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Sim Lab > Session 24. Lung Isolation (Double Lumen and Bronchial Blockers) > Flashcards

Session 24. Lung Isolation (Double Lumen and Bronchial Blockers) Flashcards

1
Q

trachea

A

anterior: C shaped rings
posterior: smooth muscle (trachealis)

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2
Q

right lung

A

3 lobes
upper
middle
lower

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3
Q

left lung

A

2 lobes
upper
lower

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4
Q

which lung is larger

A

right

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5
Q

lung lobes

A

are further divided

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6
Q

right bronchus length

A

1-2.5cm

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7
Q

left bronchus length

A

5cm

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8
Q

left bronchus vs right bronchus angle

A

left is more acute than right
(more horizontal than right)

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9
Q

left bronchus vs right bronchus diamter

A

right typically larger diameter than left

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10
Q

right upper lobe takeoff

A

short
can occur above carina at level of trachea

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11
Q

right upper lobe takeoff can cause

A

easy occlusion
difficult to visualize

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12
Q

what indicates a right upper lobe short takeoff

A

mercedes sign

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13
Q

lung isolation indications: pt condition

A

infection
bleeding
bronchopleura fistula
cyst
hypoxia due to unilateral lung process

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14
Q

what can a bronchopleural fistual cause

A

decreased negative pressure

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15
Q

lung isolation indications: procedures

A

thoracic aortic aneurysm repair
lung resection
thoroscopy
esophageal surgery
single side pulmonary transplant
rib fixation
thoracic spine surgery anterior approach

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16
Q

lung isolation contraindications

A

none

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17
Q

what should you be mindful of during lung isolation

A

dont palce left DLT if left bronchus lesions (etc)

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18
Q

lung isolation issues

A

similar to laryngoscopy

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19
Q

left double lumen tube

A

std for lung isolation
goes into left bronchus

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20
Q

right double lumen tube

A

not common
oblique bronchial cuff (allows RUL ventilation)

not interchangeable with left DLT

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21
Q

double lumen sizing

A

35-41Fr

most common: 37-39Fr
female: 37
male: 39

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22
Q

right double lumen tube indications

A

left bronchus lesions/stenosis
surgery involving high up on left bronchus

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23
Q

types of right double lumen tubes

A

mallinckrodt: oblique
protex: bean
sheridan: 2 cuffs
rusch: oblique

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24
Q

tracheal lumen

A

clear
10ml syringe

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25
Q

bronchial lumen

A

blue
3ml syringe

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26
Q

stylet is placed in what lumen

A

bronchial (blue) lumen

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27
Q

compressible adapter (DLT)

A

allows for clamping (Isolation)
allows for bronchoscopy

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28
Q

y piece (DLT)

A

connects lumens to circuit
bronchial: left
tracheal: right

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29
Q

where can you get a tube clamp for DLT

A

ask scrub tech

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30
Q

kids (8+) DLT size

A

26Fr

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31
Q

peds DLT

A

typically not used
isolate w/regular ETT mainstem

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32
Q

women DLT size

A

37Fr

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33
Q

men DLT size

A

39Fr

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34
Q

where do you lubricate DLT

A

base of cuffs

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35
Q

why is pre-ox important prior to DLT insertion?

A

extra pre-ox needed bc pts have lung pathology
pts more susceptible to apnea
DLT insertion typically involves longer apneic period

36
Q

when do you remove stylet from DLT

A

once bronchial tip past cords

37
Q

what can happen if you fail to remove sylet from DLT

A

trachea perforation

38
Q

how do you get bronchial cuff into left bronchus?

A

exaggerated counter clockwise rotation (90-180 deg) of tube towards pts left

39
Q

typical DLT insertion depth

A

28-31cm
(dont rely on this)

40
Q

how do you verify DLT placement?

A

bronchoscope down tracheal lumen

41
Q

what should you avoid when inflating bronchial cuff?

A

avoid herniating over carina

42
Q

what should you hear when you clamp the tracheal lumen on a Left DLT?

A

left side breath sounds
(left is bronchia lumen
right is tracheal)

43
Q

what should you hear when you clamp the bronchial lumen on right DLT?

A

left side breath sounds
(right is bronchial
left is tracheal)

44
Q

what can happen if DLT moves a few milimeters?

A

can have a leak
risk loss of lung isolation

45
Q

Left DLT is placed
bronchial lumen is clamped
you hear breath sounds on left
what does this tell you?

A

bronchial: left
tracheal: right

if i clamp the bronchial, i should hear breath sounds on the right

I am hearing breath sounds of the left because the DLT has been placed too deep.
- tracheal cuff is in the bronchus
- bronchial cuff is in a lobe

46
Q

Left DLT is placed
bronchial lumen is clamped
you do not hear breath sounds on the left
clamp tracheal to isolate right lung
surgeon says that right lung is inflating
what does this tell you?

