Lungs, Lungs, Lungs
Estimating pulmonary functional reserve is a two step method, the first step is whole lung tests, which of the following is NOT a whole lung test?
A. Arterial Blood gas
B. Exercise tolerance testing
C. Pulmonary function tests
D. Carbon monoxide diffusion capacity (DLCO)
B
All of the following are true regarding normal flow volume loops except:
A. Flow rates are shown along the y axis in liters per second
B. Inspiratory flow is demonstrated above the x axis and expiratory flow is below the x axis
C. Zero on the y axis represents residual volume and total lung capacity
D. It is drawn in a clockwise direction
B, opposite, inspiratory flow is demonstrated below the x axis and expiratory flow is above the x axis
If you hear bilateral breath sounds when you are only ventilating through the bronchial lumen, what does this indicate?
A. Correct position of the DLT
B. DLT too deep into the right bronchus
C. DLT too deep into the left bronchus
D. DLT too shallow
D, too shallow/not occluding, so ventilating both lungs through bronchial lumen
One complication of DLT use is tracheobronchial tree trauma, what are 4 examples?
1. Ecchymosis of mucous membranes.
2. Arytenoids dislocation.
3. Vocal cord rupture.
4. Tissue necrosis from bronchial balloon.
If the patient is in a lateral position, which scenario produces the BEST matched pulmonary ventilation/perfusion ratio?
A. Anesthetized, chest open, spontaneously breathing
B. Awake, spontaneous ventilation
C. Anesthetized, spontaneously breathing
D. Anesthetized, paralyzed, mechanically ventilated
B
Dependent lung receives > portion of blood flow vs. non-dependent.
Ventilation increased in the dependent lung.
If they patients whole lung tests are abnormal, which tests would you conduct next? SATA
A. Predicted postoperative function tests
B. Spirometry
C. Exercise tolerance testing
D. Split lung function tests
E. Pulmonary artery occlusion
F. Forces vital capacity
The individual lung function tests: A, C, D, & E
B - a whole lung test
F - a PFT/whole lung test
Which of the following flow volume loops would be seen in the setting of restrictive lung disease?
https://docs.google.com/document/d/185neWm2aJPt1i_5OIAROXo6AYc7wujO9_aoVSxAYw3A/edit?usp=sharing
C - Restrictive disease shows up on the flow volume loop simply as decreased overall lung volumes.
Pulmonary volumes and inspiratory and expiratory efforts are decreased
If you are using a left double lumen ETT, how would you initiate one sided right lung ventilation?
A. Clamp the tracheal lumen
B. Clamp the bronchial lumen and leave the balloon deflated
C. Clamp the bronchial lumen and inflate balloon with 3ml of air
D. Clamp the bronchial lumen and inflate balloon with 10ml of air
C
During one lung ventilation, which of the following is false regarding hypoxic pulmonary vasoconstriction?
A. It increases the fraction of physiologic shunt
B. Inhalational agents at concentrations >1.5 MAC decrease the HPV response
C. It diverts blood away from the non-ventilated lung regions
D. The maximal response reduces blood flow by 50%
E. Main stimulus is decreased alveolar and mixed venous O2 tension
F. NTG, Nitroprusside, Hydralazine, Prostacyclin, and PDE inhibitors all inhibit HPV, thereby worsending shunt & decreasing PaO2
A, HPV decreases fraction of physiologic shunt!
Care of the patient with superior vena cava syndrome includes:
A. Aggressive fluid replacement
B. IV placement in the lower extremities
C. Pulse oximeter placement on the right upper extremity only
D. Supine positioning
B
- IV Lines should be placed in lower extremities
- Fluids should be given with caution
- Remain in sitting position
- Pulse ox placement depends on location of mass/what vasculature is being compressed
In which west zone is the V/Q mismatch decreased and alveoli are distended?
A. Zone 1
B. Waterfall Zone
C. Zone 2
D. Zone 3
A
Zone 2 = waterfall zone
Which of the following flow volume loops would be seen in the setting of an intrathoracic tumor?
https://docs.google.com/document/d/185neWm2aJPt1i_5OIAROXo6AYc7wujO9_aoVSxAYw3A/edit?usp=sharing
B
Flow Volume loop= Inspiration - intrapulmonary pressure cause the obstructed segment to widen so gas flow is normal. Expiration= gas flow is impeded d/t greater pressure outside the airway causing the segment to collapse.
If your DLT is too deep into the right bronchus and you're ventilating through the bronchial lumen, what breath sounds would this produce?
A. Right middle and lower lobe
B. Left upper and lower lobe
C. Left lung or right upper lobe, depending on depth of tracheal cuff
D. Diminished or absent bilaterally
A
C would be if ventilating through tracheal lumen
Which of the following is true regarding pain management and thoracic surgery?
A. Thoracic epidurals are the most common technique for post-thoracotomy pain and are performed at the T6 level
B. Inadequate pain control postoperatively can present as tachypnea, tachycardia, and hypertension
C. NSAIDs and alpha 2 adrenergic agonists are not appropriate pain management techniques for the pain level produced by thoracic surgery
D. If you utilized epidural duramorph intraoperatively for pain control, continue postoperatively on the floor with a PCA
B
A - T7-8
D - NO PCA on floor if epidural narcotics have been given!
Inadequate pain control leads to splinting, tachypnea, tachycardia, hypertension, hypercoagulability, inability to cough, retention of secretions & atelectasis.
The aforementioned symptoms contribute to postoperative:
Hypoxia, Hypercapnia, Respiratory Failure, Adverse cardiac events.
