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1. ANESTHESIA CONSIDERATION FOR THORACIC SURGERY AND OLV Prepaired by: Wasihun Aragie Adviser: Eyayalem Melese(BSc,MSc) 1

2. Outline             Introduction Preoperative evaluation and Preparation Intraoperative monitoring Definition of One Lung Ventilation Physiology of LDP and OLV Methods of lung separation Intra operative management Termination of surgery and Anesthesia Post operative complications and their managment Post operative pain control Conclusion References 2

3. Objective At the end of the this session the learner will be able to :  Perform Preoperative assessment for patients with Thoracic surgery.  Prepare the patient for thoracic surgery.  Explain about One lung ventilation .  Explain about the methods of lung separation .  Manage intraoperative complications associated with OLV .  Explain about Postoperative complications and their managements. 3

4. Introduction  History  In the last century, thoracic surgery was primarily done to treat infectious disease  Now the most common indications are related to pulmonary, esophageal, and mediastinal malignancies.  The development of single-lung isolation techniques accelerated from 1950–1960 with the development of double-lumen endotracheal  Pri n c i p le o f o n e lu n g v entil a t i o n is o n e lung for the a nesthet i s t . tubes. surgeon and one for the 4

5. Anatomical lung and physiological Overview of air ways and 5

6. 6

7. Preoperative Evaluation  Preoperative anesthetic assessment before chest surgery is a continually evolving science and art.  The objective of the preoperative assessment is to identify patients who have concurrent medical problems requiring further diagnostic evaluation or treatment before surgery.  Addition to the routine assessment focus on the extent and severity of active pulmonary disease and cardiovascular involvement . 7

8. Preoperative Evaluation…  The goals of the preoperative evaluation are: 1. To ensure that patients can safely tolerate anesthesia for planned surgical procedures; and 2. To identify risks associated with the overall perioperative period, pulmonary or cardiac complications.  Preoperative evaluation includes History, Physical examinations, Investigations 1.History  Dyspnea  Cough  Exercise Tolerance( MET , …)  Medications  Cigarrate Smoking 8

9. Preoperative Evaluation… 2.Physical Examination  Cyanosis  Clubbing  Respiratory Rate and Pattern  Breath Sounds  wet sounds  dry sounds 9

10. Evaluation of Cardiovascular system Sign and symptoms of pulmonary hypertension  Splitting of second heart sound  Pulmonic regurgitant murmur  Tricuspid regurgitant murmur  Elevated jugular venous pulse or CVP 10

11. Pulmonary Function Testing Goals of PFT 1. To identify the patient at risk of increased postoperative morbidity and mortality. 2. To identify the patient who will need short-term or long-term postoperative ventilator support. 3. To evaluate the beneficial use of bronchodilators. Suggests high risk if:  FVC<50%  FEV 1 <2L  FEV 1 /FVC <50%  RV/TLC >50% effect and reversibility of airway obstruction with the 11

12. Difference between Restrictive and Obstructive pulmonary Diseases  Res t r i ct i ve: any dise a s e s that i m pair lu n g ex p ansion l i ke(AR D S, p n eu m ot h orax, e f fusion)  FVC  FEV 1  FEV 1 /FVC  RV/TLC ↓ ↓ n o r m al n o r m al  Obstructive: result from narrowing or obstruction of the smaller bronchi and larger bronchioles (Asthma, COPD, foreign body, any tumor)  FVC  FEV 1  FEV 1 /FVC  RV/TLC normal ↓ ↓ ↑ 12

13. Assessments of respiratory function and Risk stratification  Respiratory Mechanics (FEV 1, MVV, FVC, RV/TLC) ppoFEV 1 %= preoperative FEV 1 %×( 1 −% functional lung tissue  Lung Parenchymal Function  Diffusing capacity for Carbon Monoxide(DLco).  Cardiopulmonary Interaction  Formal laboratory exercise testing gold standard  Maximal oxygen consumption (VO 2 max)  Stair clamping (Estimate VO 2 max) removed/100)  6-minute walk test  (distance/30)  status of saturation >> >> 13

14. Assessments of respiratory function and Risk Strat… Predicted postoperative FEV 1 (ppoFEV1 o/o ) 30o/o-400/o Consider extubation based on: • Exercise tolerance • DLCO • V/0 scan • Associated diseases >40 o/o Extubate i n operat i ng room if : • Pat i ent AWaC ( a l ert warm , and comfortable ) Staged wean i ng from m e c han i c a l v e n t i l a ti o n . C on s i de r e x t uba t i on if >20 ° / o plus : • T ho r a c i c e p i d u r a l an a l g e s i a 14

