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,ANE
URYSM
• 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 or

Have to stop when walking at my own pace on the level.

4 Stop for breath walking 100 meters or

After 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 Volumes

• 4 Volumes
• 4 Capacities
IRV • Sum of 2 or
IC
more lung
VC
TV
TLC
volumes
ERV
FRC
RV 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  Increased DLCO

(<80% (>120-140% predicted)
predicted)
 Asthma (or normal)
 Obstructive lung
disease
 Pulmonary
 Parenchymal disease hemorrhage

 Pulmonary vascular  Polycythemia

disease
 Left to right shunt
 Anemia
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 MEAN PAP >40MMHG

OCCLUSION OF RT /LT MAIN SEVERE BREATHLESSNESS
STEM BRONCHUS PACO2 >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

% 100% 50% 40% 25%

PREDPREOP
PFT UNITS NORMAL PNEUMO LOBEC SEGMENTAL
RESECTION
DLCO %PPRE OP 100 >60 -

%POST OP PRED >40%

EXERCISE STAIR >10FLIGHTS >5 >3 >2

TESTING CLINBING(PRE OP)

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

O2 SPO2 FALL WITH NONE <3 <5 <5

EXERCISE

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
1 2 3 4
BMI
• <21Body Mass
>=21
Index
FEV1% • >65Obstruction
50-64 36-49 <35
PRED • Dyspnoea
MMRC • 0-1Exercise2 Capacity 3 4
DYSPNEA
SCALE

6MWDIST >=350M 250-349 150-249 <149

ANCE
 SHAPIRO’S POINT SCORING
CATEGORY 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, 0
MI WITHOUT SEQ >2YR
DYPNEA ON EXERTION,PND,PEDAL 1
EDEMA,CCF,ANGINA
III CNS NORMAL 0

CONFUSION,OBTUNDATION,AGITATION SPASTICITY,BULBAR LESIONS 1

MUSCLE WEAKNESS 1
SHAPIRO’S POINT SCORING
TOTAL SCORE 7
CATEGORY POINTS

IV ABG ACCEPTABLE 0

PACO2>50MMHG 1
Pa02<60MMHG ON ROOM AIR

METAB PH ABNORMALITY >7.50 OR <7.30 1

V .POST OP AMBULATION WITH IN 36 HRS-SITTING AT 0

BEDSIDE

EXPECTED COMPLETE BED 1

CONFINEMENT FOR 36 HRS
FORMULAS

EQUATION NORMAL VALUES

ALVEOLAR O2 PAO2=(PB-47)FIO2- 110MMHG(FIO2=0.21
TENSION (PAO2/R) )
ALVEOLAR – A-aO2=PAO2-PaO2 <10MMHG
ARTERIOLAR O2
GRADIENT
PaO2/PAO2 >0.75
ARTERIAL O2 CaO2=(SaO2) 20ML/100ML BLOOD
CONTENT (HB×1.34)+PaO2(0.00
31)
MIXED VENOUS O2 CvO2=(SvO2) 15ML/100 ML
CONTENT (HB×1.34)+PvO2(0.00
31
ARTERIAL-VENOUS Ca02-Cv02 4-6ML/100ML
O2 CONTENT DIFF
 EQUATION NORMAL VALUES
INTRAPULMONARY (CcO2-CaO2)/CcO2- <5%
SHUNT Qs/Qt CVO2)

PHYSIOLOGICAL PaCO2-PECO2/PaCO2 0.33

DEAD SPACE VD/VT

O2 CO(CaO2-CvO2) 250ML/MIN
CONSUMPTION(VO2)

O2 TRANSPORT CO(CaO2) 1000ML/MIN

DO2

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
TIME COURSE BENIFITS
12-24 HRS • 4-8 WEEKSDECREASED
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 GAS AIRWAY ETT POSITION PA CARDIOVASC
CATEGORY EXCHANGE MECH PRESSURES ULAR
STATUS

1.ESSENTIAL ROUTINE COLOR OF FEEL BAE,BALLOT NO NIBP,PULSE

ONITORING IN HELATHY TISSUES,SPO BAG,STETH , ABLE OXYMETRY
ALLPTS PTS WITHOUT 2,PETCO2 PIP,PETCO2 BALLON IN WAVE
SPCL INTRA SUPRASTERN FORM,ECG,P
OP AL ETCO2,ESOP
CONDITIONS NOTCH,FOB HAGEAL
AFTER LDP STETH,±CVP,
±IABP
2.SPCL HEALTHY + ABG SPIROMETRY, FOB IN IF +IABP,CVP,PA
INTERMITTEN PTS WITH INDIVIDUAL SUPINE AND LOBECTOMY CATHTER,
T OR CONT SPCL AND WHOLE LDP OR LUNG ±TEE
MONITORING PROCEDURE LUNG RESECTION
S OR SICK
PTS WITH
ROUTINE
PROCEDURE
TIERED SYST PT GAS AIRWAY ETT POSITION PA CARDIOVASC
CATEGORY EXCHANGE MECH PRESSURES ULAR
STATUS

3.ADVANCED SICK PTS +QS/QT,VD/V +AIRWAY FREQ FOB PA,Q,PVR,SV PA,TEE

MONITORIIN WITH SPCL T,VBGS RESISTAN R,DAO2-
G INTRA OP CE DVO2
CONDITIONS
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 Movement of endobronchial tube/blocker, air leak

pressure or volume

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 Too far out Deflate & advance

either lumen ventillated

Both lungs ventilate via Br.lumen in trachea/ cuff Deflate & advance
bron.lumen,neither when overinflated
ventillated via tracheal lumen

No ventillation via bronchial ?entered other side reposition

lumen

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 -approaches
INTRA 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
two-lung ventilation (if possible).
Gradual desaturation:
• Fio2 1.0.
•   Check position of double-lumen tube or
blocker with fiberoptic bronchoscopy.
•   Ensure that cardiac output is optimal;
decrease volatile anesthetics to < 1 MAC. 
•  Apply a recruitment maneuver to the
ventilated lung (this will transiently make the
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