Intraoperative hypoxia during thoracic surgery
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Intraoperative Hypoxia During Thoracic Surgery. Tarek Ashoor. Objectives. Shunting and its significance. Alveolar dead space . Physiology of LDP. HPV and the factors affecting it. Causes of hypoxia in one lung ventilation. How to manage them. Introduction. Shunting is :

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Objectives
Objectives

  • Shunting and its significance.

  • Alveolar dead space .

  • Physiology of LDP.

  • HPV and the factors affecting it.

  • Causes of hypoxia in one lung ventilation.

  • How to manage them.


Introduction
Introduction

  • Shunting is :

  • Shunting is simply the passage of venous blood (Venous admixture) to the left side of the heart .

    So What?


Introduction cont
Introduction (cont.)

The venous admixture causes dilution of the PaO2 in the arterial blood ending in


Introduction cont1
Introduction (cont.)

The venous admixture causes dilution of the PaO2 in the arterial blood ending in

Hypoxia


Introduction cont2
Introduction (cont.)

This occur physiologically due to:

  • Thebesian veins of the heart

  • The pulmonary bronchial veins

  • Mediastinal and pleural veins

    Accounting for normal A-aD02, 10-15 mmHg


Introduction cont3
Introduction (cont.)

  • Transpulmonary shunt occur due to continued perfusion of the atelectatic lung (or part of it).

  • Perfused Non-ventilated part of the lung


Introduction cont4
Introduction (cont.)

Dead space:

Space in the respiratory tract that doesn’t share in gas exchange.

This accounts for the normal difference between PaCO2 and ETCO2 (5 mmHg).


Introduction cont5
Introduction (cont.)

Alveolar dead space:

Parts in the lungs that are ventilated but not perfused.

Ex: Pulmonary embolism




Physiology of the ldp
Physiology of the LDP paralyzed patients in LDP (cont.)

  • Upright LDP, lateral decubitus


Physiology of olv
Physiology of OLV paralyzed patients in LDP (cont.)

  • The principle physiologic change of OLV is the redistribution of lung perfusion between the ventilated (dependent) and blocked (nondependent) lung

  • Many factors contribute to the lung perfusion, the major determinants of them are hypoxic pulmonary vasoconstriction, and gravity.


HPV paralyzed patients in LDP (cont.)

  • HPV, a local response of pulmonary artery smooth muscle, decreases blood flow to the area of lung where a low alveolar oxygen pressure is sensed.

  • HPV aids in keeping a normal V/Q relationship by diversion of blood from underventilated areas.

  • HPV is graded and limited, of greatest benefit when 30% to 70% of the lung is made hypoxic.

  • But effective only when there are normoxic areas of the lung available to receive the diverted blood flow


Two lung ventilation and olv
Two-lung Ventilation and OLV paralyzed patients in LDP (cont.)


Factors affecting regional hpv
Factors Affecting Regional HPV paralyzed patients in LDP (cont.)


Factors affecting regional hpv1
Factors Affecting Regional HPV paralyzed patients in LDP (cont.)

  • 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) by preferentially constrict normoxic lung vessels


Hypoxemia in olv
Hypoxemia in OLV paralyzed patients in LDP (cont.)

Causes of hypoxemia in OLV:

  • Mechanical failure of 02 supply or airway blockade

  • Hypoventilation

  • Factors that decrease Sv02 (CO, 02 consumption)


Hypoxemia in olv1
Hypoxemia in OLV paralyzed patients in LDP (cont.)

  • If severe hypoxemia occurs:

    -Am I using FiO2= 1?

    • Is my tube in correct position?

    • Is the tube clear (no secretions)

    • Am I using vasodilator?


Hypoxemia in olv2
Hypoxemia in OLV paralyzed patients in LDP (cont.)

  • If severe hypoxemia occurs:

    After asking those Questions consider:

    • CPAP (5-10 cm H2O, 5 L/min) to nondependent lung, most effective

    • PEEP (5-10 cm H2O) to dependent lung, least effective

    • Intermittent two-lung ventilation

    • Clamp pulmonary artery.


Right robert shaw fob internal view from tracheal lumen
Right Robert Shaw paralyzed patients in LDP (cont.)– FOB Internal View from Tracheal Lumen


Left robert shaw fob internal view
Left Robert Shaw paralyzed patients in LDP (cont.)–FOB Internal View


Broncho cath cpap system
Broncho-Cath CPAP System paralyzed patients in LDP (cont.)


Rich man s cpap
Rich Man paralyzed patients in LDP (cont.)’s* CPAP

*Guageguided CPAP system

*Permits measuring actual pressure applied

Adjust to 5-10 cmsH2O


Poor man scpap dlett
POOR MAN paralyzed patients in LDP (cont.)’sCPAP (DLETT)

  • 1 = BABYSAFEUnit

  • 2 = Attached to surgical DLETT lumen

  • 3 = O2 tubing to aux. O2port on anesthesia machine

  • 4 = adjust flow so bag is just full(not quantitative)


Cpap with arndt
CPAP with Arndt paralyzed patients in LDP (cont.)

  • 1 = BABYSAFE system

  • 2 = special connector (in kit) for Arndt CPAP administration through blocker lumen

  • 3 = adjuster valve

  • 4 = standard anesthesia circuit


  • X = Don paralyzed patients in LDP (cont.)’t place tight sealed catheter in endotracheal tube to try and deliver CPAP!!! It can lead to ………………. →



Questions
Questions paralyzed patients in LDP (cont.)

  • The increase in alveolar PCO2 decrease alveolar PO2

  • Pulmonary embolism increase the difference between the PaCO2 and ED CO2.

  • Shunting cause mainly hypercarbia

  • Pulmonary oedema may occur in the nondependent lung during single lung ventilation.


Questions cont
Questions(cont.) paralyzed patients in LDP (cont.)

  • Application of CPAP to the nondependent lung is the least effective way to guard against hypoxia during single lung ventilation.

  • The use of vasodilator is the appropriate way to manage hypertension during single lung ventilation.

  • Valvular lesions of the heart have no impact on PO2 during single lung ventilation.


Questions cont1
Questions(cont.) paralyzed patients in LDP (cont.)

  • HPV is an all or non reflex.

  • Decrease in FiO2 than 1% is important to guard against absorption collapse in the ventilated lung during single lung ventilation.

  • Patients under single lung ventilation should receive below average IV fluids.


Questions cont2
Questions(cont.) paralyzed patients in LDP (cont.)

  • Single lung ventilation cause 50% shunting.

  • High dose of inhalational anaesthetic is appropriate in controlling hypertension during single lung ventilation.


Questions cont3
Questions(cont.) paralyzed patients in LDP (cont.)

  • Hypotension increase the alveolar dead space.

  • Physiological shunting accounts for the normal difference between the alveolar and the pulmonary end capillary PO2.


  • THANKS paralyzed patients in LDP (cont.)


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