15. 3.Evaluation and Testing  ECG  Chest Radiography  Arterial Blood Gas Analysis  Blue bloaters:  Pink puffers:  Significance of Bronchodilator Therapy  Regional Perfusion Test  Regional Ventilation Test  Computed Tomography 15

16. Preoperative Preparation  Proper, vigorous preoperative preparation can improve the patient’s ability to face the surgery with a decreased risk of morbidity and mortality.  Stop Smoking For 2-3 month → → → improves in ciliary function, improves closing volume, and reduction in sputum production For 4 - 6 weeks For 48 hours → decreases incidence of post-operative complications. → decrease the level of carboxyhemoglobin  Infection: broad spectrum antibiotics. Cefazolin is routinely administered perioperatively. 16

17. Preoperative Preparation…  Hydration and removal of Bronchial Secretions:-  Hydrating the patient decreases the viscosity of the bronchial secretions and facilitates their removal from the air ways.  Acetylcysteine (Mucomyst)  Potassium iodide  Postural drainage, Vigorous coughing, Chest percussion  Wheezing  The presence of acute wheezing represents a medical emergency, and elective surgery should be postponed until effective proper treatment has been instituted. 17

18. Preoperative Preparation….  Preparation of Bronchodilator drugs  Sympathomimetic Drugs (adrenalin, albuterol, salbutamol)  Phosphodiesterase Inhibitors (aminophylline)  Steroids  Parasymphatolytic drugs (atropine) 18

19. Effects of Anesthesia on lung volume and capacity  Total lung capacity (TLC)  Vital capacity is decreased by 25% to 50%  Residual volume (RV) increases by 13%.  Expiratory reserve volume decreases by 25% and 60%  Tidal volume (VT) decreases by 20%. 19

20. Intraoperative Monitoring All patients undergoing anesthesia for thoracic surgical procedures require use of standard American Society monitors .  Precordial stethoscope  Pulse oxymetry  NIBP  Capnography  ECG  ABG analysis of Anesthesiologists or ASA  Direct Arterial Catheterization  CV Catheterization  PAC 20

21. ONE LUNG VENTILATION One Lung Ventilation (OLV) is a technique that allows isolation of the individual lungs and each lung functioning independently by preparation under anesthesia. OLV provides :  Protection of healthy lung from infected/bleeding one  Diversion of ventilation from damaged airway or lung  Improved exposure of surgical field OLV causes :  More manipulation of airway, more damage of the airway  Significant physiologic change and easily development of hypoxemia 21

22. Indication for one lung ventilation (OLV) Absolute indication  Isolation of one lung from the other to avoid spillage or contamination  Infection  Massive hemorrhage  Control of the distribution of ventilation  Bronchopleural cutaneous fistula  Surgical opening of a major conducting airway  Giant unilateral lung cyst or bulla  Life-threatening hypoxemia due to unilateral lung disease  Unilateral bronchopulmonary lavage  Video assisted Thoracoscopic surgery 22

23. Indication for OLV… Relative indications  Surgical exposure— high priority  Thoracic aortic aneurysm  Pneumonectomy  Upper lobectomy  Surgical exposure— low priority  Esophageal surgery  Middle and lower lobectomy  Bilateral sympathectomies 23

24. Brain storming Lung isolation V S Lung separation?? 24

25. Blood position flow in the lungs LD UP right Position 25

26. Physiology of the Lateral Decubitus Position  In the lateral decubitus position, the distribution of blood flow and ventilation is similar to that in the upright position, but turned by 90 degrees. 26

27. Physiology of the LDP… 1,Lateral position, awake, breathing spontaneously,  Vertical hydrostatic pressure gradient is smaller  Dependent lung has ↑perfusion & ↑ventilation 2,Lateral position, awake, breathing spontaneously, Example: Thoracoscopy under intercostal block chest closed chest open  Two complications can arise from the patient breathing spontaneously with an open chest. These are: A) Mediastinal shift B) Paradoxical breathing 27

28. Physiology of the LDP… A) Mediastinal shift B) Paradoxical breathing 28

29. Physiology of the LDP… 3,Lateral 4,Lateral 5,Lateral position, p o si t i o n, p o si t i o n, anesthetized, a n est h eti z ed, a n est h eti z ed, breathing spontaneously, breathing spontaneously, chest chest closed open paralyzed, chest open 29

