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Bronchoscopy, Mediastinoscopy, and Thoracotomy Paul M. Heerdt Anastasios Triantafillou Fun-Sun F.

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A 60-year-old man suffered from cough, intermittent hemoptysis, and weight loss for 2 months. He smoked one pack of cigarettes per day for 40 years. A chest radiograph 1 month ago ie ealed a right middle lo!e infiltrate, which was treated with anti!iotics !ut did not respond. "u!se#uent e aluation re ealed a carcinoma. He is now scheduled for fi!eroptic !ronchoscopy, mediastinoscopy, and possi!le thoracotomy for lo!ectomy or pneumonectomy. A. $edical %isease and %ifferential %iagnosis 1. How are lung carcinomas diagnosed and what is your prediction for the most likely type of malignancy& 2. 'hat are the less common manifestations of !ronchogenic carcinoma& (. )he patient has a long history of cigarette smoking. 'hat does this mean to you& *. +reoperati e , aluation and +reparation 1. How would you e aluate the patient preoperati ely& 2. 'hat are the pulmonary function guidelines that indicate increased risk of mor!idity and mortality in ma-or general sur.ery& /. lntraoperati e $anagement 1. How would you premedicate, monitor, and anestheti.e the patient for fi!eroptic !ronchoscopy and mediastinoscopy& 2. How many types of !ronchoscopes are there and what are the intraoperati e considerations of each& (. 'hat is the indication for mediastinoscopy& Are there potential complications& 4. )he decision was made to proceed with thoracotomy and right middle lo!ectomy. How would you alter management& 0. 'hat are the indications for single-lung entilation and how can it !e accomplished& 6. 'hat are the contraindications to the use of dou!le-lumen endotracheal tu!es& 1. 'ould you use a right- or a left-sided dou!le-lumen tu!e& 2. How would you know if the tu!e is in the correct position& 3. How many types of !ronchial !lockers are a aila!le& 'hat are the ad antages and disad antages of !ronchial !lockers& 10. How will systemic o4ygenation !e monitored during single-lung entilation& 'hat is the mechanism of o4imetry& 11. )he patient was put in the lateral decu!itus position for thoracotomy. %escri!e the effects of the lateral position on pulmonary !lood flow and respiration. 12. 'hat is hypo4ic pulmonary asoconstriction& 1(. 'hat are the effects of anesthetics on hypo4ic pulmonary 5 asoconstriction and their clinical implication& 14. %iscuss pulmonary !lood flow distri!ution, shunt flow, and +ao2 67lo2 8 1.09 during single-lung entilation. 10. How could you impro e o4ygenation during single-lung entilation& 16. :ight middle lo!ectomy was performed. 'ould you e4tu!ate the trachea at the end of the procedure&

%. +ostoperati e $anagement 1. 'hat are the immediate life-threatening complications that follow lo!ectomy or pneumonectomy& 2. 'hy is it important to control postoperati e pain& How would you achie e this mutant& A. $edical %isease and %ifferential %iagnosis A.1. How are lung carcinomas diagnosed and what is your prediction for the most likely type of malignancy& )he symptoms of nonproducti e cough and hemoptysis along with the unresol ed lung infiltrate suggest carcinoma. Howe er, la!oratory test result are needed to confirm the diagnosis and e4tent of disease. )hey include sputum cytology, !ronchoscopy and ,!rush !iopsy, !iopsy of palpa!le nodes ;n the neck or a4illa, mediastinoscopy, needle 5aspiration !iopsy, and possi!ly e4ploratory thoracotomy. *efore thoracotomy, an e4tensi e search is made for metastases that would contraindicate surgery. /ancers of the lung comprise 16< of all malignancies and account fcr 22< of cancer deaths worldwide. *ronchogenic carcinomas comprise the ast ma-ority of lung cancers presenting for resection and can !=dassified into four ma-or types> small cell, large cell, s#uamous cell, and adenocarcinoma. 7or the purpose of deciding whether a certain tumor is resecta!le, small cell tumors are kept distinct and the others lumped into a ?non-small cell? category. ;n general, non-small cell tumors are most effecti ely treated with surgery, and small cell tumors are not. )his patient has a non-small cell carcinoma 6s#uamous9 and is thus a candidate for resection. 7urther su!classification of tumors to aid in predicting response to therapy is performed with the )@$ system> tumor site, si.e, and local e4tent 6)9A presence and location of regional lymph node in ol ement 6@9A and presence of distal metastases !eyond the ipsilateral hemithora4 6$9. )he )@$ classification is used in the staging of !ronchogenic carcinomas. ;n general, small cell carcinoma has spread !eyond the !ounds of possi!le resection !y the time of presentation and is primarily managed with chemotherapy with or without radiation. )he 0-year sur i al after curati e resection is less than 1<. ;n contrast, non-small cell cancers found to !e locali.ed at the time of presentation should !e considered for resection. )he 0-year sur i al after primary resection of non-small cell carcinoma is dependent on tumor staging !ut can !e as high as 20< for small tumors without regional lymph node in ol ement or metastases 6stage ;9. Bnfortunately, most patients 6a!out 40<9 present with circumscri!ed e4trapulmonary e4tension andCor lymphatic spread to ipsilateral mediastinal or su!carinal lymph nodes 6stage ;lia9 and e4hi!it a 0-year postresection sur i al of less than 20<. A.2. 'hat are the less common manifestations of !ronchogenic carcinoma& ;n general, other manifestations of lung tumors are primarily related to mass effects oraltered meta!olism. ;n addition to the !ronchial o!struction e ident in this patient, mass effects include in asion into the chest wall, compression of great essels 6e.g., superior ena ca al syndrome9, tracheo!ronchial displacement, paresis of the recurrent laryngeal or phrenic ner es, and +ancoast syndrome 6pain and upper e4tremityweakness secondary to in asion of the !rachial ple4us, as well as first and second thoracic and eighth cer ical ner e roots9. :ecogni.ed meta!olic manifestations of lung tumors in general include symptoms that resem!le those of myasthenia gra isA peripheral neuritis in ol ing !oth motor and sensory componentsA /ushing syndromeA carcinoid syndromeA hypercalcemia and hypophosphatemia 6from ectopic parathyroid hormone ');-1- or +)H-related peptide !y epidermoid cancer9A

