BRONCHIECTASIS

DR.K.M.LAKSHMANARAJAN

BRONCHIECTASIS

• CLINICAL DISCUSSION OF BRONCHIECTASIS

• PULMONARY FUNCTION TESTS• PHYSIOLOGY OF ONE LUNG

VENTILATION• ISOLATION OF LUNGS• ANESTHETIC MANAGEMENT

CLINICAL DISCUSSION

• DEF • Abnormal ,persistent ,irreversible

dilation and distortion of medium sized bronchi (5th to 9th gen) by more than 2 mm

• May be due to bronchial distension as a result of chronic obstruction and recurrent infection

PREDISPOSING FACTORS

• Congenital• Primary• Secondary • Mounier –kuhn syn-tracheo

bronchomegaly• William campbell syn-bronchomalacia• Pulmonary sequestration• Kartageners

synd(bronchiectasis,sinusitis,situs inversus)

• Young ‘s synd-idiopathic obstructive azoospermia

• Yellow nail synd-lymphedema,yellow nails,pleural effusion

• Cystic fibrosis• Alpha 1 AT def• Hypogammaglobulinemia• Chandra-khetarpal synd-

levocardia,sinusitis,bronchiectasis with out ciliary abnomality

ACQUIRED

• INFECTIONS-MEASLES,WHOOPING COUGH,BRONCHITIS,BRONCHIOLITIS,ENDOBRONCHIAL TB

• BRONCHIAL OBSTRUCTION-FOREIGN BODY,TUMOUR,LYMPHNODES,LA,ANEURYSM

• ASSOCIATED IMMUNE DISORDERS-ULCERATIVE COLITIS,SLE,RHEUMATOID ,ABPA

TYPES

• CYLINDRICAL• SACCULAR(CYSTIC)• VARICOSE• FUSIFORM

• LT LOWER LOBE COMMON• BECAUSE LT IS LONGER AND

NARROW• UPPER LOBE• INVOLVES POSTERIOR AND APICAL

SEGMENTS• COMMON IN TB,CYSTIC

FIBROSIS,ABPA

DRY BRONCHIECTASIS

• BRONCHIECTASIS SICCA• ONLY HEMOPTYSIS PRESENT• NO SPUTUM PRODUCTION• TB

MIDDLE LOBE(BROCK’S SYN)

• Recurrent atelectasis of RT middle lobe in the absence of endobronchial obst

• Which can lead to bronchiectasis and fibrosis

• Due to TB lymph node obstruction middle lobe bronchus

• RML-bronchus-narrow & slit like lumen• RML surrounded by nodes• RMLbefore bifurcation –runs longer

course• Lacks collateral ventilation

PSEUDO BRONCIECTASIS

• TEMPORARY BRONCHIAL DILATATION OCCURING IN AN AREA OF LUNG AFFECTED BY PNEUMONIC CONSOLIDATION,TRACHEO BRONCHITIS/LUNG COLLAPSE

COMPLICATIONS

• HEMOPTYSIS• METASTATIC ABSCESS• PNEUMOTHORAX• CORPULMONALE• AMYLOIDOSIS• RECURRENT PNEUMONIA• PYOTHORAX• LUNG ABSCESS

CF

• PERSISTENT COUGH• RECURRENT COUGH• LARGE QUANTITY OF PURULENT

SPUTUM PRODUCTION• HEMOPTYSIS• PERSISTENT COARSE LEATHERY

CRACKLES• BRONCHIAL BREATHING• CLUBBING

COUGH

• REFLEX ACT OF FORCEFUL EXPIRATION AGAINST CLOSED GLOTTIS

• BRONCHORRHOEA• IF THE QUANTITY >100ML /DAY• COPIOUS AMOUNT –CHANGES IN

POSTURE –DUE TO IRRITATION OF HEALTHY BRONCHIAL MUCOSA

• LARGE AMOUNT OF COLORLESS SPUTUM –ALVEOLAR CELL CARCINOMA

• OFFENSIVE OR FOETID ODOUR SPUTUM

• LUNG ABSCESS• BRONCHIECTASIS• AMEBIC BACTERIAL INFECTION

HEMOPTYSIS

• FRANK –BLOOD ONLY-CARCINOMA• SPURIOUS HEMOPTYSIS-SECONDARY

TO URI ABOVE THE LEVEL OF LARYNX

• PSEUDO HEMOPTYSIS-DUE TO PIGMENT,PRODIGIOSIN PRODUCED BY GRAM NEGATIVE ORGANISM ,SERRATIA MARCESCENS

• ENDEMIC HEMOPTYSIS –INFECTION WITH LUNG FLUKE (PARAGONIMUS WESTERMANI)

SEVERITY OF HEMOPTYSIS

• Mild -<100 ml/day• Moderate 100-150 ml • Severe 200 ml • Massive >500 ml/day or >150 ml /hr or

100 ml /day for more than 3 days

DYSPNEA

• AWARENESS OF ONE ‘S OWN RESPIRATION WHICH IS UNPLEASANT AND DISTRESSED

• NOT BREATHLESSNESS• BREATHLESSNESS-NOT

DISTRESSED,MAY BE PLEASURABLE(AFTER EXERCISE )

DYSPNEA

• PROGRESSIVE DYSPNEA, • WORSENING COUGH, AND• PRODUCTION OF INCREASED

QUANTITIES OF PURULENT SPUTUM, • WITH ONSET OVER 1 TO 3 DAYS, • USUALLY AFTER AN UPPER

RESPIRATORY TRACT INFECTION, • DEFINES AN EXACERBATION OF

CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

PND – IN RS

• BECAUSE OF POOLING OF SECRETIONS,

• GRAVITY-INDUCED DECREASES IN LUNG VOLUMES, OR SLEEP-INDUCED INCREASES IN AIRFLOW RESISTANCE

ORTHOPNEA IN RS

• OCCASIONAL IN LUNG DISEASE • INSTANT ORTHOPNEA IS

PARTICULARLY CHARACTERISTIC OF THE RARE CONDITION OF PARALYSIS OF BOTH LEAVES OF THE DIAPHRAGM

DYSPNEA GRADE- MODIFIED BORG CATEGORY SCALE

RATING INTENSITY OF SENSATION

 0 NOTHING AT ALL

 0.5 VERY, VERY SLIGHT (JUST NOTICEABLE)

 1 VERY SLIGHT

 2 SLIGHT

 3 MODERATE

 4 SOMEWHAT SEVERE

 5 SEVERE

 6  

 7 VERY SEVERE

 8  

 9 VERY, VERY SEVERE (ALMOST MAXIMAL)

10 MAXIMAL

MRC GRADING OF DYSPNEA

1 Breathless only with strenuous exercise

2 Short of breath when hurrying on the level or up a slight hill

3 Slower than most people of the same age on a level surface orHave to stop when walking at my own pace on the level.

4 Stop for breath walking 100 meters orAfter a walking few minutes at my own pace on the level

5 Too breathless to leave the house.

ROIZEN’S CLASSIFICATION

GRADE 0 NO DYSPNEA WHILE WALKING ON THE LEVEL AT NORMAL PLACE

1 I AM ABLE TO WALK AS FAR AS I LIKE ,PROVIDED I TAKE MY TIME

2 SPECIFIC STREET BLOCK LIMITATION- IHAVE TO STOP FOR A WHILE AFTER ONE OR TWO BLOCKS

3 DYSPNEA ON MILD EXERTION-I HAVE TO STOP AND REST GOING FROM THE KITCHEN TO BATH ROOM

4 DYSPNEA AT REST

CHEST PAIN-CAUSES

• PLEURISY • INFLAMMATION OF OR TRAUMA TO

THE JOINTS, MUSCLES, CARTILAGES, BONES, AND FASCIAE OF THE THORACIC CAGE IS A COMMON CAUSE OF CHEST PAIN.