30. Physiology of the LDP… 6,One-lung ventilation, anesthetized, paralyzed, chest open  Two-lung ventilation in the lateral position: nondependent lung 40% C.O. 60% dependent lung  Shunt 5% in each lung  C.O participating in gas exchange 35% nondependent 55% in the dependent  Right-to-left transpulmonary shunt  Active HP V , b l o o d fl o w n o n depen d ent h y p o x i c l u ng will b e decre a sed by 5 % ( 3 5 / 2) = 1 7 .5%+5%=2 2 .5%+5%=2 7.5 %( pa o 2 = 1 5 m m Hg) 30

31. Physiology of One Lung Ventilation  Venous admixture  Venous admixture increases from a value of approximately 10% to 15% during two-lung ventilation to  Shunt and OLV  Physiological shunt  About 2-5% CO. 30% to 40% during OLV. The PaO 2 range of 9–16 kPa  Accounting for normal A-aDO 2 , 10-15 mmHg  Including drainages from: 31

32. Physiology of OLV…  Cardiac output and OLV  Decreased CO may reduce SvO 2 and thus impair SpO 2 in presence of significant shunt  Hypovolemia  Compression of heart or great vessels  Thoracic epidural sympathetic blockade  Air trapping and high PEEP  Increased CO increases PA pressures which increases perfusion of the non- ventilated lung → increase of shunt fraction  Gravity and V-Q 32

33. Physiology of OLV…  Hypoxic Pulmonary Vasoconstriction  HPV is a physiological response of the lung to alveolar hypoxia, which redistributes pulmonary blood flow from areas of low oxygen partial pressure to areas of high oxygen availability. Mechanism of action:  HPV is graded and l i m ited, of greatest benef i t when 3 % t o 7 % o f t h e l u ng is m ade h y p o x ic.  HPV is effective only when there are normoxic areas of the lung available to receive the diverted blood flow 33

34. Physiology of OLV…  HPV is inh i b i ted d i rectly by v o latile anesthetics (less with N 2 O), vas o d i lato r s (NTG, NO, dobutamine, ß 2 -agonist), increased PVR (MS, MI, PE) and hypocapnia.  HPV is indirectly inhibited by PEEP; vasoconstrictor drugs (epinephrine, norepinephrine, phenylephrine, and dopamine) constrict normoxic lung vessels preferentially. 34

35. Physiology of OLV… Potentiators of HPV  Almitrine may potentiate HPV. Almitrine is nonspecific pulmonary vasoconstrictor.  Prostaglandins may play a role in HPV inhibition, & therefore prostaglandin inhibitors have been investigated as potentiators of HPV.  Ibuprofen & a cyclooxygenase inhibitor have been found to potentiate HPV lung. in Hypoxic 35

36. Methods of Lung Separation OLV is achieved by either; 1,Double lumen ETT (DLT) 2,Bronchial blocker  Single-lumen ET with a built-in bronchial blocker (univent tube)  Single-lumen ET with an isolated bronchial blocker( ardnt , wire guided tube) 3,  Endobronchial tube Endobronchial intubation of a single-lumen ET 36

37. Double-Lumen Endobronchial Tube  Are currently the most widely used. Types of DLT are: A. Carlens Tube  The first DLT used for OLV  A left sided DLT with a carinal hook B, White, a right-sided Carlens tube C, Robertshaw Tube  All have two cuffs, one terminating in the trachea and the other in the mainstem bronchus  Right-sided or left-sided available  Available size: 41,39, 37, 35, 28 French (ID=6.5, 6.0, 5.5, 5.0 and 4.5 mm respectively) 37

38. Left sided Robert show Double Lumen  Characteristics:  Most commonly used  The bronchial lumen is longer, and a simple round opening and symmetric cuff  Better margin of safety than Rt DLT  Easy to apply suction and/or CPAP to either lung  Easy to deflate lung  Lower bronchial cuff volumes and pressures  Can be used Left lung isolation: clamp bronchial + ventilate/ tracheal lumen  Right lung isolation: clamp tracheal + ventilate/bronchial lumen 38

39. DLT…  Guide for Length and Size of DLT. For 170 cm height, tube depth of 29 cm for every 10 cm height change, 1 cm depth change or (Ht in cm/10) +12 39

