-1.0)
– Keeps PaO2 higher
– Leads to vasodilation of dependent lung, allowing it to
accept increased blood volume
– It may take up to 20 mins. after you go on one lung
ventilation for the pt. to desaturate; check an ABG after
10 mins. on one lung ventilation

89. Strategies to Maintain PaO2
• 3. Use fiberoptic to re-check tube placement
• 4. Apply a recruitment maneuver to the
ventilated lung (this will transiently make the
hypoxemia worse).
• 5. ensure that the cardiac output is normal
decrease volatile anaesthetic to <1 MAC

90. Strategies to Maintain PaO2
• 5. CPAP to Nondependent lung
– A. Most effective way to Rx hypoxia during OLV (5-
10cm H2O)-
– Idea: CO2 can be ventilated adequately by the
dependent lung and a continuous supply of O2 to
unventilated up lung will replace what little oxygen is
removed from it
– CPAP also diverts blood flow away from the
unventilated up lung to the ventilated dependent lung
– CPAP supplies O2 to some of the alveoli that are
perfused in the nondependent lung
– Remember to inform surgeon first- this step may
expand the retracted lung

91. Strategies to Maintain PaO2
• 6. PEEP to dependent lung only!
– Idea: it improves oxygenation by increasing FRC and
decreasing atelectasis. (5 cm H2O)
– PEEP may have a negative effect by increasing PVR in
the dependent lung and causing more blood to flow to
the nondependent lung, thereby increasing shunt
– Only small increments of PEEP should be added at a
time
– IN a pt with normal pulmonary function, it is
mandatory to start recruitment maneuver and PEEP
from the start of OLV
– If hypoxia continues, CPAP and PEEP can be
incrementally increased in the nondependent &
dependent lungs

92. Strategies to Maintain PaO2
7. Intermittent reinflation of the nonventilated lung
8. Partial ventilation techniques of the nonventilated
lung:
a. Oxygen insufflation in the lumen of DLT with
cannula
b. High-frequency ventilation
c. selective Lobar collapse (using a bronchial
blocker)

93. Strategies to Maintain PaO2
9). Mechanical restriction of the blood flow to the
nonventilated lung
a) surgeon can directlyclamp the bllod flow to the
non ventilated lung
b) inflation of pulmonary artery catheter balloon
10). Last resort, return to two lung ventilation

94. Ventilation parameters for
OLV
PARAMETE
R
SUGGESTED GUIDELINES
TIDAL
VOLUME
5-6 ml/kg Maintain:
Peak airway pressure < 35 cm
H20
Plateau airway pressure < 25 cm
H2O
PEEP 5 cm H2O Pt with COPD: no added PEEP
RESPI. RATE 16 - 18 / min Maintain normal paco2
MODE Volume or
pressure
Pressure control for pt at high
risk of injury (bullae)

95. Tiered monitoring system for thoracic surgery based on the amount of preexiting lung
diseaes , general physical condition of the patient ,and the planned operation
Tiered
system
Patient
category
Gas
exchange
Airway
mechanics
Endotrach
eal tube
position
PA
pressures
Cardiovasc
ular status
Tier 1 :
Essential
monitors
used in all
patients
Routine
healthy
patients
without
special
intraop
conditions
spo2
PETCO2
Feel of the
breathing
bag,
stethescope
PIP
PETCO2
AEBE
(except
ipsilateral
tube
cLamp
because
ipsilateral
breath
sounds
dissapear )
FOB after
placed in
LDP
Not
measure
NIBP,
pulse
oximeter
waveform,
ECG,
PETCO2,
esophagael
stethescope
, +_ CVP,
+_
invasive
arterial
pressure
monitoring

96. Tier 2 :
Special
intermitten
t or
continuous
monitoring
needs
Healthy
patients
wilH
special
procedures
or sick
patients
with
routine
procedures
As above
plus
frequent
ABG
studies
As above
PLUS
spitrometr
y
Individual-
and whole-
lung
compliance
FOB to
verify tube
position
while in
supine
position, as
well as in
the LDP
Measure
PAP if
lobectomy
or lung
resection
As above,
plus
arterial
pressure
monitoring
, + CVP,
+ PA
catheter (if
poor EF,
PA HTN),
+_ TEE
Tier 3 :
Advanced
monitoring
Sick
patients
with
special
intraoperat
ive
conditions
as above As above
plus
airway
resistance
As above
plus
frequent
rechecks to
verify
position
As above
plus PA =
TEE

97. Nitrous oxide
• The use of N2O/O2 mixtures is associated with a
higher incidence of post-thoracotomy
radiographic atelectasis (51%) in the dependent
lung than when air/oxygen mixtures are used
(24%).
• increase pulmonary artery pressures in patients
who have pulmonary hypertension
• N2O inhibits HPV
• N2O is contraindicated in patients with blebs or
bullae.
• For these reasons N2O is usually avoided during
thoracic anesthesia.

98. Principles of Fluid Management
1. Total positive fluid balance in the first 24-hour
perioperative period should not exceed 20 mL/kg.
2. For an average adult patient, crystalloid administration
should be limited to < 3 L in the first 24 hours.
3. There should be no fluid administration for third space
fluid losses during pulmonary resection.
4. Urine output > 0.5 mL/kg/hr is unnecessary.
5. If increased tissue perfusion is needed postoperatively,
it is preferable to use invasive monitoring and inotropes
rather than to cause fluid overload.

