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Core Topics in Thoracic Anesthesia
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Book description

Providing an easily readable source of information about the current spectrum of anesthesia and critical care management of patients undergoing thoracic surgery, this book forms part of the successful Core Topics brand. The book provides practical assistance to those commencing careers in thoracic anesthesia and will also to be a useful aide-memoire to those already working in the field. The comprehensive content includes discussion of some of the more contentious issues in the management of thoracic patients as well as giving a flavour of the rapid evolution of new techniques that are of increasing importance in the field, such as lung-assist devices, different modes of ventilation and VAT surgery. Both editors are practising cardiothoracic anesthetists/intensivists at an internationally recognized centre for thoracic surgery, particularly lung transplantation. The contributors are chosen for their clinical expertise and to give a spectrum of opinion across the range of thoracic anesthesia.

Reviews

'… can be recommended for trainees in thoracic anaesthesia, and it would be a useful, concise reference for the occasional thoracic case presenting to the specialist.'

Source: Anaesthesia and Intensive Care

'… concise but comprehensive … All anaesthesia providers in the field will find this valuable for their daily practice and preparation for examinations.'

Source: Doody's

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Contents


Page 1 of 2


  • Chapter 9 - Anesthesia for tracheal surgery
    pp 64-67
  • View abstract

    Summary

    The knowledge of certain aspects of thoracic anatomical arrangements is of great importance to the thoracic anesthetist. Throughout its course the esophagus lies directly behind the trachea, with the recurrent laryngeal nerves lying in the groove in between. In the upper (extra thoracic) trachea, the isthmus of the thyroid overlies the trachea anteriorly with the thyroid lobes lying laterally. The carina marks the bifurcation into right and left bronchi. The bronchus for each segment divides about 15 times into terminal bronchioles. Blood from each segment is drained by intersegmental veins that lie in the connective tissue around the segment, which generally leads to a single branch from each segment. The borders of the thoracic paravertebral space are imprecise. It is thought that the prevertebral fascia and anterior longitudinal ligament usually form a barrier to communication to the contralateral paravertebral space, breached only by lymphatic channels.
  • Chapter 10 - Anesthesia for mediastinoscopy and mediastinal surgery
    pp 68-74
  • View abstract

    Summary

    The primary task of the lungs is respiration. Respiration is the exchange of gases between an organism and its environment with the utilization of O2 and production of CO2. The most important physiological measure is the compliance of the intact respiratory system. The movement of O2 and CO2 in and out of the capillaries both in the lungs and in the peripheral tissues depends on gas diffusion. Positive pressure ventilation results in most of the ventilation being directed into the upper rather than the lower lung. The blood flow gradient due to gravity favors the dependent lung during one-lung ventilation (OLV). If the non-dependent lung is not ventilated any blood flow to it becomes shunt flow. This results in a larger alveolar-to-arterial oxygen tension difference with a lower PaO2 for a given oxygen concentration under identical circumstances, when compared to two-lung ventilation in the same position.
  • Chapter 11 - Anesthesia for video-assisted thoracoscopic surgery
    pp 75-80
  • View abstract

    Summary

    The twin requirements of respiration (ventilation and perfusion) result in the lungs both being exposed to the external environment and the internal environment through the bloodstream. Many of the drugs that people use as anesthetists are metabolized in the lungs including sympathomimetics, antihistamines, opiates and local anesthetics. Drugs used in the treatment of asthma and bronchospasm are bronchodilators, leukotriene antagonists, and magnesium sulphate. Opiates, propofol, thiopentone and muscle relaxants are used during anesthesia on the respiratory system. Mucolytics are prescribed in order to facilitate expectoration by decreasing the viscosity of sputum. They have been shown to benefit some patients with chronic obstructive airways disease and chronic cough with a reduction in exacerbations of the condition. Patients with respiratory disease are likely to be particularly sensitive to small decreases in respiratory muscle function secondary to residual muscle weakness.
  • Chapter 12 - Anesthesia for lung resection
    pp 81-85
  • View abstract

    Summary

    This chapter reviews common respiratory disease processes. It provides an overview of the disorders that may be met by the thoracic anesthetist, and considers their anesthetic implications. Infective disorder described in the chapter includes pneumonia, tuberculosis, aspergillus, bronchiectasis, and cystic fibrosis. Patients with pneumonia may present with a history of cough, production of purulent sputum and fever, together with pleuritic chest pain and shortness of breath. Hematogenous spread causes generalization of the disease and can cause miliary tuberculosis (TB) and/or TB meningitis. The chapter discusses airway obstructive disorders such as asthma and chronic obstructive pulmonary disease (COPD), along with interstitial lung disease and the disease involving the pulmonary circulation. Pulmonary embolism usually occurs as a complication and consequence of deep vein thrombosis. Lung cancer remains the commonest cause of cancer death worldwide.
  • Chapter 13 - Surgical treatment options for emphysema
    pp 86-90
  • View abstract