A

bronchial: left
tracheal; right

if i clamp the bronchial, i should not hear breath sounds on the left.

I am not hearing breath sounds on the left because the tracheal cuff is in the correct spot

My right lung is still inflating because the bronchial cuff is in the wrong bronchus.

47
Q

bronchial blocker types

A

cohen
EZ
arndt
uniblocker

48
Q

cohen blocker

A

wire w/wheel

49
Q

ez blocker

A

2 cuffs
one on either side of carina

50
Q

arndt blocker

A

wire loop that grabs bronchoscope

51
Q

uniblocker

A

not commonly used

52
Q

bronchial blocker adapter ports

A

ETT
circuit
blocker
bronchoscope

53
Q

bronchial blocker adapter is essential for

A

simultaneous:
ventilation
securing blocker
bronchoscopy

54
Q

which blockers have murphy eyes

A

cohen
arndt

55
Q

what sixe ETT are needed to use bronchial blockers?

A

larger size
(8.0+)

56
Q

what FiO2 is required when placing bronchial blocker

A

100% FiO2

57
Q

most common bronchial blocker

A

EZ blocker

58
Q

EZ blocker cuff syringe

A

10mL

59
Q

risk of right bronchial blocker

A

air trapped in right upper lobe

60
Q

what are bronchial blockers great at?

A

lobe isolation

61
Q

confirmation of blocker placement

A

bronchoscopy
auscultation
direct visualization via VAT or thorocotomy

62
Q

gold std for bronchial blocker confirmation

A

VAT
thorocotomy

63
Q

what is suction used for in bronchial blockers?

A

helps deflate lung

64
Q

why do you increase insufflation pressure during bronchial lung isolation?

A

presses down on lung

65
Q

increase pressure in thorax causes

A

decreased CVP
decreased preload
decreased CO
increased HR

66
Q

how do you compensate for decreased CVP?

A

give fluids

67
Q

why should you avoid placing catheters into lung?

A

surgeon could staple through it

68
Q

hypoxic pulmonary vasoconstriction

A

blood shunted from hypoxic alvoli to the ones exposed to O2
(isolates the lung)

69
Q

volatile agent impact on HPV

A

decrease
minimal impacts <1MAC

70
Q

tidal volume for lung isolation

A

3ml/kg
allows HPV to occur

71
Q

increased RR can cause

A

air trapping

72
Q

how to prevent air trapping

A

increase I:E ratio

73
Q

what happens with a higher tidal volume in lung isolation

A

incr PIP
incr PEEP
compress vessels (incr Resistance)
decr BF
decr O2 capacity/exhange
incr hypoxia

74
Q

lung isolation fluid management

A

keep dry (<3L in 24 hrs)
ignore 3rd space losses
use inotropes to manage hemodynamics

75
Q

increased fluids causes

A

increased shunting
depended pulmonary edema

decreased O2/CO2 diffusion

76
Q

N2O in lung isolation cases

A

no benefit
causes atelectasis
incr pulm artery pressures
inhibits hPV

77
Q

N2O contraindicated in pts

A

w/blebs or blullae

78
Q

hypothermia and HPV

A

inhibits HPV

79
Q

why do you use 100% FiO2 in lung isolation

A

it induces atelectasis on operative side
(deflates lung being worked on)

80
Q

hypoxia level in lung isolation

A

> 90% SpO2
PaO2 >60mmHg

(no actual low level - some pts can tolerate lower levels)

81
Q

why should you maintain 70-80% FiO2 in lung isolation

A

gives quick method to increase O2 delivery while you fix the issue

82
Q

HPV and CO2

A

HPV more effective in respiratory acidosis

HPV less effective in respiratory alkalosis

(CO2 is acidic - keep pt slightly higher on CO2)

83
Q

Lung isolation ventilation management

A
  1. ensure 100% FiO2
  2. check DLT/blocker positiion
  3. ensure optimal CO
    decrease VA <1MAC
  4. apply recruitment maneuver to ventilated lung
  5. apply PEEP 5cmH2O to vent. lung
  6. apply CPAP 1-2cmH2O to nonvent lung
  7. intermittent reinflaction of non-vent lung
  8. partial vent techniques of non-vent lung
  9. mech restriction of blood flow to non-vent ung
84
Q

what pts should you not apply PEEP to?

A

COPD/emphysema pts

85
Q

partial ventilation techniques of non-vent lung

A

o2 insufflation
high-freq ventilation
lobar collapse vs entire lung collapse

86
Q
A

Sim Lab (23 decks)

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