• REDNESS, SWELLING, AND SORENESS OF THE COSTOCHONDRAL JUNCTIONS IS CALLED TIETZE'S SYNDROME

• PHT

INVESTIGATION-SCHIRMER TEST

• ASSESESSMENT OF CILIARY FUNCTION

• PELLET OF SACCHARINE PLACED IN ANT CHAMBER OF NOSE

• TIME TAKEN TO REACH THE PAHARYNX

• NORMALLY NOT MORE THAN 20 MINTS

SPUTUM EXAMINATION

• 3 LAYERED SPUTUM • UPPER-FROTHY,WATERY• MIDDLE-TURBID,MUCOPURULENT• LOWER-PURULENT,OPAQUE

XRAY CHEST

• RING SHADOWS• TRAM TRACK SIGN• GLOVED FINGER APPEARANCE• FIBROSIS• COR PULMONALE

CT SCAN

• Thick sections –specific• Thin –sensitive• Proximal airway bronchiectasis-ABPA• Nodular bronchiectasis-Myco bact

avium

• Bronchography

SMOKING

• Contents• Carcinogens

Tar

Polynuclear aromatic hydrocarbons

Betanapthylamine

N-nitrosonornicotine

Benzopyrene

Nickel,arsenic

Polonium 210

Nitrosamines,hydrazine,vinyl chloride

• Co carcinogens phenol,cresol,catechol• Tumor accelerator indole,carbazole

• 400 substances• Nicotine –ganglion stimulant /depressant

NICOTINE • Increase both systolic and diastolic• Heart rate• Force of contraction• Myocardial oxygen consumption• Coronary blood flow• Peripheral vaso constriction

• CO-causes COPD,POLYCYTHEMIA,CNS IMPAIRMENT

• Smoking index • SI=no of cigars /day ×total duration in

years• SI <100 –mild smoker• SI101-300-moderate smoker• >300-heavy smoker• Pack year• No of pack years=1 pocket of

cigarette/day×no of years(1 pack=20 cigars

• Risk 40 Times more if 2 packs /day for 20 years

EXAMINATION

• Build• Nourishment• Dyspnea• Cyanosis• Anemia• Jaundice• Clubbing• Lymphadenopathy• Eyes• Pedal edema

CYANOSIS

• Bluish discoloration of skin & mucous membrane due to increased quantityof reduced HB >5 gm/dl or >30 %of total HB and Pao2 <85% or due to the presence of abnormal HB pigments in blood perfusing these areas

• Central • Peripheral • differential

CYANOSIS

• Due to methemoglobinemia-remains brown after exposure to air

• But cyanosis –change to bright red

• Intermittent cyanosis – EBSTEINS ANOMALY

CYANOSIS IN RS

• HYPOXIA• CORPULMONALE• SILENT CHEST• ASPIRATION

ANEMIA

• DUE TO HEMOPTYSIS • EXCESSIVE SPUTUM • PROTEIN LOSS• LOSS APPETETITE -MALNUTRITION

JAUNDICE

• PULMONARY INFARCTION• DRUGS (ATT)• LIVER SECONDARIES• PNEUMONIA • CORPULMONALE-LIVER CONGESTION

CLUBBING

• Selective bulbous enlargement of distal portion of digit due to incresed subungual soft tissue

• Normal angle between nail and nail bed 160 °(lovibond angle)

• Minimum duration need for clubbing manifestation -2- 3 weeks

• First appears in index finger

GRADING OF CLUBBING

• 1-OBLITERATION OF ANGLE BETWEEN NAIL AND NAIL BED /POSITIVE FLUCTUATION TEST

• 2.PARROT PEAK APPEARANCE(AP DIAMETER INCREASED)

• 3.DRUMSTICK APPEARANCE• 4.HYPERTROPHIC OSTEOARTHROPATHY • SHAMROTH SIGN

CLUBBING(HIPPOCRATES FINGERS)

• INDICATES UNDERLYING SUPPURATION /MALIGNANCY

• PACHYDERMOPERIOSTOSIS-PRIMARY FORM OF CLUBBING WITH SKIN CHANGES

• THYROID ACROPATHY-CLUBBING IN SEVERE THYROTOXICOSIS

• UNIVERSALLY PRESENT IN PANCOAST TUMOUR

HYPERTROPHIC PULMONARY OSTEOARTHROPATHY

• PAINFUL SWELLING OF THE WRIST,ELBOW,KNEE ,ANGLE,WITH RADIOLOGICAL EVIDENCE OF SUBPERIOSTEAL NEW BONE FORMATION

• FAMILIAL /IDIOPATHIC

HPOA

• UNIVERSALLY PRESENT IN PANCOAST TUMOUR

• OTHERWISE CALLED AS

Pierre Marie-Bamberger syndrome

THEORIES OF CLUBBING

• Neurogenic –vagal stimulation –vasodilation and clubbing

• Humoral- GH,PTH,estrogen ,bradykinin –vasodilataion

• Ferritin – decreased ferritin in systmic circulation causes dilatation of AV anastomosis and hypertrophy of distal terminal phalanx

• Hypoxia –persistent hypoxia –opening of AV fistula • SHUNT THEORY• PLATELET DERIVED GROWTH FACTOR-latest /most

acceptable

PSEUDO CLUBBING

• Hansen’s disease-due to resorption of tissue

• Vinyl chloride worker-focal tissue reaction

• Leukemia –tissue infiltration• Hyperparathyroidiam –bone resorption

EYES

• Horners synd-pancoast tumour• iridocyclitis-TB/collagen vascular

disease• Phlycten –TB• Chemosis –sv syndrome • Choroid tubercle –TB • Papilledema –copd /svc obstruction• Color blind-ethambutol(red green color)

PEDAL EDEMA

• CORPULMONALE• PROTEIN LOSS IN SPUTUM

PULSE

• Wave form felt by finger ,produced by cardiac cycle ,which traverses the arterial tree in peripheral direction

• Pulsus paradoxus• Exaggerated reduction in strength of pulse during

normal inspiration or exaggerated inspiratory fall in systolic pressure of more than 10 mmhg during normal breathing

• CARDIAC TAMPONADE • Constrictive pericarditis• COPD /ACUTE SEVERE ASTHMA• SVC OBSTRUCTION

• REVERSE PULSUS PARADOXUS• Insp rise in arterial pressure• HOCM • IPPV• AV dissociation

NECK EXAMINATION-LYMPH NODE

• ROUND 0.5 CM DIAMETER FIRM –SIGNIFICANT

• LARGE FIXED –MALIG• HARD /CRAGGY MATTED-TB• VIRCHOW’S NODE –LT

SUPRACLAVICULAR NODE(TROSIER’S SIGN)

• PARIETAL PLEURA-AXILLARY NODE• RT LUNG/LT LOWER LOBE-RT SCN• LT UPPER LOBE-VIRCHOWS NODE

PRESENCE OF VEINS

• SVC OBSTRUCTION

EXTERNAL MANIFESTATION

• 1.ASTERIXIS –RESP FAILURE • TYPES OF RESP FAILURE

• 2.HALITOSIS - CONDITION OF HAVING STALE OR FOUL-SMELLING BREATH. SUPPURATIVE LUNG DISEASE

• GYNECOMASTIA-INH,DIGOXIN,BRONCHOGENIC CARCINOMA

• 3.HORNERS SYND-PANCOAST SYND

TB MARKERS

• TINEA VERSICOLAR• LUPUS VULGARIS • ERYTHEMA NODOSAM • SCROFULDERMA • EPIDIDYMORCHITIS

RES TRACT

• URT• LRT • 1.SUPRACLAVICULAR AREA• 2.INFRACLAVICULAR AREA• 3.MAMMARY REGION• 4.AXILLARY • 5.INFRA AXILLARY • 6.SUPRASCAPULAR • 7.INTERSCAPULAR • 8.INFRASCAPULAR

