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Flashcards in Test 1 Deck (77):
1

5 absolute indications for OLV

Isolation of 1 lung r/t infection/hemorrhage

Unilateral bronchopulmonary lavage

Bronchopleural fistula

Large ruptured bullae

Tracheobronchial tree disruption (TEF)

2

5 surgeries necessitating lung separation

Thoracic procedure (lobectomy, transplant, thoracoscopy)

Mediastinal procedures w/ sternotomy

Descending thoracic aortic aneurysm

Pulmonary embolectomy

Esophagogastrectomy

Anterior thoracic spine sg

3

3 methods of selective lung ventilation

Single lumen tube with endobronchial intubation

Selective bronchial intubation with MLT

Single lumen tube with endobronchial blocker (Univent, WEB)

4

Most common method of OLV

Why?

Left sided DLT

More distance to LUL (5 cm)so less likely to isolate upper lobes. With RLT there is only 2 cm from carina to RUL

5

Insertion depths for left DLT

27.5 to 31.2 cm

6

Most common used DLT

Robertshaw

7

Cuffs of Robertshaw tube (DLT)

Color

Inflation amt

Trachea cuff is clear
- 10-20cc

Bronchial cuff is blue
- 2-3 cc

8

Tracheal cuff ventilates which lung

How

Ventilate both lungs if blue is not clamped

To ventilate only right lung clamp blue (bronchial) lumen

9

DLT side for large male

41 French (each lumen 6.5mm)

10

DLT for normal male

39 French (6.0mm ID)

11

DLT size normal female, small male

37 French (5.5mm ID)

12

DLT size small female

28 French (5.0mm ID each)

13

DLT size not usually used, smallest

28French (4.5mm ID each)

14

Placement of DLT

-blade

- insertion

MAC blade easiest

Insert with tube end facing right.
Pass bronchial cuff through cords.
Remove stylet
Turn exactly 90 degrees forward

Pull up on chin helps

Advance until resistance felt

15

Where do you tape DLT

Middle of mouth

16

If bronchial lumen too deep where is tube

Left mainstem bronchus

Not ventilating LUL

17

Bronchial cuff herniated at carina what occurs

Too much air in cuff

Ventilating both lungs

18

Bronchial lumen above carina what occurs

Ventilate both lungs

19

Right main stem bronchial intubation with left DLT

Only ventilate R lung (not including RUL)

20

4 methods of checking placement of DLT

- check bilateral breath sounds and chest excursion

- selectively clamp lumens one at a time and listen

- open port and listed for air flow through clamped lung

-check placement with fiberoptic bronchoscope

21

How do you verify placement with fiberoptic bronchoscope

Insert into tracheal lumen and look for bronchial cuff placement

22

When verifying placement of DLT with FOB what should you see?
- through tracheal lumen
-through bronchial lumen

If not there?

Tracheal lumen
Bronchial cuff should be visualized as crescent shaped

If see too much not in far enough
If don’t see at all, in too far

Bronchial lumen
ID left upper and lower bronchus

23

3 uses of FOB in OLV

Verify tube placement
Suction
???

24

6 indications for right side DLT

Left pneumonectomy

Left tracheobronchial disruption or TEF

Mediastinal lesion compressing L mainstem

L bronchial stent

L lung transplant

Descending thoracic aortic aneurysm compressing L main bronchus

25

4 advantages of inhalation anesthetic on OLV

Bronchodilation

Decreases HPV

Ensures amnesia

Rapidly eliminated, less hemodynamic response

26

3 advantages of opiod use in OLV anesthetic

No sig. hemodynamic compression

Smooth transition to emergence

Minimal decrease in HPV

27

Effect of 1 MAC of volatile agent during OLV

Decrease HPV response from 50% to 40%

Increases Qs/Qt (flow to nondependent lung) 4%. Sats on 100% FiO2 96-98%

28

Proportion of blood flow to each lung during OLV in lateral decubitus position

Without inhalation agent
Dependent- 80%

Non-dependent- 20%

With inhalation agent
Dependent 76%

Non-dependent 24%

29

5 factors that may increase shunt during OLV and effect on HPV

Atelectasis (increase HPV)
Systemic vasodilators(inhibits HPV)
High PA pressures (inhibits HPV0
Low FiO2 (inhibits HPV)