40. Size of DLT 40

41. DLT Placement  Before insertion prepare &check the tube, stylate, FOB, 10ml syringe for tracheal cuff and 3ml syringe for bronchial cuff, connector,  Use mackintosh blade 3  Lubricate tube  Insert tube with distal concave curvature facing anteriorly  Remove stylet once through the vocal cords  Rotate tube 90 degrees (in direction of desired lung) large hemostat  Advancement of tube ceases when resistance is encountered. 41

42. DLT Placement …  Check its location 1 st 2 nd step :- the tracheal cuff –inflate &equal ventilation of both lungs step: - is to clamp the right side (in case of left sided tubes), inflate bronchial cuff slowly 3 rd step:- remove the clamp & check both lungs are ventilated with both cuffs inflated. Final step :- selectively &breath sounds on the clamp each side &watch for ipsilateral (clamped) side. absences of movement 42

43. DLT Placement…  Other methods to ensure position of a DLT  fluoroscopy  chest x-ray  selective capnography  pediatric fiberoptic bronchoscope  Continuous spirometry &clinical observation  Surgeon; may be able to palpate, redirect or assist in changing DLT position from within wrong lung, etc.). the chest (by deflecting the DLT away from the 43

44. Problems of Malposition of the Double-Lumen Tube  DLT in wrong bronchus  DLT may be passes too far down either the right or left mainstem bronchus  DLT not inserted for enough  A right-sided DLT may occlude the right upper lobe orifice.  The left upper lobe orifice may be obstructed by a left side DLT.  Bronchial cuff herination & may obstruct the bronchial lumen  Rare complication  tracheal rupture,  over inflation of the bronchial cuff, 44

45. Contraindications to Use of DLT  Full stomach  Lesion (stricture, tumor) along pathway of DLT (may be traumatized);  Patients, too small (<25-35kg) or too young (< 8-12 yrs.)  Anticipated difficult intubation;  Extremely critically ill patients who have a single-lumen tube already in place  Under these circumstances, -using a single-lumen tube ,a bronchial blocker 45

46. Clinical Approach to OLV management  After positioning recheck the position of DLT  Two-lung ventilation should be maintained for as long as possible  Use FIO2 of 1.0  VT =Two strategies:  high tidal volume (10-12 ml/kg) without PEEP or  moderate tidal volume (6-8 ml/kg) with PEEP  Adjust RR to keep PaCO 2 = 35+/-3 mmHg  CPAP(5 to 10 cm H 2 O) keeps this lung “quiet” and prevents it from collapsing completely. 46

47. Management of hypoxemia during OLV  FiO 2 = 1.0  Intermittent two-lung ventilation  Manual ventilation  Check DLT position with FOB  Check hemodynamic status  CPAP (5-10 cm H 2 O, 5 L/min) to nondependent lung, most effective  PEEP (5-10 cm H 2 O) to dependent lung, least effective  Clamp pulmonary artery 47

48. Choices of Anesthesia for Thoracic Surgery  A choice of anesthesia for thoracic surgery depends on:-  The patient's cardiovascular & respiratory status  The particular effects of anesthetic drugs on CVS and RS & other organ systems.  The ideal thoracic anesthetic technique would be:  Rapid in onset and offset and produce inhibition of airway reflexes and bronchodilation  It would allow the use of a high FiO 2 without inhibiting hypoxic pulmonary vasoconstriction.  It would also produce no adverse cardiovascular effects. 48

49. Choices of Anesthesia for Thoracic Surgery…  Before induction  IV - lidocaine allow used to treated brochospasm occurring during anesthesia.  Atropine - for antimuscarinic effects of acetylcholine & protect cholinergic induced bronchoconstriction  Induction  Propofol Satisfactory in most patients.  Etomidate elderly or those with cardiovascular instability  ketamine may be the drug of choice for reactive airway  Halothane is preferable for inhalation induction as it is least pungent 49

50. Choices of Anesthesia for Thoracic  Neuromuscular blockade  Consider suxamethonium for difficult intubation,  Avoid drugs which have histamine release effect  Use vecronium and pacronium  Maintenance of anaesthesia  Isoflurance most suitable Surgery…  Avoid halothane: has marked inhibitory effect on hypoxic pulmonary vasoconstriction  Nitr o us o x i d e is co n trai n d i c a ted in patien t s with cysts or b u llae bec a u s e it c a n expand t h e air s p a c e and cause ru p t u re.  TIVA(propofol and fentanyl) 50