TRACHEA

• TRAIL’S SIGN • UNDUE PROMINENCE OF CLAVICULAR

HEAD OF STERNOMASTOID ON SAME SIDE TO WHICH TRACHEA IS DEVIATED

CHEST DEFORMITIES

• Flat chest –AP and transverse diameter ratio 1:2-TB /fibrothx

• Barrel chest-AP and TD 1:1-COPD (emphysema )

• Pigeon (pectus carinatum)-forward protrusion of sternum /adjacent costal cartilage-childhood asthma,marfans

• Pectus excavatum (funnel /cobblers chest)-exaggeration of hollowness of normal hollowness

• Harrisons sulcus-indrawing of ribs • Rickety rosary • Scorbutic rosary

RS PROPER

• RR-THORACO ABD IN WOMEN • CHEST MOVEMENTS• RHYTHM OF RESPIRATION • TRACHEAL TUG-OLLIVERS SIGN-

ANEUYSM OF AORTIC ARCH• INSPIRATORY TRACHEAL DESCENT-

COPD

NORMAL PERCUSSION NOTE

• CHRONIC BRONCHITIS• BRONCHIAL ASTHMA• INTERSTITAIL LUNG DISEASE• DIFFUSE EMPHYSEMA

• TIDAL PERCUSSION

• TRAUBES PERCUSSION • Two parellel vertical lines• One from LT 6 th costochodral jn • Another From 9th rib in midaxillary line• LT costal margin • Boundaries RT –LT lobe of liver• LT –spleen• Above –LT lung• Below-LT costal margin• Content –fundus of stomach

VESICULAR BREATH SOUNDS

• Low pitched ,rustling in nature produced by attenuating and filtering effect of lung parenchyma

• Normally no pause

BRONCHIAL BREATH SOUNDS

• Loud high pitched with an aspirate and gutteral quality

• Duration of inspiration is shortened • Tubular• Cavernous• Amphoric

ADDED SOUNDS

• Crackles • Non musical ,interrupted added sounds

of short duration • Explosive in nature• Types • Fine –loud ,short duration ,arise from

alveoli• Coarse –low pitched ,loud,arise from

bronchus and bronchioles

CRACKLES

• Early inspiratory- chronic bronchitis• Mid insp –bronchiectasis• Late insp –

asbestosis ,fibrosis,ILD,pulm edema• Expiratory – chronic bronchitis,pulm

edema

MECHANISM OF CRACKLES

• Bubbling of airflow thro secretions in bronchial level

• Sudden opening of successive bronchioles and alveoli with rapid equalisation of pressure-explosive sounds

• Crackles with out sputum-ILD• With sputum-parenchymal disease

RONCHI

• Musical ,continous • Low pitched (sonorous)-from large airways• High pitched (sibilant)-smaller airways

HAMMANS MEDIASTINAL CRUNCH

• Clicking ,rhythmical sound synchronous with cardiac cycle

• Mediastinal emphysema • Cavity –def• Gas containing space with a wall

thickness >1mm• Bulla <1mm thickeness

ANATOMY OF RS

• LARYNX C3-C6• TRACHEA – C6-T5• 11 CM-15CM• 2-2.5 CM DIAMETER(OWN INDEX

FINGER DM)

• 2 BRONCHI • RT -2.5 CM , LT -5 CM • RT 10 SEG ,LT -10 SEG

FUNCTIONAL SUBSEGMENTS

OXYGEN FLUX

• Amount of o2 leaving lt ventricle /min in arterial blood

• =CO*SAO2*HB% *1.31• 5000*98/100*15.6/100 *1.31• 1000 ml/min

PFT

PFT

• SPIROMETRY• HANDHELD SPIROMETER• BODY PLETHYSMOGRAPHY• N2 WASHOUT• HELIUM DILUTIONAL TECH• BED SIDE TESTS• ABG• V/Q SCAN• PERFUSION SCINTIGRAPHY

WORLD SPIROMETRY DAY

• STATIC TESTS• DYNAMIC LUNG• MUSCLES OF RESPIRATION• COMPLIANCE• DLCO

GOALS OF PREOP - PFTS

• Quantify the severity • Follow up of disease• Observe response to treatment.• Predict likelihood of post-operative

complications

INDICATIONS• > 60 yrs

• Evidence of chronic pulomonary disease

• Heavy smokers

• Patients with dyspnoea on exertion

• Morbidly obese pts.

• Patients with thoracic surgery

• Myasthenia gravis,GBS,polyneuritis.

• To see response of bronchodilators

• To assess degree of disability due to occupational lung diseases

SPIROMETRY

• SPIROMETRY IS THE MEASUREMENT OF AIR FLOW INTO AND OUT OF THE LUNGS

• INVENTED BY JOHN HUTCHINSON • HE COINED THE TERM VITAL CAPACITY•  

C/I TO SPIROMETRY

• Hemoptysis (spitting up blood from the lungs or bronchial tubes)

• Pneumothorax (free air or gas in the pleural cavity)

• Recent heart attack • Unstable angina • Aneurysm (cranial, thoracic, or abdominal) • Thrombotic condition (such as clotting

within a blood vessel) • Recent thoracic or abdominal surgery • Nausea or vomiting

PREPARATION FOR SPIROMETRY

• SHOULD NOT HAVE EATEN HEAVILY WITHIN THREE HOURS OF THE TEST

• TO WEAR LOOSE-FITTING CLOTHING OVER THE CHEST AND ABDOMINAL AREA.

SPIROMETRY

• That the patient’s trunk and neck remain erect during the maneuvers

• The patient looking straight forward during the entire test

• Without bending over (the latter not only affects the way the trachea is stretched, but may also lead to saliva dripping into the equipment).

• FVC –minimum duration – 6 sec (3 sec for children <10 yrs)

• Children > 6 yrs –allowed • Max no of maneuvers-8• the largest and second largest FVC and

or FEV1 must not differ by more than 150 mL

BED SIDE LUNG TESTS

• BREATH HOLDING (SABRASEZ)TEST• Pt asked to take deep breath and hold it

for as long as possible • >30 sec –normal • <15 sec-reduced vital capacity• Normal person – hold up to 1 min

SNIDERS MATCH BLOWING TEST

• Lighted match stick held at 6 inches (15 cm ) from pt mouth

• Pt asked to blow out the match with out pursing lips

• Rough estimate of exp capacity /MBC• If cant –MBC <60 L/MIN OR FEV1 <1.6L• IF NOT ON 8 CMS DISTANCE –FEV

1<1L

DEBONOS WHISTLE TEST

• INSTRUMENT HAS TUBE AND SIDE HOLES

• WHISTLE AT END • PT ASKED TO EXHALE AS

FORCEFULLY AS POSSIBLE INTO THE TUBE

• ESTIMATES PEFR UP TO 300 L/MIN

WATCH AND STETHOSCOPE TEST

• Auscultation over the trachea during forced expiration

• Normal values -3-4 secs• >6 sec-obstructive airway

HAND HELD SPIROMETRY

• FEV 1& PEFR• PEFR =HT (CM)-80* 5 • Normal PEFR 480-700 L/MIN(MALES)• 300-500 L//MIN(FEMALES)

WRIGHT RESPIROMETER

• MEASURES MINUTE VOLUME /TIDAL VOLUME

• PEROPERATIVE USE

TESTS FOR VO2 MAX

EXERCISE TESTING-GOLD STANDARD

• For cardiopulmonary reserve• Normal VO2 max >40 ml/kg/min• 5 flights= >20 ml/kg/min-low post op

complications• 2 flights-vo2 =16 ml/kg/min• 1 flight = <10 ml/kg/min-inoperable • 10-15 ml/kg/min-high risk• 1 flight=20 steps ,6 inch ht

EXERCISE INCIDENCE OF CARDIOPULMONARY COMPLICATION

< 1 FLIGHT OF STAIRS 89%

<2 FLIGHTS 50%

<3 FLIGHTS 11%

6MIN WALK TEST

• A practical simple test that requires a 100-ft hallway but no exercise equipment or advanced training for technicians

• This test measures the distance that a patient can quickly walk on A FLAT, HARD SURFACE in a period of 6 minutes

• Used as a one-time measure of functional status of patients, as well as a predictor of morbidity and mortality

• C/I TO 6MWT – UNSTABLE ANGINA • RESTING HR > 120 /MIN• BP > 180/100 MMHG • IF SAPO2 FALLS < 4 %-HIGH RISK FOR

PNEUMONECTOMY

6MWT

• 180 FEET IN 1 MIN(6 MIN WALK DISTANCE 1080FT)=VO2 MAX 12 ML/KG/MIN

• <2000FT DISTANCE=VO2MAX <15ML/KG/MIN

SHUTTLE WALK TEST

• If the repeat test is performed on the same day, 30 minutes rest should be allowed between tests

• A comfortable ambient temperature and humidity should be maintained for all tests. The walking track must be the same for all tests for a patient: Cones are placed nine metres apart.