Surgical interference/compression of operative lung

30

Management of hypoxia in OLV

Notify surgeon sat < 90%
Suction
Recheck tube position with FOB
Oxygen from sidearm to operative lung via insufflation
Change vent mode
Change I:E ratio
PEEP 5 cmH2O to dependent
CPAP 5 cm H2O to non-dependent
150ml Oxygen into non-ventilated lung
Intermittent ventilation of non-dependent lung
Early clamping of PA if pneumonectomy

31

Goal of management of hypoxia during OLV

Decrease shunt

32

Benefit and disadvantages of PEEP and CPAP to lung during OLV

PEEP alone makes sat worse bc Less blood to dependent lung worsening shunt

Add 2.5 CPAP to non depending lung improves sat by providing O2 to blood going to nondependent lung

Add 5 CPAP to non dependent lung improves sat even more

33

4 contraindications for DLT

- Unable to replace existing ETT
- unable to maintain adequate PO2 w OLV
- technically difficult- anatomy, size
- full stomach

34

4 complications of DLT

- hypoxemia
- tracheobronchial tree disruption
- traumatic laryngitis
- DLT becomes temporary part of suture line

35

2 main disadvantages of bronchial blockers

Slow deflation time

Blockage of bronchial blocker by blood/pus

36

7 indications for wire-guided endobronchial blocker

- ETT or trach in place
- RSI and OLV
- known and unknown difficult airway
- nasotracheal intubation
- small adult pt
- selective lobar ventilation
- trauma

37

What is the most versatile method for OLV

Left DLT

38

12 steps of mgmt of hypoxia with OLV

- notifies surgeon of low sat, interventions, exact sat
-ask for help
- decrease volatile agent
- increase FIO2
- change vent to PC
- manipulate PEEP
- manipulates MV
- administer inhaler
- suction ventilated lung
- insufflates with O2
- PEEP down lung, CPAP up lung

39

8 indications for securing pt airway

Anesthesia
Hemodynamic instability
Decreased LOC
Pain mgmt
Severe dyspnea- Acc muscle use
Severe hypoxemia/hypercarbia
Severe acidosis
Inability to protect airway

40

Normal TMD

>6cm (more than 3 fingerbreadths)

41

Normal mouth opening

>4cm
2-3 fingerbreadths

42

Neck circumference > ______ predicts difficult airway

60cm

43

LEMON assessment

Look
- facial trauma, large incisiors, beard, large tongue
Evaluate (3-3-2)
- interincisor gap, hyomental distance, TMD
Mallampati
Obstruction
Neck mobility

44

7 risk factors for aspiration

Short tasting times
Pregnancy
Increased abdominal pressure
GI disease
GERD
Bowel obstruction
NM disease or nervous system dysfunction

45

6 complications of airway mgmt

Failed intubation
CVCI
Airway trauma
Aspiration
Mainstem intubation
Bronchospasm

46

6 disadvantages of face mask for general

Ties up hands
Higher FGF
Access difficult
More desat than LMA
Higher work of breathing
Poor correlation of ETCO2 and PCO2

47

4 complications from using face mask

Pressure necrosis
Nerve injury
Gastric insufflation
Pollution

48

8 complications of LMA

Aspiration
Gastric distention
Airway obstruction
Trauma (uvula edema)
Laryngospasm
Dislodgement
Nerve injury

49

5 advantages of LMA

Ease of insertion
Smooth emergence
Low pollution
Avoid complications of face mask and intubation
Protect from barotrauma

