ANESTHESIA FOR NONCARDIAC THORACIC SURGERY

CONSIDERATIONS MARTHA RICHTER, MSN, CRNA

OBJECTIVES
The student will

Correlate physiological comorbidity issues with the anesthesia care plan List position considerations specific to these surgical procedures Describe the use of DLT and general considerations Identify factors to prevent exacerbation of pulmonary vasoconstriction

PULMONARY FUNCTION CRITERIA

Suggests high risk if:

FVC<50% FEV1 <2L FEV1/FVC <50% RV/TLC >50% Diffusing capacity <50% predicted PaCO2 >45 mmHg

PFTS - RESTRICTIVE
PARAMETER FVC FEV1 FEV1/FVC RV/TLC INTRINSIC dec normal normal normal EXTRINSIC dec normal normal increased

PFTS-OBSTRUCTIVE
PARAMETER FVC FEV1 FEV1/FVC RV/TLC asthma normal dec dec inc bronchitis normal dec dec inc emphysem normal dec dec inc

CLINICAL S&S:Pulmonary hypertension, RVH, Cor Pulmonale

Prominent neck veins, prominent A waves& perhaps prominent V waves on EKG Prom left parasternal heave & rocking motion synchronous with heartbeat may be noted Auscultate: pulm comp of 2nd heart sound increases

CLINICAL S&S contd.

High pitched, early systolic ejection click Systolic ejection murmur R-sided atrial S4 gallop indicating inc RVEDP Middiastolic R-sided S3 gallop, usually clear evidence of impaired RV function. Differentiated: gallops inc in intensity with inspiration

CLINICAL S&S contd

Early diastolic, pulmonary regurg murmur ind functional impair secondary to dilation of PA root Rt heart failure with chronic dependent edema, large tender liver, ascites, dilated distended neck veins

CXR in Pulmonary HTN

Main pulmonary vessels dilated Characteristic of COPD with hyperinflated lungs, low flat diaphragm Evidence of RVH; clockwise cardiac rotation, loss of air space behind the sternum on a lateral view

LV DYSFUNCTION CONTRIBUTORS
Hypoxia, hypercarbia, acidosis CAD/valvular disease Systemic hypertension Ventricular interdependence Alterations in intrathoracic pressure

PREPARATION OF PT FOR SURGERY

PREOP

PATIENT EDUCATION

Stop smoking Breathing exercises/mucolytics&expectorants Bronchodilation Aminophylline Cromolyn sodium Parasympatholytics sympathomimetics Weight reduction

INTRAOP GOALS
Minimize anesthesia time Control secretions Prevent aspiration Bronchodilation Intermittent hyperinflation

POSTOP GOALS
Continue preoperative measures Mobilize secretions Early ambulation cough & deep breathing analgesia

DRUG THERAPY-a review

Sympathomimetics

Beta agonists that inc formation of cyclicAMP=bronchodilation Metaproterenol Albuterol terbutaline

DRUG THERAPY-a review

Parasympatholytics decrease intracellular levels of cyclicGMP , which modulate bronchoconstriction Atropine Ipratropium bromide

DRUG THERAPY-a review

Phosphodiesterase Inhibitors

Inhibits enzymatic breakdown of Cyclic-AMP, which increases cellular levels Aminophylline

Therapeutic bld levels 5-20ucg/ml Loading 5-7mg/kg infused over 20 min Cont inf 0.5-0.7 mg/kg/h

DRUG THERAPY a review

Steroid reduce mucosal edema and suppess inflammation beclomethasone

DRUG THERAPY a review

Cromolyn sodium
Mast cell stabilizer preventing degranulation and release of histamine

DRUG THERAPY - a review

Digitalis

Useful with left sided failure (CHF) or supraventricular dysrhythmias with rapid ventricular response

REMEMBER THE RESPIRATORY MONITORS

Breath sounds Airway pressure Oxygenation ventilation

REMEMBER THE CV MONITORS

Precordial/esophageal stetheoscope EKG Blood pressure Cvp Pap Art line

WHAT ABOUT POSITION CONSIDERATIONS?