• The distance walked around the cones is 10 metres.

SHUTTLE WALK TEST

• THE PATIENT SHOULD REST FOR AT LEAST 15 MINUTES BEFORE BEGINNING THE ISWT. RECORD: BLOOD PRESSURE.

• HEART RATE. • OXYGEN SATURATION. • DYSPNOEA SCORE• SPEED IS GRADULLY INCREASED

EVERY MIN• INABILTIY TO COMPLETE 25 SHUTTLES

–INDICATES VO2 MAX <15 ML/KG

COOPER TEST

• Kenneth H. Cooper conducted a study for the United States Air Force in the late 1960s. One of the results of this was the Cooper test in which the distance covered running in 12 minutes is measured. Based on the measured distance, an estimate of VO2 max (in ml/min/kg) is

• VO2 MAX=d12-505/45

• where d12 is distance (in metres) covered in 12 minutes

STATIC TESTS

LUNG VOLUMES

• TV –volume of air inspired/exp at quiet breath -7-10ml /kg

• IRV-max volume of air that can be expired after normal inspiration

• 3200-3500 ml• ERV-max volume of air can be expired

after normal exp-1200 ml• RV-volume of air remaining in the lungs

after max expiration 1500-2100ml• Closing volume 15-20%of VC (volume of

gas expelled during Phase IV of single breath N2 test)

Lung VolumesLung Volumes

IRV

TV

ERV

• 4 Volumes4 Volumes• 4 Capacities4 Capacities

• Sum of 2 or Sum of 2 or more lung more lung volumesvolumes

RV

IC

FRC

VC

TLC

RV

CAPACITY

• Vital –max volume of air can expired after max inspiration-4000ml/2100-2600ml/m2

• TLC-total volume of air contained in the lungs at max inspiration

• IC-max volume of air can be inspired after normal expir-2000-2900 ml

• FRC-volume of air remaining in lungs after normal expiration 2300-3300ml

DEAD SPACE

• Anatomical -150 ml(2 ml/kg)• Physiological –fraction of tidalvolume

not available for gas exchange

CLOSING CAPACITY

• Volume at which small airways states to close down in the dependent lung

• Measured by single breath N2 wash out tech

• If CC rises above FRC –hypoxemia• CC increase –smokers,obesity,rapid

IVF ,chronic bronchitis• CC=CV+RV

TLC

• Gold standard for measuring restrictive pattern

• Mild = <80% predicted • moderated <60 %• Severe <40%

DYNAMIC TESTS

• FVC – after max inspiratory effort , exhales as forcefully and rapidly as possible

• Rate Of airflow indirectly relates to flow resistance properties

• Exhalation –atleast for 4 secs• Not to be interrupted by cough,glottic

closure

• FEV 1 – FIRST SECOND OF FVC MANUEVER

• FEV 0.5 – 50%• FEV 1- 75-80%• FEV2 -94 %• FEV 3 -97%

FEV 1 SEVERITY OF OBSTRUCTION

<70% MILD

<60% MODERATE

<50% SEVERE

FEV 1(LITRES) DEGREE OF OBSTRUCTION

3-4.5 NORMAL

1.5-2.5 MILD TO MODERATE

<1.0 HANDICAPPED

0.8 DISABILITY

0.5 SEVERE EMPHYSEMA

PEFR

• MAX FLOW RATE MEASURED DURING FVC MANUEVER AT 0.1 SECS

• EXTRAPOLAGTED IN L/MIN

• USED TO MONITOR THERAPEUTIC RESPONSES

• NORMAL >500 LITRE/MIN• <200 LITRE/MIN-IMPAIRED COUGHING• PFR 200-1200 ML(MID EXP FLOW

RATE)-MEASURED BY HAND HELD SPIROMETRY/PNEUMATOGRAPHY

MAX MID EXP FLOW RATE

• 25-75% OF EXP VOLUME • DOESN’T INCLUDE INITIAL HIGHLY

EFFORT DEPENDENCY• EFFORT INDEPENDENT• 4.5-5.0 LITRES/SEC

MVV (MBC)

• Pt breaths as hard and fast as possible for 12 secs

• Extrapolated to 1 min• Litre/min• Decreased in obstructive disease• MVV=FEV1*35• =150-175 LITRES/MIN

RESPIRATORY MUSCLE STRENGTH

• MAXIMUMSTATIC INSPIRATORY PRESSURE (PIMAX) NEAR RV –MEASURED

• MAX STATIC EXPIRATORY PRESSURE (PEMAX)-NEAR TLC

• NORMAL PIMAX = -125 CMH20• PEMAX = +200CMH20• < -25CMH2 0-SEVERE INABILITY TO

TAKE BREATH• <+40CMH20 OF PEMAX-SEVERE COUGH

IMPAIRMENT

LUNG COMPLIANCE

• CHEST WALL • LUNG • TOTAL • COMPLIANCE = CHANGE IN

VOLUME /CHANGE INALVEOLAR - INTRATHORACIC PRESSURE GRADIENT

• NORMAL 200 ML/CMH20 IN UPRIGHT

• CHEST WALL COMPLIANCE -200 ML/CM2

• TOTAL COMPLIANCE 100 ML/CMH20• MEASURED BY SWALLOWING LATEX

BALLOON IN ESOPHAGUS –CONNECTED TO CATHETER TO PRESSURE TRANSDUCER

PULMONARY RESISTANCE

• MEASURED BY BODY PLETHYSMOGRAPH

• NORMAL RAW – 0.5 TO 2 CM/SEC

DISTRIBUTION OF VENTILATION

• SINGLE BREATH N2 WASHOUT• MULTIPLE N2 BREATH• RADIO ISOTOPE TECHNIQUE(XE 133)

PERFUSION

• RADIOISOTOPE • PULMONARY ANGIOGRAM

MATCHING VENTILATION PERFUSION

• ABG• VQ SCAN• DEAD SPACE MEASUREMENT• INTRA PULMONARY SHUNT• NORMAL PA02-PaO2=8 mmhg

DYSPNEA DIFFERENTIATION INDEX

• PEFR*PaO2/1000• LOW IN RESP DYSPNEA• %DDI OF PULMONARY =2.1±1.0• OF CARDIAC =4.0±1.4

DLCO

• DEPENDS ON• CHARAC ALVEOLAR CAP MEMBRANE• EFFECTIVE SURFACE AREA OF GAS

EXCHANGE• VOLUME OF BLOOD IN ALVEOLAR

CAPILLARIES• CARDIAC OUTPUT• NORMAL 20-30 ML/MIN/MM

• DLCO=CO(ML)/MIN/MMHG

PACO-PcCO

• CORRECTED DLCO

MEASURED DLCO  X (1.7 HB/(10.22+HB)

WHERE [HB] IS THE MEASURED HEMOGLOBIN CONCENTRATION (G/DL).