hypokalemia 6ectopic secretion of adrenocorticotropic hormone !y small cell cancer9A and hyponatremia 6inappropriate secretion of antidiuretic hormone or possi!ly atrial natriuretic factor !y small cell cancer9. A.(. )he patient has a long history of cigarette smoking. 'hat does this mean to you& /igarette smoking promotes the de elopment of chronic o!structi e pulmonary disease, which includes d4ronic6!.onchitis, peripheral airway disease, and emphysema. , idence of these chronic changes can !e found in preoperati e pulmonary function test results. +atients who continue to smoke until surgery are at greater risk of postoperati e pulmonary complications than those who do not. Howe er, although car!o4yhemoglo!in concentrations decline su!stantially within 12 hours of smoking cessation, how long smoking must !e discontinued to see a !enefit in terms of significantly reducing postthoracotomy respiratory complications is unclear. ;n cardiac surgery patients, smoking must !e discontinued for 2 months !efore an impact on postoperati e pulmonary function can !e demonstrated. *. +reoperati e , aluation and +reparation *.1. How would you e aluate the patient preoperati ely& All preoperati e e aluations should indude a complete history, physical e4amination, and la!oratory tests. A history of smoking, cough, sputum production, and orthopnea or c!ispnedare hallmarks of cardiopulmonary disease, and impaired e4ercise tolerance can !e helpful in anticipating the patient5s response to the stress of anesthesia and surgery. *ecause most patients are not admitted to the hospital !efore surgery and thus will pro!a!ly ha e !een initially e aluated in an outpatient setting !y a clinician other than that pro iding intraoperati e care, a !rief re iew of symptoms, physical limitations, inter al changes, and airway anatomy should !e performed. ;n addition to routine electrocardiogram and !lood analysis, patients should undergo preoperati e pulmonary function testing to help define relati e risks for the magnitude of resection planned. A con enient way to categori.e respiratory assessment is !y characteri.ing the following> o :espiratory mechanics> forced ital capacity 67D/9, forced e4piratory olume in 1 second 67,D19, ma4imum oluntary entilation 6$DD9 or ma4imum !reathing capacity 6$*/9, and the residual olumeCtotal lung capacity ratio 6:DC)E/9 o /ardiopulmonary reser e> ma4imal o4ygen uptake 6Do2 ma49, stair clim!ing, 6-minute walk o Eung parenchymal function> diffusing capacity of lung for car!on mono4ide 6%Eco9 and arterial +ao2, +aco2 *.2. 'hat are the pulmonary function guidelines that indicate increased risk of mor!idity and mortality in ma-or general surgery& )he reported mortality from lung resection is !etween 2< and 4< with the ma-or causes primarily pulmonary in origin 6e.g., pneumonia, general respiratory failure, !ronchopleural fistula, empyema, and pulronary em!olism9. 7rank respiratory insufficiency occurs in a!out 0< of patients after lung resection and is associated with a 00< mortality, which reflects in part a median age of 66 years and a relati ely high incidence of concomitant nonpulmonary disease. +ulmonary function guidelines for defining increased risk in any patient undergoing surgery are particularly applica!le to those undergoing thoracotomy. "pirometry F 7D/ less than 00< of predicted F 7,D; less than 00< of 7D/, or 2 E F $DD 6$*/9 less than 00< of predicted, or 00 E per minute

F %E/G less than 00< of predicted F :esidual olumeCtotal lung olume greater than 00< Arterial *lood Hases F Arterial +co2 greater than 40 mm Hg F Arterial +oe less than 00 mm Hg +ulmonary Dasculature +ulmonary artery pressure during unilateral occlusion greater than (0 mmHg ;n addition, consideration should !e gi en in assessing the risks associated with he e4tent and location of the proposed resection 6)a!le 2.19. Howe er, e ol ing clinical )a!le 2>1. $inimal +ulmonary 7unction )esi /riteria for Darious-"i.ed +ulmonary :esections
BIOPSY OR PNEUMONECTOM NORMAL LOBECTOMY SE MENTA Y L 40 >100 I10 40-10 100 I00 I40 I(0 I2 I2 I1 I0.6 >100 I00 40-00 I40 2 I1.6 I0.6-1.6 I0.6