POSITION SUPINE ,

Clinical application Cardiac Mediastinal Major liver/vascular trauma Pericardial tamponade Lung biopsy

MORE POSITION CONSIDERATIONS

POSITION CLINICAL APPLICATION Anytime there is a desire to prevent flooding to tracheobronchial tree during procedures TB Pulmonary abscess

PRONE

MORE POSITION CONSIDERATIONS

POSITION LATERAL DECUBITUS-may vary the obliqueness betw 45 to 135 deg to provide opt access CLINICAL APPLICATION Standard thoracotomy position Improves exposure in certain cardiothoracic, vascular or gastroesophageal procedures

PHYSIOLOGY CONSIDERATIONS OF LATERAL DECUBITUS

Distribution of perfusion
Dependent lung

Distribution of ventilation
Independent lung blood flow increases more rapidly than ventilation

LATERAL DECUBITUS
PATIENT AWAKE, BREATHING SPONTANEOUSLY

Less Zone 1, more zone 2&3 Blood flow to dependent lung >blood flow to independent lung Ventilation greater in dependent lung Diaphragm of dependent lung pushed higher & stretched tighter

LATERAL DECUBITUS
PATIENT ANESTHETIZED, SPONTANEOUSLY BREATHING, CHEST CLOSED
Depend lung better perfused FRC dec both lungs Depend lung becomes less compliant, upper lung becomes more compliant Increase in shunt and dead space ventilation

LATERAL DECUBITUS
PATIENT ANESTHETIZED, PARALYZED, MECHANICALLY VENTILATED, CHEST CLOSED
Depend lung better perfused Vent to nondepend lung even greater Mech vent obviates effect of depend lung diaphragm contraction Weight of abd contents physically restricts expansion of dependent lung

LATERAL DECUBITUS
PATIENT ANESTHETIZED, SPONTANEOUSLY BREATHING, CHEST OPEN
MEDIASTINAL SHIFT PARADOXIC RESPIRATION

LATERAL DECUBITUS
PATIENT ANESTHETIZED, VENTILATION CONTROLLED, CHEST OPEN
OPEN CHEST INCREASES COMPLIANCE OF BOTH LUNGS Airway pressure dec in both lungs CI increases; no change in MAP CO2 elim greater from nondepend lung Dec amt of Zone 1 and dead space ventilation

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

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

SEPARATING THE LUNGS

HOW:
DOUBLE LUMEN ENDOTRACHEAL TUBE UNIVENT ENDOTRACHEAL TUBE BRONCHIAL BLOCKERS

SEPARATING THE LUNGS

WHY?

To selectively ventilate/collapse a lung during intrathoracic operations

ABSOLUTE

Prevention of cross contam diseased to nondiseased lung Redistrib vent Required unilateral bronchopulm lavage

SEPARATING THE LUNGS

RELATIVE INDICATIONS
Surgical exposure for thoracic aortic aneurysm Exposure for upper lobectomy Exposure for pneumonectomy Exposure for esophageal resection Exposure for subsegmental resection

COMORBIDITY & RISK

Patients scheduled for thoracotomy are at inc risk of cardioresp failure or death if:

Preexisting cardiopulmonary disease Obesity Advanced age TUMOR: eval for myasthenic syndrome, IADH(seen with small cell) Consider pericardial involve Consider pulmonary hypertension

GA & ONE LUNG ANESTHESIA

No N2O Avoid hypoxemia CVP for infusion vasoactives Art Line Ketamine infusion may be a choice Good muscle relaxation Be very particular about DLT placement after intubation AND after positioning changes

GA & ONE LUNG ANESTHESIA

Hypoxia that occurs may require
Get an ABG May need to revent the collapsed lung CPAP to dependent lung PEEP if CPAP doesnt help

Re-expand the deflated lung carefully at the conclusion of resection. Positive pressure is held at 35-40 cm H2O to allow surgeon to view suture lines and check to air leaks Extubate(DLT); reintubate with normal ETT, continue emergence as

CONTRAINDICATIONS TO DLT
Lesion along the tubes pathway Difficulty obtaining direct vision intubation Critically ill pts who dont tolerate apnea Full stomach/inc risk of aspiration Any combination of above

REGIONAL/GA
May use combined thoracic epidural with GA Level of thoracic epidural determined by surgery Make sure a band of anesthesia exists after test dose Utilizes min narcotics, lower gas concentrations Enables quicker emergence/recovery with benefits of good analgesia

RIGID BRONCHOSCOPY
Performed for:

Removal FB, massive hemoptysis, dilate tracheobronchial strictures, laser bronchoscopy, stent placement, biopsy and staging of malignant processes, establishment of an emergent airway

RIGID BRONCHOSCOPY
Worry about: Sharing the airway with the surgeon

Requires extremely high vigilance and excellent ongoing communication Ventilating sidearm to maintain oxygenation & ventilation

Arrhythmias, hypertension, hypoxemia

RIGID BRONCHOSCOPY
Need to know:

Level of the lesion What is the lesion suspect for h/o ischemic processes How do the lungs sound

RIGID BRONCHOSCOPY
Position: sitting or supine Glyco early antisialogogue Routine monitors Usually sedation + topical, spray as go Use short acting drugs Postop hypoxemia will usually correct with supplemental O2 Keep the sedation light to avoid hypoventilation! Remember laser precautions if the laser is the surgical method

FIBEROPTIC BRONCHOSCOPY
Allow evaluation of the tracheobronchial tree deeper than rigid Use for:

Pulmonary disease diagnosis, staging carcinomas, lavage/aspiration of thick secretions in acute atelectasis, transbronchial biopsy and brushings

FIBEROPTIC BRONCHOSCOPY
Risks are related to reasons for procedure. Goes up in patients with comorbidities of cardiac disease, severe hypoxemia and bleeding diathesis. Absolute contraindications may include unstable CV system, current life threatening cardiac arrhythmias, and severe hypoxemia.

FIBEROPTIC BRONCHOSCOPY
Problems during the procedure:

Coughing Hypertension Tachycardia

usually b/o inad anes/top

May require lung separation if bleeding develops

FIBEROPTIC BRONCHOSCOPY
EBL is usually negligible Need to know from surgeon:

Proceed thru ETT? (req 7.5-8.0) Proceed next to ETT? (req 5.0-6.0)

PNEUMONECTOMY
INDICATIONS:

Non-small cell lung CA Drug resistant TB, mycobacterium, fungal infections, necrosis Trauma (last resort)

PNEUMONECTOMY
Preop assessment may include:

How is their respiratory reserve? Check the PFTs Is there Pulmonary HTN? b/o RV dys, valv dis, any arrythmias? Any concommitant CV dis? Hoarseness? May indicate recurrent laryngeal nerve involvement Eaton-Lambert syndrome = muscle wasting; may influence relaxant choice

PNEUMONECTOMY
Preop

Hydration, antibiotics, bronchodilators, place thoracic epidural Monitors: art line, CVP, PA on contralat side DLT

Fluids: run dry; EBL usually

500cc

PNEUMONECTOMY
Anticipate:

Unrecognized flood loss Postop pulmonary edema, atelectasis Dysrhythmias DVT & Pulm Emb occur 20% Persistent air leak Excessive mediastinal shift = life threatening

PNEUMONECTOMY
MEDIASTINAL SHIFTS:

IPSILATERAL
Hypotension, arrhythmias, cardiac herniation, pulmonary edema

CONTRALATERAL
Dec lung function, dec venous return

CHEST TUBES are kept clamped to prevent this: brief unclamp for drainage of flds.

LUNG REDUCTION SURGERY or PNEUMOPLASTY

Palliation for terminal emphysema; alternative to lung transplant Risk with reactive airway disease, CAD and pulmonary HTN Exclusions: pulm HTN, bronchospasm, LV dysfunct, bronchitis, inc sputum prod, persistent smoking, previous thoracotomy/pleurodesis, obesity, cachexia

PNEUMOPLASTY
FEV1 PREOP average 25-30% pred 3-6% inhospital mortality 25% morbidity

Air leaks Resp failure Pulm embolism pneumonia

Procedure goal: 20-30% lungs resect, reshaping diaphragm and chest wall. This allows improve lung recoil (dec LV & inc exp flow)

PNEUMOPLASTY
PREOP

Maximize bronchodil therapy Minimize narcotics Place thoracic epidural Your goal is to extubate in the OR!

PNEUMOPLASTY
Monitors include art line, CVP Prepare for DLT Procedure may begin with FOB by surgeon, then proceed with resection Resection may be unilateral / bilateral best side first Run them dry Remember your PIP

PNEUMOPLASTY
The need for reintubation and ventilation is associated with extremely high morbidity.