PREDICTED DLCO

• (HT IN MTS)↑3 ×6(1- AGE-34)

100

DIFFUSING CAPACITY

Decreased DLCO (<80% predicted)

Obstructive lung disease

Parenchymal disease

Pulmonary vascular disease

Anemia

Increased DLCO (>120-140%

predicted)

Asthma (or normal)

Pulmonary hemorrhage

Polycythemia

Left to right shunt

OBSTRUCTIVE DISORDERS

• Characterized by a limitation of expiratory airflow• Examples: asthma,

COPD

• Decreased: FEV1, FEF25-

75, FEV1/FVC ratio (<0.8)

• Increased or Normal: TLC

• Scooped out appearance seen.

RESTRICTIVE LUNG DISEASE

• Characterized by diminished lung volume due to:

• change in alteration in lung parenchyma (interstitial lung disease)

• disease of pleura, chest wall (e.g. scoliosis), or neuromuscular apparatus (e.g. muscular dystrophy)

• Decreased TLC, FVC

• Normal or increased: FEV1/FVC ratio

LARGE AIRWAY OBSTRUCTION

• Characterized by a truncated inspiratory or expiratory loop

UPPER AIRWAY OBSTRUCTION

CRITERIA FOR ELECTIVE VENTILATION

• TV- < 2ML/Kg• VC-<15 ml/kg• FEV1-<50% predicted• FEV1/FVC-<50%• Maximum inspiratory pressure <20cm

of H20

PREOP EVALUATION

• THOROUGH HISTORY• CLINICAL EXAMINATION• INVESTIGATIONS

EXTRA PULMONARY INTRATHORACIC SYMPTOMS

• PLEURAL EFFUSION• CHEST WALL PAIN• DYSPHAGIA(ESOPHAGUS)• SVC SYNDROME • PERICARDITIS• BRACHIAL PLEXUS • HOARSENESS • STRIDOR• HORNERS SYND

EXTRA THORACIC METASTATIC SYMPTOMS

• BRAIN• BONE • LIVER• ADRENALS• GIT• KIDNEYS• PANCREAS

EXTRA THORACIC NON METASTATIC SYMPTOMS

• Ectopic ACTH-CUSHING’S SYND• HYPONATREMIA• SIADH• HYPERCALCEMIA• CARCINOID SYND• EATEN LAMBERT SYND• HYPOGLYCEMIA• CLUBBING• THROMBOPHLEBITIS

EATEN LAMBERT SYND

• ASSOCIATED WIT SMALL CELL LUNG CANCER

• AUTO IMMUNE DISEASE• ANTIBODY DIRECTED AGAINST AN

ANTIGEN CROSS REACT WITH VOLTAGE GATED CALCIUM CHANNLES INVOLVED IN ACH RELEASE

• PRESYNAPTIC DEFECT• EMG – INCREMENTAL PATTERN

• PPO FEV 1%=PRE OP FEV1%×(1-% OF FUNCTIONAL LUNG TISSUE REMOVED /100)

PRE OP PFT & RISK FOR PNEUMONECTOMY

TESTING PHASE PFT INCRESED RISK

WHOLE LUNG ABG HYPERCAPNIA IN ROOM AIR >45MMHG

SPIROMETRY FEV1<50 %

FEV1<2 L

MBC<50%

RV/TLC >50%

SINGLE LUNG TESTS SPLITLUNG FUCNTION PRED POST OP FEV1 <0.85 L>70 % BLOOD TO DISEASED LUNG

MIMIC POST OP CONDITIONS TEMP UNILATERAL OCCLUSION OF RT /LT MAIN STEM BRONCHUS

MEAN PAP >40MMHGSEVERE BREATHLESSNESSPACO2 >60 MMHG

LT PULMONARY ARTERY PaO2 <45MMHG

MINIMAL PRE OP MEASUREMENTS OR PREDICTIONS FOR LUNG RESECTION

PFT UNITS NORMAL PNEUMO LOBEC SEGMENTAL RESECTION

FEV1 LITRES >4.0 >2.1-1.7 >1.2-1.0 >0.6-0.9

%(PRE OP) >80 OF FVC >50 >40 >40

LITRES(PPO) >0.9-0.8 >1 >0.6-0.9

FEV25-75% LITRES >2 >1.6 0.6-1.6 >0.6

FVC LITRES >5 >2 - -

MVV LITRES 100 >50 >40 >25

% PREDPREOP

100% 50% 40% 25%

PFT UNITS NORMAL PNEUMO LOBEC SEGMENTAL RESECTION

DLCO %PPRE OP 100 >60 -

%POST OP PRED >40%

EXERCISE TESTING

STAIR CLINBING(PRE OP)

>10FLIGHTS >5 >3 >2

VO2 MAX(LIT/MIN) 2.8 >1 >1 >1

O2 SPO2 FALL WITH EXERCISE

NONE <3 <5 <5

PaO2 MMHG(PRE OP) >90 >80 >70 >60

Paco2 40 <45 <50 <55

THREE LEGGED STOOL

• LUNG MECHANICS, PARENCHYMAL FUNCTION, AND CARDIOPULMONARY INTERACTION—SHOULD BE MADE FOR EACH PATIENT.

• THESE THREE ASPECTS OF PULMONARY FUNCTION FORM THE “THREE-LEGGED STOOL” THAT IS THE FOUNDATION OF PRETHORACOTOMY RESPIRATORY ASSESSMENT

RT HEART FAILURE/PHT• PVR >190 dymes/sec/cm

• LOUD P2

• LOSS OF NORMAL S 2 SPLIT

• S4

• HIGH PITCHED ESM

• X RAY

• DILATATION OF MAIN PULMONARY ARTERY

• FULLNESS OF APICAL PULM VESSELS

• ANTICLOCK WISE CARDIAC ROTATION

• LATERAL FILM – ENCROACHMENT OF RETROSTERNAL AIR SPACE

CONT

• ECG• RAD• ENLARGEMENT OF RV• TALL R WAVE /S WAVE IN V2-V6• INVERTED T WAVE V1-V6• RA ENLARGEMENT• DEPRESSED ST V2-V6• PROMINENT P WAVE II,III• BIPHASIC P WAVE V1

CONT

• ↑PAP,PVR,RA,RV

• PUMONARY DIASTOLIC MURMUR

• S3

• PARASTERNAL HEAVE

• DEPENDENT EDEMA

• TENDER LIVER

• ASCITES

• DISTENDED NECK VEINS

BODE INDEX OF COPD

• Body Mass Index• Obstruction• Dyspnoea• Exercise Capacity

1 2 3 4

BMI <21 >=21

FEV1% PRED

>65 50-64 36-49 <35

MMRC DYSPNEA SCALE

0-1 2 3 4

6MWDISTANCE

>=350M 250-349 150-249 <149

SHAPIRO’S POINT SCORINGCATEGORY POINTS

I.EXPIROTORY SPIRORAM

A.NORMAL %FVC+%FEV1/FEVC 150 0

100-150 1

<100 2

PRE OP FVC <20 ml/kg 3

POST BRONCHODILATOR FEVI/FVC<50% 3

II CVS NORMAL 1

CONTROLLED HT,MI WITHOUT SEQ >2YR

0

DYPNEA ON EXERTION,PND,PEDAL EDEMA,CCF,ANGINA

1

III CNS NORMAL 0

CONFUSION,OBTUNDATION,AGITATION SPASTICITY,BULBAR LESIONS 1

MUSCLE WEAKNESS 1

SHAPIRO’S POINT SCORING

CATEGORY POINTS

IV ABG ACCEPTABLE 0

PACO2>50MMHG Pa02<60MMHG ON ROOM AIR

1

METAB PH ABNORMALITY >7.50 OR <7.30 1

V .POST OP AMBULATION WITH IN 36 HRS-SITTING AT BEDSIDE

0

EXPECTED COMPLETE BED CONFINEMENT FOR 36 HRS

1

TOTAL SCORE 7

FORMULAS

EQUATION NORMAL VALUES

ALVEOLAR O2 TENSION

PAO2=(PB-47)FIO2-(PAO2/R)

110MMHG(FIO2=0.21)