TEST $*/ $*/ 7,D; 7,D; 7,D2s-10<

UNIT EitersCminute +ercentage predicted titers +ercentage predicted liters

e4perience wit7,Dis-is4 aspects of preoperati e e aluation and perioperati e care has come to complicate simple application of finite patient-selection criteria for thoracic surgery. ;n particular, the fa ora!le perioperati e outcome of patients with se erely impaired pulmonary function 6i.e., 7,D; J 1 E per minute9 undergoing lung olume reduction surgery has !rought into #uestion the !lanket application of con entional criteria and underscored the importance of deciding at what point increased risk !ecomes prohi!iti e. 7urthermore, the de elopment of minimally in asi e techni#ues for pulmonary resectionKincluding pneumonectomyKhas raised the #uestion of whether standard selection criteria should !e adapted. /omplicating matters further is that although preoperati e pulmonary function test results,are alid indices of physiologic performance, the actual predicti e use of a range of alues for a single parameter is poorly defined. Accordingly, emphasis has now !een directed toward integrating multiple aspects of preoperati e e aluation 6e.g., respirometry, entilationCperfusion scanning, and e4tent of planned resection9 into an approach for estimating postoperati e function. 'ith this techni#ue, the utility of 7,D; as a predictor of pulmonary complications is su!stantially impro ed. +atients shown to ha e a predicted postoperapp 7,D; less than 40< of the predicted are now considered at increased risk ofie de elopment of postoppostoperati 7,D1cations. , en so, continuing refinements of intraoperati e and postoperati e management, the use of goal-specific analgesia techni#ues and more sophisticated throm!osis pre ention regimens has pro!a!ly attenuated the incidence of complications in the high-risk group. /. ;ntraoperati e $anagement /1. flow would you premedicate, monitor, and-anestheti.e the patient for fi!eroptic !ronchoscopy and mediastinoscopy& /urrent practice at most institutions dictates that patients are not usually in the hospital !efore surgery, so traditional oral or parenteral premedication !efore transport to the operating room is largely o!solete. 7urthermore, !ronchoscopy and mediastinoscopy are now essentially

outpatient procedures necessitating relati ely rapid hospital discharge. *ecause !ronchoscopy is to !e followed !y mediastinoscopy and only possi!ly thoracotomy in this patient, intra enous mida.olam immediately upon entry into the operating room is sufficient for an4iolysis and su!se#uent amnesia. ;n addition, a small intra enous dose of glycopyrrolate, 0.2 mg, is often useful as an antisialagogue, particularly in patients who smoke. *ecause a ma-or intraoperati e consideration for mediastinoscopy is intermittent compression or occlusion of the innominate artery !y the mediastinoscope, the pulse o4imeter is placed on the right hand and a !lood pressure cuff on the left arm. "hould innominate compression occur, a dampening of the pulse o4imetry trace will !e e ident while !lood pressure measurement remains accurate. 7inally, along with electrocardiogram, temperature should !e monitored and a warming !lanket applied 6despite the potential for a short procedure, elderly patients in particular can !ecome hypothermic9. 7or induction and maintenance of anesthesia and muscle rela4ation, agents with a relati ely short duration of action are desira!le. Anesthesia would !e induced with propofol, tracheal intu!ation with a single-lumen endotracheal tu!e facilitated with ecuronium or cisatracurium, and anesthesia maintained with ( to 4 mgCkg of fentanyl and a potent inhalation agent in o4ygen. %uring fi!eroptic !ronchoscopy, the de ice can !e introduced !y means of a swi el adapter into the endotracheal tu!e and entilation controlled. 7or the mediastinoscopy, anesthesia will !e maintained with a potent inhalation agent in com!ination with nitrous o4ide, and additional doses of a nondepolari.ing muscle rela4ant of intermediate duration are adminered if needed, although this is the e4ception. C.2. How many types of ron!"os!opes are t"ere and w"at are t"e intraoperati#e !onsiderations of ea!"$ )here are three types of !ronchoscopes in current use> fle4i!le fi!eroptic, rigid entilating, and rigid Denturi 6"anders in-ector9. )he fi!eroptic !ronchoscope can !e used in the sedated patient under local anesthesia, which allows also for e4amination of ocal cord mo ement, or after endotracheal intu!ation in patients under general anesthesia. 7or e4amination in the awake sedated patient, upper airway local anesthesia can !e accomplished !y gargling iscous lidocaine. Eower airway anesthesia can !e produced with lidocaine administered ia an atomi.er with a long no..le or a ne!uli.er mask, and !ilateral superior laryngeal ner e !locks andCor transtracheal !lock. ;ntra enous sedation is supplemented with 0.0-mg increments of mida.olam, until the patient is calm and cooperati e !ut not o!tunded and o!structed. ;n contrast to fi!eroptic !ronchoscopy, rigid !ronchoscopy usually necessitates general anesthesia. )he rigid entilating !ronchoscope has a sidearm adapter that can !e attached to the anesthesia machine. A aria!le air leak usually e4ists around the !ronchoscope, so highflow rates of inspired gases and packing of the oropharyn4 are needed. ;n addition, loss of olatile anesthetic to the operating room en ironment must !e considered. )he rigid Denturi-effect !ronchoscope relies on an intermittent 610 to 12 times per minute9 high-pressure o4ygen -et to entrain air and insufflate the lungs with an air-o4ygen mi4ture. )he -et is deli ered through a reducing al e into a 16- or 12-gauge needle inside and parallel to the lumen of the !ronchoscope. )he ma-or disad antages of this !ronchoscope include lack of control of the inspired o4ygen concentration and ina!ility to administer inhaled anesthetics. Accordingly, anesthesia must !e maintained !y intra enous techni#ues with propofol infusion a common method. *ecause !ronchoscopic procedures can !e relati ely short, continuous succinylcholine infusion remains an option for these procedures. Howe er, when followed !y another procedure such as the thoracoscopy scheduled for this patient, an intermediate-duration nondepolari.ing muscle rela4ant is often desira!le.