51. Fluid Management  There is an increased potential for pulmonary oedema to develop. Right pneumonectomy is associated with the highest risk of this  Pulmonary oedema may develop due to several factors.  Raising pulmonary vessel hydrostatic pressures.  Loss of lymphatic drainage occurs.  Decreased pulmonary capillary oncotic pressures complication.  No more than 10ml/kg of crystalloid in the first hour intraoperatively and  1.5L in the first 24 hours postoperatively. 51

52. Termination of surgery and Anesthesia  Placed in supine position before extubation.  Both lumens of the DLT should be suctioned to remove any mucus, blood, or debris from each lung  Reinflating the collapsed lung; Hyperinflation of the lungs is an important maneuver to remove air from the pleural space at the conclusion of thoracic surgery  The surgeon pours warm saline into the pleural cavity while the anesthesiologist applies increasing levels of inflation cmH2O) by manually compressing the reservoir bag pressures (up to 30–40 52

53. Termination of surgery and Anesthesia…  Both lungs must be fully re-expanded and the mediastinum must be midline at the completion of one-lung ventilation.  If mechanical ventilation of the lungs must be continued into the postoperative lumen tube. period, it will be necessary to replace the DLT with a single-  Anesthesia is lightened &spontaneous ventilation reestablished  Plac e - si t ti n g p o si t i o n after re m o v al o f D L T allowed to breath O 2 enric h ed ai r . 53

54. Complications and their management Thoracic Surgery Following  Atelectasis (most common)  cardiovascular herniation  hemorrhage from a major vessel  Pneumothorax,  Dysrhythmias 54

55. Neurovascular injury  Dependent eye  Dependent ear pinna specific to LDP  Brachial plexus (dependent and nondependent)  Suprascapular nerve(dependent and nondependent)  Sciatic nerve (nondependent)  Peroneal nerve (dependent) 55

56. Postoperative Analgesia  Tho r a c o t o m y is am o n g t h e m o s t pai n f u l of a ll o perati v e p r ocedu r es. Go o d analgesia is essen t ial h y p o ven t ila t i o n d u e to pain m ay i n cre a se the ri s k o f p o st o perati v e p u l m o n ary co m p l icatio n s  Systemic opioids: Systemic opioids remain the mainstay of post-thoracotomy analgesic techniques.  Their major clinical limitation is a narrow therapeutic window.  Well-controlled opiate infusion may provide comparable analgesia. 56

57. Postoperative Analgesia…  NSAIDS: NSAIDs have opioid-sparing benefits when commenced postoperatively. They do not produce respiratory depression.  Epidural analgesia: Thoracic epidural infusions of opiates appear to be more effective than lumbar  Intercostal nerve blocks: Intercostal nerve blocks performed intraoperatively are of benefit for a short period immediately postoperatively.  Interpleuaral analgesia: Interpleural analgesia is performed by directly infusing local anaesthetic into the pleural cavity. 57

58. Thoracic Anesthesia in ETHIOPIA 58

59. Thoracic Anesthesia in ETHIOPIA 59

60. SUMMERY  Adequate preoperative evaluation can help influence and thereby improve perioperative care.  Proper, vigorous preoperative preparation can improve the patient’s ability to face the surgery with a decreased risk of morbidity and mortality.  Management of OLV is a challenge for the anesthesiologist, requiring knowledge, skill, vigilance, experience, and practice.  Many methods can be used for OLV. Optimal methods depends on indication, patient factors, equipment, skills and level of training.  FOB is the key equipment for OLV.  A choice of anesthesia depends on patient's cardiovascular &respiratory status.  Adequate postoperative pain control is necessary to ensure a good respiratory effort. 60

61. Reference 8 th  Miller's Anesthesia Edition, Ronald D. Miller, MD, Lars I. Eriksson, MD, P h D, Lee A. F leis h e r , M D , J e a n i ne P . W iene r - Kro n is h , M D , W ill i am L. Y o u n g , MD 8 th  Clinical Anesthesia Edition, Paul G. Barash, MD, Bruce F. Cullen, MD, Robert K. Stoelting, MD, Michael K. Cahalan, MD, M. Christine Stock , MD  Practical Handbook of Thoracic Anesthesia  Tortora principle of physiology and anatomy edition). 13 rd (biological text book 2012 th  G. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray Clinical 6 th Anesthesiology, Edition  Harrison’s Principles of Internal Medicine. New York: McGraw- Hill, 2008, 19 th edition.  Stoelting Anesthesia and Co-existing disease. Philadelphia: Churchil 5 th Livingstone, 2008, edition. 61

62. Thanks for Your Attention 62