ALVEOLAR –ARTERIOLAR O2 GRADIENT

A-aO2=PAO2-PaO2 <10MMHG

PaO2/PAO2 >0.75

ARTERIAL O2 CONTENT

CaO2=(SaO2)(HB×1.34)+PaO2(0.0031)

20ML/100ML BLOOD

MIXED VENOUS O2 CONTENT

CvO2=(SvO2)(HB×1.34)+PvO2(0.0031

15ML/100 ML

ARTERIAL-VENOUS O2 CONTENT DIFF

Ca02-Cv02 4-6ML/100ML

EQUATION NORMAL VALUES

INTRAPULMONARY SHUNT Qs/Qt

(CcO2-CaO2)/CcO2-CVO2)

<5%

PHYSIOLOGICAL DEAD SPACE VD/VT

PaCO2-PECO2/PaCO2 0.33

O2 CONSUMPTION(VO2)

CO(CaO2-CvO2) 250ML/MIN

O2 TRANSPORT DO2

CO(CaO2) 1000ML/MIN

RESP QUOTIENT VCO2/VO2=R 0.8

TYPES OF RESP FAILURE

• FOUR TYPES• TYPE III-POST OP ATELECTASIS• PAIN-IMPAIRED COUGHING

• TYPE IV-INADEQUATE BLOOD SUPPLY/PERFUSION TO INTERCOSTAL /RSPIRATORY MUSCLES IN SHOCK

PRE OP INVESTIGATIONS • HB-ANEMIA,POLYCYTHEMIA• TC,DC-ACTIVE INFECTIONS• SPUTUM CULTURE-ANTIBIOTIC CHOOSE• SUGAR-HYPOGLYCEMIA(PARANEOPLASTIC

SYMPTOM)• UREA,CREAT-METASTASIS-TO KIDNEY• ELECTROLYTES-HYPONATRMIA,SIADH• LFT-RVF,ON ATT,METASTASIS• COAGULOPATHY ASSAY

• X RAY CHEST• ECG-RV FAILURE,CORPULMONALE• HRCT• TREADMILL TEST• ECHO• V/Q SCAN• BRONCHOGRAM,FOB

PRE OP PREPARATION

WHY PRE OP PREPARATION • 3 REASONS FOR POST OP

COMPLICATIONS

• MAY BE DUE TO PRE OP/INTRA OP/POST OP

• 1.PRE OP RESP DYSFUNCTION –POSITIVE CORRELATION

• 2.THORACIC SURGERY PERSE CAN IMPAIR LUNG FUCNCTION

• 3.THORACOTOMY/UPPER ABDOMINAL INCISION-SEVERE PAIN –RESISIST DEEP BREATHING/COUGHING-ATELECTASIS

REGIMEN

• 1.STOP SMOKING• 2.DILATE AIRWAYS• 3.LOOSEN SECRETIONS• 4.REMOVE SECRETIONS• 5.ADJUNCT MEDICATIONS• 6.INCREASED

EDUCATION/MOTIVATION

STOPPING SMOKING

• 4-8 WEEKSTIME COURSE BENIFITS

12-24 HRS DECREASED CO,NICOTINE

48-72 HRS COHB normalised,CILIARY FUNCTION IMPROVES

1-2 WKS DECREASED SPUTUM PRODUCTION

4-6 WKS PFTS IMPROVES

6-8WKS IMMUNE FN & METABOLISM NORMALISES

8-12 WKS DECREASED OVERALL POST OP MORBIDITY /MORTALITY

DISADVANTAGES OF STOPPING SMOKING

• ACUTE NICOTINE WITHDRAWL-ANXIETY

• HYPERSECRETORY AIRWAYS• BRONCHOSPASTIC STATE• INCREASED INCIDENCE OF DVT

LATEST BRONCHODILATORS

• ACLIDINIUM BROMIDE• INDACATEROL • BOTH ARE INCREASING FEV1 & FVC

EFFECTIVELY

LOOSENING SECRETIONS

• MECHANICAL NEBULIZER• 2-4 MICRONS PARTICLES

• ULTRASONIC NEBULISER• 0.8-1 MICRONS PARTICLES

REMOVING SECRETIONS

• COUGHING• CHEST PHYSIOTHERAPY• FET• ACTIVE CYCLE BREATHING

CHEST PHYSIOTHERAPY

• CUPPED HANDS• ELECTRIC VIBRATORS• 15-20 MINS SEVERAL TIMES/DAY• C/I-LUNG ABSCESS• HEMOPTYSIS• METASTASIS TO RIBS

SEQUENTIAL POSITIONS FOR COMPLETE POSTURAL DRAINAGE

• 1) Upper lobes, anterior segments• 2) Upper lobe, posterior segment, right posterior

bronchus• 3) Upper lobe, posterior segment, right posterior

bronchus• 4) Right middle lobe• 5) Left lingula• 6) Lower lobes, apical segment• 7) Lower lobes, anterior basal segment• 8) Lower lobe, lateral basal segment• 9) lower lobes, posterial basal bronchus

FET

• FORCED EXPIRATION STARTING FROM mid lung volume (50% of IRV) TO LOW LUNG VOLUME (RV)

• FOLLOWED BY RELAXATION OF DIAPHRAGMATIC BREATHING

• WIH OUT CLOSURE OF GLOTTIS• WITHOUT COMPRESSIVE PHASE OF

COUGH

4 PHASES OF COUGH

• 1. THE INSPIRATORY PHASE• 2. THE CONTRACTIVE PHASE• 3. THE COMPRESSIVE PHASE • 4. THE EXPULSIVE PHASE

• The inspiratory phase: the posterior cricoarytenoid muscle, innervated by the recurrent laryngeal nerves maximally abducts the vocal cords

• The contractive and compressive phases: the true and false vocal cords close tightly, with the false cords turned down, and the expiratory muscles (diaphragm, abdominal, chest wall, and pelvic floor muscles) contract, resulting in a dramatic increase in intrathoracic pressure.

• The true vocal cords close first, followed by the false cords, then the aryepiglottic folds. The later two actions are mediated by the thyroarytenoid muscles.

• The final phase of the cough cycle is expulsive, with rapid expiration (peak flow of 25,000 cm/sec) and vibration of the vocal cords, supraglottic structures, and posterior glottis.

LARYNGOSPASM

• Laryngospasm is a maladaptive exaggerated glottic closure reflex, mediated solely by the SLN ( tactile stimulation of the endolarynx) . Stimulation of the esophagus with acid or with sudden distension may cause laryngospasm

ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT)

• can be performed in sitting, lying or postural drainage positions

• BREATHING Control (also called abdominal breathing)

• ¨ Rest one hand on your abdomen, keeping shoulders and upper chest relaxed and

• allow your hand to rise gently as you breathe in. (If you imagine air filling the abdomen

• like a balloon this may help)

• ¨ Sigh out gently• ¨ Ensure shoulders remain relaxed• ¨ Over a few seconds, gradually

increase depth of breathing while maintaining relaxation

• Breathing control is an essential part of the cycle to allow rest.