/.(. 'hat is the indication for mediastinoscopy. Are there potential complications& $ediastinoscopy is performed to esta!lish diagnosis of specific lesions within the mediastinum or as a screening procedure to determine whether the malignancy has spread to mediastinal lymph nodes. ;f such spread is demonstrated !y fro.en section, a patient is pro!a!ly not a surgiLtandidate and the planned lung resection is a!orted. /on entional cer ical mediastinoscopy in ol es a small incision at the sternal notch for introduction of the scope and sampling of nodes within the mediastinum proper. Accordingly, the pleural space is not usually entered and a chest tu!e is not indicated. Howe er, occult preumothora4 is a possi!le complication. Gther procedures ha e !een descri!ed for e4amination of the intrapleural space with a mediastinoscope inserted either through an e4tension of a cer ical incision or ia a small anterior thoracotomy. 7or these procedures, the chest may !e e acuated through a catheter after closure or a chest tu!e may !e inserted. /omplications during mediastinoscopy are relati ely rare 61< to 2<9 and generally are the result of ner e in-ury 6recurrent-laryngeal or phrenic9 or !iopsy of ad-acent structures 6e.g., pleura, esophagus, superior ena ca a, a.ygous ein, pulmonary artery, and aorta9. "hould a ma-or ascular structure !e perforated, !lood loss can !e rapid and profound, possi!ly necessitating emergent stemotomy. *ecause packing or ascular clamps may ha e to !e applied to the superior ena ca a, clinicians should always !e aware of how enous access can !e esta!lished in a lower e4tremity. /.4. )he decision was made to proceed'ith thoracotomy and right middle lo!ectomy. How would you alter management& Although no longer regarded as mandatory for lung resection, an arterial catheter will !e placed in the left 6dependent9 radial artery, and the single-lumen endotracheal tu!e will !e replaced with a left-sided dou!le-lumen endotracheal tu!e. Although right middle lo!ectomy does not a!solutely .-e#uir5 e non entilation of the lung, it has !ecome commonplace !ecause surgical e4posure is impro ed and the need for packing and compression of the operati e lung is eliminated. @onetheless, single-lung entilation is associated with certain disad antages and complications. $ost nota!le is the large and aria!le al eolar-arterial difference in o4ygen tension 6+AG2 - +ao29 that occurs as a result of continued perfusion to the nondependent non entilated lung. )he incidence of se ere hypo4emia and hypercar!ia, howe er, is relati ely small and primarily the resultof incorrect positioning of dou!le-lumen tu!es 6%E)s9. Gther complications include traumatic laryngitis and tracheo!ronchial rupture. /.0. 'hat are the indications for single-lung entilation and how can it !e accomplished& A!solute ;ndications o ;solation from spillage or contamination F ;nfectionK!ronchlectasis and lung a!scess o $assi e hemorrhage o )o control the distri!ution of entilation o *ronchopleural fistula o *ronchopleural cutaneous fistula o Hiant unilateral lung cyst or !ulls o )racheo!ronchial tree disruption

o Eife-threatening hypo4emia resulting from unilateral lug disease o "urgical entry of ma-or conducting airway o Bnilateral !ronchopulmonary la age o +ulmonary al eolar proteinosis :elati e ;ndications F 7acilitation of surgical e4posureKhigh priority F )horacic aortic aneurysm F +neumonectomy F Bpper lo!ectomy F $ediastinal e4posure F )horacoscopy F +ulmonary resection ia median stemotomy F 7acilitation of surgical e4posure--low priority F ,sophageal resection F $iddle and lower lo!ectomies and segmental resection F +rocedures on the thoracic spine F +ost-cardiopulmonary !ypass status after remo al of totally occluded chronic unilateral pulmonary em!oli F "e ere hypo4emia resulting from unilateral lung disease )hree techni#ues are a aila!le for pro iding single-lung anesthesia> single-lumen tu!es passed endo!ronchially, single-lumen endotracheal tu!es in com!ination with !ronchial !locking catheters, and dou!le-lumen endotracheal tu!es. Although arious %E)s ha e !een designed and used clinically 6e.g., :o!ertshaw, /arlens, and 'hite9, the most common models in use are disposa!le and made of poly inyl chloride 6+D/9. "uch a tu!e was chosen for this procedure. %ou!le-lumen endotracheal tu!es are a aila!le in fi e si.es> 22-, (0-, (1-, (3-, and 41-7rench catheter gauge 6si.e in 7rench e#uals (.14 times e4ternal diameter in millimeters, or 4 times internal diameter plus 29. "i.e is generally determined from patient si.e with a erage-si.e men accommodating a no. (3A and a eragesi.e women, a no. (1. /.6. 'hat are the contraindications to the use of dou!le-lumen endotracheal tu!es& %ou!le-lumen endotracheal tu!e placement should !e carefully considered in the following situations> o +atients with a lesion 6e.g., airway stricture and eridohuninal tumor9 that is present somewhere along the pathway of the tu!e and thus could !e traumati.ed. o "mall patients for whom a (0-7rench tu!e is too large to fit comforta!ly through the laryn4 and a 22-7rench tu!e is considered too small. o +atients whose upper airway anatomy may preclude safe insertion of the tu!e 6e.g., recessed -aw, prominent teeta&till neck, anterior laryn49. o ,4tremely critically ill patients who ha e a single-lumen tu!e already in place and who cannot tolerate !eing taken off mechanical entilation and positi e end-e4piratory pressure 6+,,+9 for ashort period. Howe er, under these circumstances, single-lung entilation can !e achie ed !y using an endo!ronchial !locker or endo!ronchial tu!e in a mainstem !ronchus. /.1. 'ould you use a right- or a left-sided dou!le-lumen tu!e& A left-sided %E) is prefera!le for most procedures !ecause the length of the left mainstem !ronchus 6appro4imately 00 to 00 mm9 is much longer than that of the right mainstem