50

3 advantages of LMA compared to face mask

Hands free
Better seal in bearded
Lass facial nerve and eye trauma

51

5 advantages of LMA compared to ETT

Useful for difficult intubation
Less coughing on emergence
Ability to ventilate until airway reflexes restored
Reduced CV response
Less laryngospasm and bronchospasm

52

2 disadvantages of LMA vs ETT

Less safe in prone or jackknife position
Less secure airway

53

Machine end of ETT has a ______ connector (size)

15mm

54

6 uses of FOB

Intubation (awake/asleep, nasal, oral)
Confirm ETT placement
Confirm placement of DLT
Clear secretions
Bronch with lovage for aspiration or blood in ETT
Bronch exam with intervention

55

3 advantages of FOB

Useful if difficult or impossible to intubate with rigid laryngoscopes

Onstable Cspine

Overcome anatomic variations

56

7 disadvantages of FOB

-expensive, fragile, difficult to use
-more time and prep required
-difficult or impossible with blood, secretions, hypoxemia
- gastric distension, rupture
- laryngeal trauma
-technical issues (fogging, anatomy, light source)

57

4 structures at risk of damage from DL

Dental injury
Cspine injury
Lips, tongue, palate, Laryngospasm, esophagus

58

2 uses of reinforced ETT

- kinking possible (prone, neck sg)
- ETT placed in tracheostomy

59

3 differences in microlaryngeal tracheal tube and conventional ETT

Larger cuff
Narrow body
Longer body

60

3 safety features of laser ETT

-cuff filled with blue indicator so see if hit
- saline in cuff helps put out fire
- ???

61

Type of oral airway used for awake fiberoptic intubation orally

Williams, ovassapian, ROTIG

62

4 standard monitors for the intubated pt undergoing general anesthetic

ECG
BP
Capnometry
Pulseox

63

Role of oxygen analyzer in avoiding hypoxic mix of gases

Continuously measure and indicate FIO2 in breathing system. Indicate when inspired O2 deviates from desired limits

64

Single monitor which provides most clinical information

Pulse oximeter

65

Which law?
Absorption of a given thickness of a solution of a given concentration is the same as twice the thickness of half the concentration

Beers law

66

Which law? Each layer of equal thickness absorbs an equal fraction of radiation which passes through it

Lamberts law

67

Absorption of red and infared light

Oxygenated blood

deoxygenated blood

Oxygenated- 960 mm

Deoxygenated- 660 mm

68

How do differences in oxygenated and deoxygenated blood absorption generates pulse ox reading?

Change in light absorption when passing through vascular bed during arterial pulsation

69

5 clinical scenarios which may result in decreased oxygen saturation

VQ mismatch
Disconnect
Inadequate MV
Misplaced ETT
Diffusion abnormality

70

7 location which may be used to monitor oxygen saturation

Finger
Nose
Earlobe
Forehead
Lip
Tongue
Check
Forehead

71

11 Factors affecting pulse ox accuracy

Electrocautery
Motion, venous pulsation
Ambient light/radiant warmers
Nail polish, acrylic nails
Low perfusion
CO2 methemoglobin
Methylene blue/indigo carmine
Hypothermia
Tourniquet
Nonpulsatile flow (CPB)
IABP (2 systole)

72

Accuracy standard of oximeter

Accuracy bw 70-100%

73

Mandatory sat alarm for oximeter

Sat <85%

74

4 uses for pulse oximeter other than oxygen saturation

- Estimate systolic BP
- Monitor peripheral circulation (mediastinoscopy, shoulder sg)
- Locating arteries
- Warning of fluid extravasation

75

Most commonly used technology for gas monitoring

Diverting gas monitoring

76

How does nondiverting gas monitor works

Diverts some gas to monitor to interpret CO2, volatile anesthetics, N2O

77

How does infared technology for anesthetic gas concentration works?

Gases with 2 or more dissimilar atoms have specific infared light absorption

Amount of IR light absorbed is proportional to concentration of the absorbing molecules

Compare IT light absorption to known standard