• Deep Breathing Exercises• ¨ Take 3 – 4 deep breaths in, allowing the

lower chest to expand• ¨ Try to ensure neck and shoulders remain

relaxed• ¨ At the end of the breath in, hold the air in

for 3 seconds• ¨ Let the air out gently

TYPICAL CYCLE CONSISTS OF

GE REFLUX PROPHYLAXIS

• H1-BRONCHO CONST• H2 –DILATATION • SO H2 BLOKERS CAN CAUSE

BRONCHO CONSTRICTION

PRE OP DIGITALIZATION

• CONTRAVERSIAL• IF LVF PRESENT CAN BE USED• AF WITH RAPID VENTRICULAR RATE –

CAN BE USED

PRE OP AF PROPHYLAXIS

• COMMON IN LT LUNG SURGERY• DILTIAZEM • AMIADARONE CAN BE USED• PULMONARY FIBROSIS• THYROID DYSFUNCTION

PRE MED

• AVOID SEDATIVES• ANTACID PROPHYLAXIS TO BE GIVEN

INTRA OP

TIERED MONITORING TIERED SYST PT

CATEGORYGAS EXCHANGE

AIRWAY MECH

ETT POSITION PA PRESSURES

CARDIOVASCULAR STATUS

1.ESSENTIAL ONITORING IN ALLPTS

ROUTINE HELATHY PTS WITHOUT SPCL INTRA OP CONDITIONS

COLOR OF TISSUES,SPO2,PETCO2

FEEL BAG,STETH ,PIP,PETCO2

BAE,BALLOTABLE BALLON IN SUPRASTERNAL NOTCH,FOB AFTER LDP

NO NIBP,PULSE OXYMETRY WAVE FORM,ECG,PETCO2,ESOPHAGEAL STETH,±CVP, ±IABP

2.SPCL INTERMITTENT OR CONT MONITORING

HEALTHY PTS WITH SPCL PROCEDURES OR SICK PTS WITH ROUTINE PROCEDURE

+ ABG SPIROMETRY,INDIVIDUAL AND WHOLE LUNG

FOB IN SUPINE AND LDP

IF LOBECTOMY OR LUNG RESECTION

+IABP,CVP,PA CATHTER,±TEE

TIERED SYST PT CATEGORY

GAS EXCHANGE

AIRWAY MECH

ETT POSITION PA PRESSURES

CARDIOVASCULAR STATUS

3.ADVANCED MONITORIING

SICK PTS WITH SPCL INTRA OP CONDITIONS

+QS/QT,VD/VT,VBGS

+AIRWAY RESISTANCE

FREQ FOB PA,Q,PVR,SVR,DAO2-DVO2

PA,TEE

PA CATHETER

• MORMALLY IN RT PULMONARY ARTERY

• IF RT LUNG IS NON DEPENDENT,COLLAPSED-CO VALUE WILL BE LOW

• IF NON DEPEN LUNG VENTILATED WIT LARGE TIDAL VIOLUME ,PEEP,CPAP-LAP NOT CORRELATE WIT PCWP

• IF IT PAC IN DEPENDENT LUNG-EVEN WITH PEEP-LAP = PCWP

INDUCTION

• 100 % O2 –PRE OXYGENATE • FENTANYL –UNTIL RR 8-10 /MIN• SODIUM THIO PENT-2-3 MG/KG• IPPV WIT MASK• NDMR • 1-3% SEVO• EYES –

CENTRAL,CONJUGATE,FIXED ,STARING,WITHOUT TEARS,NONDILATED PUPILS

• INTUBATED

ADVANTAGE OF INHALATIONAL INDUCTION

OPIOIDS/IV INDUCTION

PRE OP EPIDURAL CATHETER

PHYSILOGY OF SPONT VENTILATION WITH OPEN CHEST

• MEDIASTNAL SHIFT• PARADOXICAL RESPIRATION

INTRA OP COMPLICATIONS

COMPLICATIONS ETIOLOGY

Hypoxemia

Intrapulmonary shunt during one-lung ventilation

Sudden severe hypotension Surgical compression of the heart or great vessels

Sudden changes in ventilating pressure or volume

Movement of endobronchial tube/blocker, air leak

Arrhythmias Direct mechanical irritation of the heart

Bronchospasm Direct airway stimulation, increased frequency of reactive airways disease

Massive hemorrhage blood loss from great vessels

Hypothermia Heat loss from the open hemithorax

CAPNOMETRY IN OLV

• The end-tidal CO2 (PETCO2) is a less reliable indicator of the PaCO2 during OLV than during two-lung ventilation,

• and the PaCO2- PETCO2 gradient tends to increase during OLV.

• Although the PETCO2 is less directly correlated with alveolar minute ventilation during OLV, because the PETCO2 also reflects lung perfusion and cardiac output it gives an indication of the relative changes in perfusion of the two lungs independently during position changes and during OLV.

• As the patient is turned to the lateral position the PETCO2 of the nondependent lung will fall relative to the dependent lung, reflecting increased perfusion of the dependent lung and increased dead space of the nondependent lung.

• However, the fractional excretion of CO2 will be higher from the nondependent lung in most patients owing to the increased fractionalventilation of this lung.

IVF MANAGEMENT

• NO VOLUME FOR THIRD SPACE LOSS• TOTAL POSITIVE FLUID IN 1 ST 24 HRS

PERI OP –NOT EXCEED 20 ML/KG• CRYSTALLOIDS <3 L IN 1 ST 24 HRS• URINE OUT PUT >0.5 ML/Kg/HR –

UNNECESSARY• IF TISSUE PERFUSION NEEDED-

IONOTROPES

OLV-INDICATIONS• 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

OLV-INDICATIONS

• 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, TMR)

• Postcardiopulmonary bypass status after removal of totally occluding chronic unilateral pulmonary emboli

• Severe hypoxemia due to unilateral lung disease

DLT CAUSE RECTIFICATION

Both lungs ventilated-when either lumen ventillated

Too far out Deflate & advance

Both lungs ventilate via bron.lumen,neither when ventillated via tracheal lumen

Br.lumen in trachea/ cuff overinflated

Deflate & advance

No ventillation via bronchial lumen

?entered other side reposition

Upper lobe no ventilation Too far down Deflate & withdraw

Obstructed breathing pattern Herniation of DLT cuff Reduce cuff /change DLT

Indications for a Right-Sided Double-Lumen Tube

• Distorted Anatomy of the Entrance of Left Mainstem Bronchus

• External or intraluminal tumor compression

• 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

LUNG ISOLATION

• SINGLE LUMEN ENDOBRONCHIAL TUBES

• Gale&waters• Magill• Machray• Gordon &green• Macintosh &leatherdale• Brompton-pallistor

BRONCHIAL BLOCKERS

• MAGILL • CRAFOORD• VERNON THOMPSON• STURTZ BECHER (WITH BLOCKERS)• VELLACOT (FOR UPPERLOBE RT BPF)• GREEN

NEWER BLOCKERS

• 1.TORQUE CONTROLLED (UNIVENT)BLOCKER

• FOB GUIDED• 2.ARNDT WIRE GUIDED BLOCKER• NYLON WIRE LOOP PRESENT WITH

FOB• MURPHYS EYE PRESENT• CENTRAL CHANNEL 1.4MM ID

• 3.COHEN BLOCKER• WHEEL GUIDED IN DISTAL TIP • MURPHY EYE PRESENT• CENTRAL CHANNEL 1.6 MM ID• 4.FUJI BLOCKER • INDEPENDENT BLOCKER• MADE UP OF SILICON• PRERORMED ANGULATION • NO MURPHY EYE• CENTRAL CHANNEL 2.0 MM ID

COHEN BLOCKER

FUJI BLOCKER

LATEST BRONCHIAL BLOCKER

• EZ BLOCKER• Due to its specific shape the EZ-Blocker®

is easy to place and will also remain in its correct position during manipulation of the patient or lung.

• The EZ-Blocker® is a catheter with a bifurcated distal end. The bifurcation resembles the bifurcation of the trachea. During insertion trough a standard endotracheal tube, both distal ends easily find their way into the two main stem bronchi.