!ronchus 6appro4imately 10 to 20 mm9. Accordingly, a right-sided %E) may not !lock the right upper lo!e when the tu!e is in too far, or the endo!ronchial cuff may !lock the left lung when the tu!e is out too far. A right-sided %E) is indicated when a left-sided %E) is contraindicated, such as when a large e4ophytic lesion is on the left mainstem !ronchus, a tight left mainstem !ronchus stenosis is present, or the left $ainctprn !ronchus is distorted !y an ad-acent tumor. C.%. How would you &now if t"e tu e is in t"e !orre!t position$ +osition of the %E) may !e checked !y listening to the !reath sounds of each lung while clamping each lumen of the %E). $any clinicians routinely use fi!eroptic !ronchoscopy to confirm position and depth of %E)s. %uring !ronchoscopy, the tracheal cartilaginous rings are anterior and the tracheal mem!rane is posterior. )herefore, right ersus left can !e discerned !y the relationship of the mainstem !ronchi to the anterior cartilaginous ring and the posterior mem!rane 67ig. 2.1A9. ;n addition. Anterior

Eeft

:ight

+osterior 7igure 2.1. :epresentati e !ronchoscopic images of !ronchial !locker and dou!le-lumen endotracheal tu!e placement. A> @ormal tracheal anatomy with cartilaginous rings anteriorly and mem!ranous trachea posteriorlyA this helps define left ersus right. A 7ogarty catheter !ronchial !locker is seen in the right F mainstem !ronchus. *> +lacement of a left-sided dou!le-lumen tu!eA upper portion of endo!ronchial cuff is e ident, as is orifice of the right upper lo!e -ust !elow tracheal carina. /> +lacement of a right-sided dou!le-lumen tu!e> upper portion of endo!ronchial cuff is e ident. %> Grifice of the rght upper lo!e isuali.ed through a port on the lateral aspect of a right-sided dou!le-lumen tu!e. the right Bpper lo!e arises from the right mainstem !rGnchus -ust !elow the tracheal carina, a useful landmark when the airway anatomy has !een o!scured !y !leeding, edema, or radiation-induced changes. 7or checking position of a left-sided %E), with the !ronchoscope inserted ia the tracheal lumen, the opening should !e 1 to 2 cm a!o e the tracheal carina. 'hen properly positioned, the upper surface of the !lue endo!ronchial cuff is isuali.ed -ust !elow the tracheal canna in the left mainstem !ronchus 67ig. 2.1*9. Alternati ely, correct positioning of a right-sided %E) is confirmed !oth !y isuali.ation of the !ronchial cuff in the right mainstem !ronchus 67ig. 2.1/9 and !y isuali.ation of the right upper lo!e orifice through a port on the lateral surface of the %E) 67ig. 2.1%9.

/.3. How many types of !ronchial !lockers are a aila!le& 'hat are the ad antages and disad antages of !ronchial !lockers& )he !ronchial !locker most often used for adults is a 7ogarty occlusion catheter with either a 12- or a 20-mE !alloon that is placed outside a single-lumen endotracheal tu!e and positioned with fi!eroptic !ronchoscopy 67ig. 2.1A9. Gther de ices that are made for endo!ronchial placement of a !locking cuff ia a catheter within the endotracheal tu!e include the Bni ent tu!e and the Arndt !ronchial !locking catheter. ;n addition, the use of gau.e tampons, a $agill !alloon-tipped luminal !locker, and 7oley catheters ha e !een reported. Ad antages *ronchial !lockers are relati ely simple to use and can !e used in children and adults who are too small for %E)s. Gther ad antages include the following> F 7acilitation of single-lung entilation in patients with a difficult airway or in whom a %E) is contraindicated F +lacement ia an e4isting single-lumen endotracheal tu!e in emergent situations F :emo ing the need to change endotracheal tu!es for postoperati e mechanical entilation %isad antages ;n comparison to %E)s, !ronchial !lockers present the following disad antages> F ;na!ility to suction or intermittently entilate the lung distal to the !locker without deflating the !alloon F )he need for !ronchoscopic positioning F %ifficulty with maintaining position in the right mainstem F G!struction of the trachea and entilation of !oth lungs should the !ronchial !locker retract into the trachea /.10. How will systemic o4ygenation !e monitored during single-lung entilation& 'hat is the mechanism of o4imetry& +ulse o4imetry has !ecome the hallmark for monitoring arterial o4ygenation during lung resection, largely supplanting the traditional practice of regularly measuring arterial !lood gases. )his techni#ue uses spectrophotoelectric o4imetric principles to determine o4ygen saturation. ;t is similar to classic o4imetry in that discrete wa elengths of light are used to measure optical density of hemoglo!in. +ulse o4imeters are essentially multiple wa elength plethysmographs. )he pulse amplitude detected is a function of the arterial distention, hemoglo!in o4ygen saturation of the inflow of arterial !lood, and wa elength of light. )o determine the arterial hemoglo!in o4ygen saturation, the o4imeter measures the ratio of the pulse amplitude of red light 6660 nm9 to the pulse amplitude of infrared light 6340 nm9. *ecause the detected pulsatile wa eform is produced solely from arterial !lood, *eer law and the amplitude at each wa elength allow e4act !eat-to-!eat continuous calculation of arterial hemoglo!in o4ygen saturation with no interference from surrounding enous !lood, skin, connecti e tissue, or !one. *ecause pulse o4imetry uses light a!sorption changes produced !y arterial pulsations, any e ent that significantly reduces ascular pulsations will reduce the instrument5s a!ility to calculate saturation. Ade#uate finger ppisation generally is lost with hypothermia of a few degrees, hypotension 6mean !lood pressure less than 00 mm Hg9, and infusion of asoconstricti e drugs. $eanwhile, the presence of dyshemoglo!inemias 6e.g., car!o4yhemoglo!in, methemoglo!in, sulfhemoglo!in9 also may affect the o4imeter accuracy.