99. Post operative
management

100. • Prevention of post op. complication
• Post op ventilation
• Post op analgesia

101. Early major complications
• Respiratory failure
• Mc cause of morbidity after thoracic surgery
• Incidence is 2% to 18%
• Defination
1) PaO2 < 60 mmhg
2) PaCO2 > 45 mmhg
3) use of post op ventilation for > 24 hrs
4) reintubation for controlled ventilation after extubation

102. • Risk factors
1) pre op decrease in respi. Function
2) elderly pt
3) coronary artery disease
4) extent of lung resection
5) failure of intraop OLV – contamination of normal
lung

103. • Prevention
• Post op thoracic epidural analgesia
• Chest physiotherapy
• early ambulation
• Early extubation
• Clearance of infection

104. CARDIC HERNIATION
• Low incidence but > 50% mortality
• Present with SVC compression syndrome
(RT) or myocardial ischemia(LT)
• CAUSES
• Increase intrapleural preesure in ventilated
hemithorax or decrease intrapleural preesure in
surgical hemithorax (like during coughing)
• Position of the pt: empty hemithorax in dependent
position
• Use of high levels of pressure and volume during
ventilation
• Applying suction in empty hemithorax

105. CARDIC HERNIATION
• MANAGEMENT
• Pt is taken in ot for re thoracotomy
• Relocation of the heart and repair of pericardial
patch repair done
• Intraop Mx is same as thoracotomy but post pt
remain intubated and shift to ICU

106. PULMONARY TORSION
• Rotation of parenchyma on its bronchovascular
pedicle due to increase mobility of lobe (usualy
after lobectomy)
• Intraop consideration:
• Use steroid to decrese pulmonary inflamation
• PEEP to expand atelectatic lung tissue

107. PULMONARY EDEMA
CAUSES
(1)Endothelial injury – increase capillary permeability
(2)Capillary pressure
(3)Lymphatic damage
(4)Lung hyperinflation
(5)Fluid overload
(6)Rt ventricle dysfunction
(7)Oxygen toxicity
TREATMENT
(1)Mechanical ventilation with PEEP
(2)Restriction of fluids
(3)Diuretics

108. Mechanical ventilation and weaning plan
Goal
no(temporal
sequence to
be followed)
Goal Achieved
primarily
by
Decreased
Fio2
Fio2<0.5 Pao2>60mm
Hg
PEEP
titration
Decreased
PEEP
Fio2<0.5 Decrease
PEEP
to<10cm
H2o
Pao2>60mm
Hg
Decreased
IMV rate
Fio2<0.5 Decrease
PEEP
to<10cm
H2o
Deceased
IMV to<1
breath/min
Pao2>60mm
Hg

110. Aggressive and intensive respiratory
care regimen
Removing secretions
• Coughing routines
• Tracheal suctioning
• Fiberoptic bronchoscopy
• Chest percussion and vibration
• All the above aided by posture
• Turning frequently

111. • Diagnosing and treating infections
– Protected brush specimen
– Bronchoalveolar lavage
– Antibiotics according to culture and sensitivity
– Results
• Dilating the airways
– Bronchodilators(b2 agonists, anticholinergics,
aminophylline)steroids

112. Other general/systemic maneuvers
• Humidification
• Spirometry
• Diuretics and fluid restriction
• Ionotropes
• Aminophylline to increase diaphragmatic
contractility
• Inhalation of 60% helium

113. •POST OPERATIVE
ANALGESIA

114. Post op pain relief
Incidence of respi complication decrease by 10% but
no change in cardiac complication
 Post op pain relief strategies
Systemic opioids
Intercostal nerve blocks
Intra pleural local anaesthetics
THORACIC EPIDURAL ANALGESIA
Paravertebral catheter
TENS
Cryo analgesia

116. • Multiple sources of afferent transmission of pain
sensations after thoracotomy.
1, Intercostal nerves at the site of the incision (usually
T4-6);
• 2, intercostal nerves at the site of chest drains (usually
T7-8);
• 3, phrenic nerve afferents from the dome of the
diaphragm; (C3-C5)
4, vagal nerve innervation of the mediastinal
pleura;
• 5, brachial plexus

117. Systemic analgesia
• OPIOIDS
• Alone are effective in controlling background pain
but for acute pain higher plasma concentrations are
required which causes sedation and hypoventilation.
• NSAIDS
• Effective in controlling shoulder pain and reduces the
opioid dosage by 30%
• DEXMEDETOMIDINE
• Adjuvant to systemic opioids and epidural LA’s.
• 0.3 to 0.4 microgram/kg/hr

118. • INTERCOSTAL NERVE BLOCKS
• It is an adjuvant method,
• Duration of analgesia is limited
• CRYo-ANALGESIA
• Application of -60 C probe to the exposed intercostal
nerves intraop produces a block which persist for 6
month but incidence of chronic neuralgia is more
• TENS may be useful in mild to moderate pain but not
useful in severe pain.
• Patient control analgesia: IV OR EPIDURAL

119. THORACIC EPIDURAL
ANALGESIA
• It is a gold standard
• Majority of thoracotomies receive epidural between
T3 to T8 segments.
• Combinations of opioids and LA’S are beneficial.
• ADVANTAGE
• It increase FRC,FVC
• Quality of analgesia is better
• Allow the pt for early ambulation and tolerate
respiratory care maneuvers and chest physiotherapy.
• Decrease dosage and side effects of parentral drugs

120. Reduction of pulmonary comlication
by thoracic epidural
Licker M, et al. Ann Thorac Surg 2006; 81: 1830-8
• %
Resp
Complic’s
n
NORMAL LUNG COPD LUNG

121. PARAVERTEBRAL BLOCK
• Catheter is placed in the paravertebral space by under
direct vision by the surgeon or percutaneously by the
anaesthetics
• Plain LA’s soluton infused percutaneously, blocks the
multilevel intercostal nerves
• ADVANTAGE
• Block is unilateral
• Analgesia is comparable to epidural
• Few failed block
• Less hypotension
• Less chances of neuraxial haematoma