FEATURES OF THE EZ-BLOCKER

• Quick and easy positioning- Minimal risk of dislocation during procedure- Optimal lung collapse- In case of postoperative ventilation no re-intubation necessary- Easy handling in case of bilateral procedures

DLT

• CARLENS • BRYCE SMITH• BRYCE SMITH & SALT(RT SIDED )• WHITE• ROBERTSHAW• BRONCHOCATH • PORTEX

DLT

• 2 LUMENS• 2 CUFFS• 2 PILOT TUBES• 2 CURVATURES

• EASY FOR SUCTIONING• RAPID CONVERTION TO TWO LUNG

VENTILATION• CPAP /PEEP TO COLLAPSED LUNG

DLT –POSITION PLACEMENT

• AT TEETH 12+(HT/10) CM

• CUFF SEALING- BY WATERSEALING METHOD

FOR PEDIATRICS

• LEYLAND RUBBER DLT FOR 6-8 YRS• BRONCHIAL BLOCKERS• MARRAO BILUMEN UNCUFFED TUBE

FOR NEONATES >1500KG,&5 YRS CHILD

• Narukis – trachoeostomy tube

COMPLICATIONS

• Traumatic injury to the airway during placement or removal • Hoarseness • Sore throat • Ecchymosis of the mucous membranes • Arytenoid dislocation • Vocal cord rupture • Vocal cord paralysis • Tracheal or bronchial laceration • Tracheobronchial rupture • Pneumothorax • Hemorrhage • Tracheal or bronchial tissue necrosis due to

excessive pressure in the DLET cuffs

Factors Affecting Regional HPV• HPV is inhibited directly

by volatile anesthetics (not N20), vasodilators (NTG, SNP, dobutamine, many ß2-agonist), increased PVR (MS, MI, PE) and hypocapnia

• HPV is indirectly inhibited by PEEP, vasoconstrictor drugs (Epi, dopa, Neosynephrine) by preferentially constrict normoxic lung vessels

HPV

• LOCAL REFLEX• EDRF-NO MEDIATED• FACTORS INHIBIT HPV• INCREASED CO• VASODILATORS• VOLATILE AGENTS>1 MAC• VASOCONSTRICTORS• CCB• BRONCHODILATORS• BETA 2 AGONISTS

FACTORS POTENTIATE HPV

• COX INHIBITORS• NO• BETA BLOCKERS• ALMITRINE

PHYSIOLOGY OF THE LDP

• Upright position LDP, lateral decubitus position

• blood flow -RT[55%] ,LT[45%] RT -45% ,LT - 35%

INTRAOP GOALS• MINIMIZE ANESTHESIA TIME• CONTROL SECRETIONS• PREVENT ASPIRATION• BRONCHODILATION• INTERMITTENT HYPERINFLATION

ANESTHETIC MANAGEMENT

INHALED ANAESTHETICS• ↓ airway irritability• Allows delivery of high FIO2 without

loss of anaesthesia• Rapidly eliminated• Provide CVS stability

COMBINE IV AGENTS WITH INHALATIONAL ANAESTHETICS TO MAINTAIN ANAESTHESIA

CHECKING DLT-LT SIDED DLT

• INFLATE TRACHEAL CUFF(5-10ML)• CHECK BAE-IF UNILATERAL BREATH

SOUNDS-TUBE TOO FAR DOWN • INFLATE BRONCHIAL CUFF-1-2 ML• CLAMP TRACHEAL LUMEN • CHECK UNILATERAL LT SIDE BREATH

SOUNDS

1.PERSISTENCE OF RT BREATH SOUND-BRONCHIAL OPENING STILL IN TRACHEA

• 2.UNILATERAL RT –INCORRECT ENTRY IN TO RT BRONCHUS

• 3.ABSCENCE OF BREATH SOUNDS OVER ENTIRE LUNG-TUBE IS TOO FAR DOWN IN LT BRONCHUS

• UNCLAMP TRACHEAL LUMEN&CLAMP BRONCHIAL LUMEN

• CHECK FOR RT SIDE-ABSENCE OR DIMINISHED BREATH-TUBE NOT FAR ENOUGH DOWN &BRONCHIAL CUFF OCCLUDING DISTAL TRACHEA(CUFF HERNIATION

AIRWAY BLOCKS FOR FOB

GLOSSOPHARYNGEAL NERVE BLOCK

• Topical spray• Direct contact of soaked

pledgets• Direct infiltration -

approachesINTRA ORAL PERISTYLOID

• INTRAORAL

-Need enough mouth opening.

-Inject submucosally 5ml of LA at

the caudal aspect of posterior tonsillar pillar

• PERISTYLOID APPROACH

-Position- supine

-A line is drawn from angle of mandible & mastoid process

PERISTYLOID APPROACH

• Styloid process palpated just posterior to angle of jaw along this line

• A short small gauge needle seated against styloid

• Needle is then withdrawn directed posteriorly

• Then 5 to 7 ml of la injected after negative aspiration

• In both approaches care to be taken not to injure internal carotid artery

SUPERIOR LARYNGEAL NERVE BLOCK

• Its internal branch arises lateral to greater cornu of hyoid bone

• Passes about 2-4 mm inferior to greater cornu

• Then pierces the thyrohyoid membrane

• Travels under the mucosa of pyriform fossa

SUPERIOR LARYNGEAL NERVE BLOCK

In the pyriform fossa By using kraus or

jacksons forceps Hold a pledget of

cotton soaked in 2 to 4% against the mucosa for about 60 sec

External approach Direct infiltration by a

25 G needle at the level of thyrohyoid membrane inferior to greater cornu of hyoid bone

RECURRENT LARYNGEAL NERVE BLOCK

• Translaryngeal block of RLN is accomplished at level of CRICOTHYROID MEMBRANE

• A 10 ml syringe with 22 or 20 gauge needle is advanced until air is aspirated

• 4 ml of 4% lignocaine injected, inducing cough which disperses it

ANTERIOR ETHMOIDAL NERVE BLOCK

MANAGEMENT OF OLV...

Initial management of OLV anesthesia:• Maintain two-lung ventilation as long as

possible• Use FIO2 = 1.0• Tidal volume, 10 ml/kg (8-12 ml/kg)• Adjust RR (increasing 20-30%) to keep PaCO2

= 40 mmHg• No PEEP (or very low PEEP, < 5 cm H2O)• Continuous monitoring of oxygenation and

ventilation (SpO2, ABG and ET CO2)

THERAPIES FOR DESATURATION DURING ONE-LUNG VENTILATION

• Severe or precipitous desaturation: Resume Severe or precipitous desaturation: Resume two-lung ventilation (if possible).two-lung ventilation (if possible).Gradual desaturation:Gradual desaturation:

• Fio2 1.0.Fio2 1.0.•     Check position of double-lumen tube or Check position of double-lumen tube or

blocker with fiberoptic bronchoscopy.blocker with fiberoptic bronchoscopy.•     Ensure that cardiac output is optimal; Ensure that cardiac output is optimal;

decrease volatile anesthetics to < 1 MAC. decrease volatile anesthetics to < 1 MAC. •   Apply a recruitment maneuver to the Apply a recruitment maneuver to the

ventilated lung (this will transiently make the ventilated lung (this will transiently make the hypoxemia worse)hypoxemia worse)

• Apply PEEP 5 cm H2O to the ventilated lung • Apply CPAP 1-2 cm H2O to the nonventilated lung

(apply a recruitment maneuver to this lung immediately before CPAP). 

• Intermittent reinflation of the nonventilated lung • Partial ventilation techniques of the nonventilated

lung:   a.    Oxygen insufflation  b.    High-frequency ventilation  c.    Lobar collapse (using a bronchial blocker) 

• Mechanical restriction of the blood flow to the nonventilated lung

OTHER MODE OF VENTILATION

• HIGH FREQ VENTILATION • 2 ML/KG• RR -60-2400 BREATHS/MIN• APNEIC INSUFFLATION

POSTOP GOALS• CONTINUE PREOPERATIVE

MEASURES• MOBILIZE SECRETIONS• EARLY AMBULATION• COUGH & DEEP BREATHING• ANALGESIA

POST OP COMPLICATIONS

• HERNIATION OF HEART• PULMONARY TORSION• MASSIVE HEMMARRAHGE• BRONCHIAL DISRUPTION• RESP INSUFFICIENCY• UNILATERAL NEGATIVE PRESSURE

PULMONARY EDEMA• RHF• RT TO LT SHUNT THRO PATENT

FORAMEN OVALE• NEURAL INJURIES

POST OP PAIN RELIEF

• CRYO ANALGESIA• EPIDURAL• INTERPLEURAL • PARAVERTEBRAL BLOCK