Gther methods to monitor arterial o4ymation continuously include transcutaneous o4ygen tension 6+tco29 and altdrial o4ygen tension using an indwelling o4ygen electrode. +tco2 re#uires special site preparation, airtight pro!e mantling, and a potentially harmful local heat source to induce arteriali.ation. $oreo er, +tco2 fails to perfectly reflect true arterial o4ygenation. An indwelling arterial o4ygen electrode is inserted into the arterial line and may increase the incidence of throm!oem!olism. /.11 )he patient teas put in the lateral decu!itus position for thoracotomy. %escri!e the effects of the lateral position on pulmonary !lood flow and respiration. ;n !oth the upright and the supine position, the right lung recei es appro4imately 00< of the total !lood flow and the left lung recei es the remaining appro4imately 40<. Hra ity causes a ertical gradient in the distri!ution of !lood flow in the lateral decu!itus position. )herefore, !lood flow to the dependent lung is significantly greater than !lood flow to the nondependent lung. 'hen the right lung is nondependent, it recei es only 40< of the total !lood flowA the dependent left lung recei es the remaining 00<. 'hen the left lung is nondependent, it recei es only (0< of the total !lood flow, whereas the dependent right lung recei es the remaining 60<. )herefore, the a erage !lood flow of the nondependent lung is appro4imately 40< of the total !lood flow, and that of the dependent lung is appro4imately 60<. :espiratory ,ffects )he lateral decu!itus position causes mechanical interference with chest mo ement and therefore limitation of lung e4pansion. $ismatching of entilation and perfusion in the lateral position occurs !ecause 6a9 gra ity redistri!utes !lood flow toward the dependent lung and 6!9 the dependent lung is compressed !y the mediastinum and a!dominal contents, impeding entilation. ;n awake spontaneously entilating su!-ects, the lower diaphragm is a!le to contract more efficiently, maintaining entilation to the dependent lung and matching increased perfusion. ;n contrast, with the patient anestheti.ed, with or without paralysis, most entilation is preferentially switched from the lower lung to the upper lung. )his preferential entilation of the upper lung, coupled with the greater perfusion of the lower lung, results in an increased degree of entilationCperfusion mismatch. /.12. 'hat is hypo4ic pulmonary asoconstriction& Al eolar hypo4ia, whether caused !y a low 7io2, hypo entilation, or atelectasis, causes pulmonary asoconstriction. )he phenomenon is called hypo4ic pulmonary asoconstriction 6H+D9. )he selecti e increase of ascular resistance in the hypo4ic lung di erts !lood away from the hpo4ic lung to the !etter entilated normo4ic lung. )he di ersion of !lood flow decreaks the amount of shunt flow that can occur throughout the hypo4ic lung. )herefore, the regional H+D response is an autoregulatory mechanism to pre ent entilationCperfusion mismatch and impro e arterial o4ygenation. /.1(. 'hat are the effects of anesthetics on hypo4ic pulmonary asoconstriction and their clinical implications& ;ntra enous anesthetics, such as thiopental, ketamine, morphine, and fentanyl, ha e no direct effect on H+D. ;n contrast, inhalation anesthetics ha e !een shown to inhi!it H+D in a doserelated fashion, although at clinical concentrations this effect is modest. Accordingly, multiple studies ha e failed to demonstrate that total intra enous anesthesia decreases the risk