Thoracic pain management techniques: NSAIDS, Local Anesthetics, Opioids, Alpha 2 adrenergic agonists
8. Which great vessel is MOST vulnerable to being compressed during a mediastinoscopy?
A. Innominate
B. Pulmonary
C. Left subclavian
D. Superior vena cava
A
The scope can place pressure on the inominate artery causing decreased blood flow to the R common carotid artery & R vertebral artery and decreased in subclavian flow to R arm.
Pressure on R innominate artery can compromise perfusion to the brain and cause a stroke
Which of the following is not true regarding zone 3?
A. V/Q mismatch is the highest in this zone
B. PA > Ppa> Ppv
C. The PA catheter should always be placed here because it is the most accurate reflection of left ventricular pressure
D. Alveolar size is decreased
B
West zone 3: Ppa > Ppv > PA
Which of the following flow volume loops would be seen in the setting of obstructive lung disease?
https://docs.google.com/document/d/185neWm2aJPt1i_5OIAROXo6AYc7wujO9_aoVSxAYw3A/edit?usp=sharing
A
Forced expiratory flow is sensitive to the development of obstructive lung disease. When flow is decreased, the portion of the curve that represents FEF 25-75% becomes concave (this is where small airway disease is picked up and you see a decrease in the flow rate). We call this scooping.
When confirming placement of your DLT via direct observation with fiber optic bronchoscope, proper position would be indicated by all of the following except:
A. Blue bronchial cuff should be visible and not herniating above the carina
B. Carina should not be visible
C. Bronchial tip should enter the bronchus
B, carina should be visible
You're nearing the end of your case and preparing for extubation, your patients minute ventilation is 9L, their RR is 8BMP, and their SpO2 is 92% on 40% fio2, what is the best extubation plan?
A. Standard extubation in the operating room
B. Transfer to ICU with DLT for staged weaning from ventilation
C. Exchange DLT for single lumen ETT under direct visualization, transfer to ICU
D. Deep extubation, pull and pray
C
Extubation criteria:
- SpO2 > 95% with FiO2 >40%.
- RR > 8 BPM & < 30 BPM.
- Tv > 5mL/Kg.
- NIF > -20cm H20.
- Mv < 10 L.
- Ability to lift head 5 seconds.
- Able to follow commands.
- No Acid base disorders
Failure to meet extubation criteria:
- Exchange double lumen with single lumen tube under direct vision.
- Single lumen endobronchial blocker tube can be used as regular SLT.
- Use tube changer if intubation was difficult
3. An ABSOLUTE contraindication to use of a double lumen endotracheal tube is
A. Dependence on bilateral lung ventilation
B. Aspiration risk
C. Intraluminal airway mass
D. Difficult airway
C
Luminal masses in the airway may become dislodged, cause excessive bleeding & may prevent passage of DLT.
Other 3 are relative.
Your patient is in the lateral decubitus position, they are awake and spontaneously breathing. You induce them and now they are anesthetized and spontaneously ventilating via an LMA, which of the following would you expect?
A. The dependent lung is more compliant
B. Dead space ventilation is decreased in the non-dependent lung, V/Q <1
C. Functional residual capacity is increased
D. Shunt is increased in dependent lung: V/ Q < .8
D
- Dependent lung receives > portion of blood flow.
- Non-dependent lung receives > portion of ventilation.
- Dependent lung less compliant:
- Mediastinal compression & upward displacement of diaphragm.
- Decreased functional residual capacity.
- Shunt increased in dependent lung: V/ Q < .8.
- Dead space ventilation increased in non-dependent lung: V/ Q >1.
Which of the following flow volume loops would be seen in the setting of an extrathoracic tumors
https://docs.google.com/document/d/185neWm2aJPt1i_5OIAROXo6AYc7wujO9_aoVSxAYw3A/edit?usp=sharing
E
flow volume loop. WILL SEE OBSTRUCTION TO INSPIRATION. On inspiration the extrathoracic tumor segment collapses the upper airway d/t the sub atmospheric pressure. expiration gas flow is not impeded d/t the + pressure in the airway prevent collapse of the trachea.
(D is normal flow volume loop)
During one lung ventilation your SpO2 is steadily decreasing, what would be your first strategy to improve oxygenation?
A. Initiate PEEP 5cm H2O on nondependent lung
B. Initiate PEEP 5cm H2O on dependent lung
C. Initiate CPAP 5cm H2O on nondependent lung
D. Reinstitute two-lung ventilation
C - need to initiate CPAP on nondependent lung first to decrease the fraction of shunt caused by lung isolation technique. If you start PEEP prior to initiate CPAP, may increase your fraction of shunt.
You are writing your care plan for a patient with a mediastinal tumor undergoing a biopsy, since you're the smartest SRNA ever, you know that: SATA
A. The procedure should be performed under local anesthesia
B. The patient should remain in the sitting position
C. If GA is required, cardiopulmonary bypass should be available
D. If the patient is short of breath, the procedure should be done under GA
A, B, & C
If any sign of respiratory compression is noted, surgery for biopsy should be performed under local anesthesia
A major goal is to keep pt spontaneously breathing, retains normal airway patency, positive pressure will not.
Positive Pressure ventilation may be impossible even with a properly placed ETT.
Radiation may be needed to shrink tumors to reduce risk of airway obstruction.
To initiate left-sided one lung ventilation with a left double lumen tube you must?
A. Deflate the left bronchial cuff
B. Clamp the tracheal lumen
C. Occlude the left bronchial port
D. Clamp the left bronchial lumen
B