of hypo4emia during single-lung entilation. /linically, a num!er of important nonanesthetic drug factors influence the effect of inhalation anesthetics on shunting and arterial o4ygenation during single-lung entilation. )he effect of a gi en increase in shunt on +ao2 depends on the a!solute le el of the initial shunt and the inspired o4ygen concentration. 7or e4ample, if the single-lung entilation shunt without isoflurane is (0< and with isoflurane is (4<, then the decrease in +ao2 will !e ery small. ;n practice, nearly 100< o4ygen is used. , enthough shunt is increased, +ao2 usually remains well a!o e 100 mm Hg. )he o4ygen saturation and o4ygen content are hardly changed. )he secondary effects of inhalation anesthetics may counteract the direct H+Dinhi!ition effect of the anesthetics. )hus, a decrease in cardiac output, mi4ed enous o4ygen tension, and pulmonary pressure, all of which may accompany deep inhalation anesthesia, would increase nondependent lung H+D at the same time that inhalation anesthetics were decreasing it. )he presence of chronic irre ersi!le disease in the essels of the nondependent lung may render these essels incapa!le of an H+D-inhi!ition response. )he presence of disease in the dependent lung will make the dependent lung less a!le to accept redistri!uted !lood flow and there!y decease the H+D effect of the nondependent lung. F "urgical interference with !lood flow to the nondependent lung also decreases the anesthetic effect on H+D of the nondependent lung. /.14. %iscuss pulmonary !lood flow distri!ution, shunt flow, and 1(a02 67102 8 1.09 during single-lung entilation. 'hen the nondependent lung is made atelectatic, H+D in the nondependent lung will increase nondependent lung pulmonary ascular resistance and decrease nondependent lung !lood flow. ;n the a!sence of any complicating factors, a single-lung H+D response should decrease the !lood flow to that lung !y 00<. /onse#uently, the nondependent lung should !e a!le to reduce its !lood flow from 40< to 20< of total !lood flow, and the nondependentCdependent lung !lood flow ratio during single-lung entilation should !e 20<> 20<. All of the !lood flow to the non entilated nondependent lung is shunt flow, andtherefore single-lung entilation creates an o!ligatory right-to-left transpulmonary shunt flow that was not present during two-lung entilation. ;f no shunt e4isted during two-lung entilation conditions 6ignoring the normal 1< to (< shunt flow due to the !ronchial, pleural, and the!esian circulation9, then we would e4pect the ideal total shunt flow during single-lung entilation to !e a minimal 20< of total !lood flow. +ao2, with fractional inspired 02 concentration 67ro29 e#ual to 1, should !e appro4imately 220 mm Hg if hemodynamic and $eta!!lic states are normal. /linically, +ao2 6+102 -- 19 ranges from 100 to 200 mm Hg. /.10. How could you impro e o4ygenation during single-lung entilation& )he following inter entions can !e used to impro e o4ygenation> o Bse 100< o4ygen. o /heck the position of the %E) with a fi!eroptic !ronchoscope o Dentilate manually to determine whether higher or lower tidal olumes and inspiratory pressures are !eneficial. "et minute entilation to maintain +aco2 at 40 mm Hg 6hypocapnia may inhi!it H+D in the nondependent lungA hyper entilation may increase airway pressure and promote !lood flow to the non entilated lung9.

o ;nsufflate o4ygen to the non entilated lung> A flow of a!out ( E allowed to freely circulate 6i.e., orifice of tu!e should !e open9 will often increase arterial o4ygen saturation (< to 4<. Apply 0 cm H2G of +,,+ to the dependent lung> $ay !e !eneficial if larger tidal olumes deli ered manually impro e arterial saturation 6i.e., recruita!le al eoli9. Alternati ely, +,,+ to the entilated lung alone may di ert !lood to the non entilated lung and worsen shunt. +artially ree4pand the non entilated lung, then cease entilation !ut keep the lumen to the non entilated side closed. o Bse differential lung continuous positi e airway pressure 6/+A+9C+,,+ search 6rarely necessary9> o Add 0 cm H2G of /+A+ to the nondependent lung during the deflation phase of a large tidal olume !reath to o ercome critical opening pressure in the atelectatic lung. A disad antage is that although lung is not entilated, it remains distended. o Apply 0 cm H2G of +,,+ to the dependent lung. o ;ncrease nondependent lung /+A+ to 10 cm H2G while maintaining the dependent lung at 0 cm H2G of +,,+. ;ncrease dependent-lung +,,+ to 10 cm H2G to match the nondependent lung /+A+. )he a!o e differential lung /+A+C+,,+ search is conducted in this way to find the optimal 6!est9 end-e4piratory pressure for each lung and minimum LsCLr for the patient as a whole. o Bse two-lung entilation intermittently. o /lamp the pulmonary artery to the nondependent lung temporarily 6rarely necessary9. /.16. :ight middle lo!ectomy was performed. 'ould you e4tu!ate the trachea at the end of the procedure& After a routine lung resection, the trachea can usually !e e4tu!ated as long as the patient is responsi e and comforta!le. Howe er, if the patient cannot maintain ade#uate o4ygenation and entilation, postoperati e mechanical support is indicated. Bnder most circumstances, when patients re#uire postoperati e entilatory support, it is ad antageous to e4change a %E) for a single-lumen endotracheal tu!e. *ecause spontaneous entilation a oids the potential ha.ards of postoperati e positi e pressure on !ronchial stump suture lines or parenchymal air leaks, the com!ination of modest /+A+ and pressure-support entilation is usually prefera!le to controlled intermittent mandatory entilation. %. +ostoperati e $anagement %.1. 'hat are the immediate life-threatening complications that follow lo!eciGmy or pneumonectomy& )he serious complications include massi e hemorrhage caused !y loosening of a ligature from a pulmonary essel, !ronchopleural fistula from disruption of a !ronchial stump, herniation of the heart after radical pneumonectomy !y the intrapericardial approach, pulmonary torsion resulting from increased mo!ility of a lo!e, acute right-sided heart failure after pulmonary re Eion, right-to-left shunting across a patent foramen o ale resulting from increased puaonary ascular resistance and right entricular pressure, in-uries of phrenic, agus, and recurrent laryngeal ner es during radical hilar dissection or e4cision of mediastinal tumors, and acute respiratory insufficiency.

%.2. 'hy is it important to control postoperati e pain& How would you achie e this control& +ostoperati e pain control is important not only for patient comfort !ut also to minimi.e pulmonary complications !y ena!ling the patient to !reathe deeply without splinting, to cough, and to am!ulate. "ystemic administration of opiates is employed most often to control postoperati e pain. )itration of mor7hine in 2-mg increments to achie e ade#uate pain relief and a oid respiratory depression can !e achie ed during emergence from anesthesia. +ostoperati ely, titration of narcotic dosages can !e achie ed !y a patient-controlled analgesia 6+/A9 de ice alone or in com!ination with supplemental analgesia from nonsteroidal antiinflammatory drugs. Alternati e methods of pain control include intercostal or para erte!ral ner e !lock, interpleural regional analgesia, epidural analgesia with local anesthetics, transcutaneous electrical ner e stimulation 6),@"9, cryoanalgesia, and intrathecal and epidural narcotics. ;ntercostal or +ara erte!ral @er e *lock ;ntercostal or para erte!ral ner e !locks with long-acting local anesthetics are often used to control postoperati e pain after thoracotomy and can !e done !y the surgeon intraoperati ely. )he !locks are placed to the intercostal ner es at the le el of the incision and two or three interspaces a!o e and !elow this le el. /atheters that can !e in-ected postoperati ely when pain occurs may !e placed in the appropriate intercostal groo es at the time of thoracotomy closure. ;nterpleural :egional Analgesia ;nterpleural regional analgesia in ol es percutaneous introduction of a catheter into the thoracic cage !etween the parietal and isceral pleura for in-ection of local anesthetic. Analgesia is thought to occur as a result of 6a9 diffusion of local anesthetic through the parietal pleura and the innermost intercostal muscle to reach the intercostal ner es where the !lockage occurs, 6!9 !lockage of the intrathoracic sympathetic chain, and 6c9 c+rect action of local anesthetic on ner e endings within the pleura. Howe er, efficacy is not uniform !ecause of the loss of anesthetic ia thoracotomy drainage, the presence of e4tra asated !lood and tissue fluid in the pleural space, and possi!ly se#uestration and channeling of the flow of local anesthetic !y the restricted motion of an operated lung. )he use of multiple or fenestrated catheters may achie e more e en distri!ution of local anesthetic o er the pleura and impro e the #uality of analgesia. ,pidural and ;ntrathecal Analgesia with Eocal Anesthetics )horacic or lum!ar epidural analgesia may !e achie ed !y a single in-ection or continuous infusion of local anesthetic alone or in com!ination with an opiate. +otential complications of this techni#ue include hypotension from sympathetic !lockade, inad ertent dural puncture, trauma to the spinal cord, and intra ascular in-ection of local anesthetics with resultant cardio ascular and central ner ous system to4icity. A single intrathecal in-ection of mpkphirte has !een successfully used preoperati ely or intraoperati ely to pro ide postoperati e pain relief for 12 to 24 hours. Howe er, it appears to !e associated with an increased incidence of late respiratory depression 64< to 1< compared with less than 1< for epidural administration9. )herefore, epidural narcotics ha e generally replaced intrathecal narcotics. )he ad antages of epidural narcotics include selecti e !lockade of spinal pain without sympathetic !lockade or loss of motor function and greater predicta!ility of pain relief o er that pro ided !y parenteral narcotics. ,pidural and intrathecal narcotics !lock the presynaptic and postsynaptic neuron cells of the su!stantia gelatinosa of the spinal cord !y passi e diffusion across the dura into the cere!rospinal fluid. )he lipophilic narcotics, such as fentanyl, methadone, and meperidine, in doses of 0.1 mg, 0 mg, and (0 mg to 100 mg, respecti ely, ha e a

relati ely short onset of action of less than 12 minutes. )hey pro ide significant pain relief in 20 to (0 minutes and ha e a duration of action of 6 to 1 hours. ;n contrast, a lipopho!ic narcotic, such as morphine, in a 0-mg dose has a relati ely slow onset of action of 10 to (0 minutes, pro ides ma4imal pain relief in 40 to 60 minutes, and has a duration of action of more than 12 hours. *ecause the thoracic epidural approach has risks of dural puncture and spinal cord damage, the lum!ar epidural route with a slightly higher dose of $orphine and ade#uate diluent olume has !een suggested. )he most serious complications of epidural narcotics are early and late respiratory depression. )he other side effects include urinary retention, pruritus, and nausea and omiting. )he narcotic antagonist, nalo4one, can re erse all these effects !ut will re erse the analgesic effect, so it must !e used cautiously. )ranscutaneous ,lectrical @er e "timulation )he ad antages of ),@" include low cost, ease of application, and lack of undesira!le side effects. Howe er, ),@" has a weak analgesic effect. ;t is generally reser ed for ad-uncti e use with narcotics to relie e postthoracotomy pain. /ryoanalgesia Eong-lasting 6( to 4 weeks9 intercostal ner e !lock can !e o!tained !y cryoa!lation. )wo (0second free.e cycles, separated !y a 0-second thaw period, are applied to each of the ner es selected. Although cryoanalgesia was initially shown to effecti ely relie e pain and impro e postoperati e pulmonary function, more detailed study has re ealed a significant incidence of paresthesia and postthoracotomy pain syndrome.