    Summary

    Thoracic surgery ranges from small low-risk procedures to major surgery, and for malignant and non-malignant disease. Assessment of the thoracic patient for surgery comprises two distinct areas. The first is the resectability of the lesion if malignant and the second is the fitness to withstand the morbidity it inevitably involves, referred to as operability by most surgeons. Lung function tests described in the chapter include spirometry, gas transfer capacity, functional tests, and arterial blood gas analysis. Sensitivity for detecting small lesions is reasonable but not as high as computerized tomography (CT) scans but the radiation exposure is very low and the investigation is widely available. In general, the resolution of the magnetic resonance imaging (MRI) scan is not superior to the CT scan and it is no better at confirming the presence or absence of invasion than CT scanning.
  • Chapter 14 - Lung transplantation
    pp 91-98
  • View abstract

    Summary

    This chapter provides an overview of the indications and techniques available for lung isolation in adult patients, using devices currently available in the UK. The double lumenendobronchial tube (DLT), bronchial blocker and an appropriately sized single lumen tracheal tube can all produce lung isolation, if placed in a main stem bronchus. There are two main configurations of bronchial blockers: the blocker is incorporated into a channel in the wall of a tracheal tube as in univent torque control blocker (TCB); and independent catheter as in Arndt Blocker. The independent bronchial blocker catheters can all be positioned coaxially down a standard tracheal tube under fiberoptic bronchoscope (FOB) guidance. Complications with the use of bronchial blockers include malposition and displacement resulting in life-threatening airway obstruction and hypoxia. Single lumen tracheal tubes, standard DLTs and bronchial blockers have all been used to provide lung isolation in patients with tracheostomy.
  • Chapter 15 - Anesthesia for pulmonary endarterectomy
    pp 99-104
  • View abstract

    Summary

    The institution of one-lung ventilation (OLV) can be problematic in approximately 20% of any case mix. A significant number will prove difficult at the lung separator insertion stage. The usual conditions of difficult intubation pertain, as well as some specific to the thoracic discipline and the pathologies encountered and exacerbated by the structure and bulk of some lung separators. The use of OLV and the adoption of the lateral decubitus position results in specific physiological changes, such as the shifts in west zones from vertical to horizontal, which are best countered by positive pressure ventilation. The open pneumothorax, weight of mediastinum, abdominal contents on adoption of the lateral decubitus position and the surgeon at work compress the dependent lung; and, all must be opposed through the narrow conduit of, often, the single lumen of a double lumen endobronchial tube (DLT).
  • Chapter 17 - Anesthesia for pleural and chest wall surgery
    pp 114-117
  • View abstract

    Summary

    Rigid bronchoscopy (RB) was a necessary art of assessment of fitness for lung resection surgery and placing lung separator devices (LSD). For RB, general anesthesia is the norm. For short procedures a propofol and opioid supplemented induction is a usual regimen, followed by a short-acting non-depolarizing agent such as mivacurium. Manufacturers of positive pressure ventilation equipment pay little attention to the needs of patient ventilation during operation of their devices. Intrinsic and extrinsic lesions of the trachea can present as life-threatening emergencies. The erosion of a major vessel in the bronchial tree occasionally results in unstoppable hemoptysis. With much of the cardiac output coming up an RB, it is impossible to do anything to intervene. The advent of self-expanding devices has considerably eased the burden of sharing access to the airway with surgeons or physicians.
  • Chapter 18 - Anesthetic implications for management of thoracic trauma
    pp 118-128
  • View abstract

    Summary

    The development of modern anesthesia techniques involving the ventilation of the patient's lungs and the use of tracheal tubes in intensive care and anesthesia was a great impetus to the development of surgery in general. The types of procedures carried out on the trachea that require general anesthesia are rigid bronchoscopy, tracheal stenting and excision of tracheal stenosis or tumors. Rigid bronchoscopy can be used for diagnostic purposes by examining and assessing the tracheobronchial tree anatomy and by the taking of a biopsy for histology. Silicone rubber stents require general anesthesia for placement while metallic expandable stents can be placed fluoroscopically or under general anesthesia. The indications for tracheal resection are symptomatic stenosis or benign and malignant tumors. Tracheal stenosis is most often caused by trauma such as prolonged intubation of the trachea in the intensive care unit.
  • Chapter 19 - Pediatric thoracic procedures
    pp 129-136
  • View abstract

    Summary

    The prognosis for patients with mediastinal pathology has improved significantly in recent years as a result of better understanding of the impact of chemotherapy and radiotherapy on malignant mediastinal tumors. The signs and symptoms of mediastinal pathology range from trivial to life-threatening, and include airway compression, superior vena cava syndrome, compression of the right heart and pulmonary arteries, and dysphagia from esophageal compression. The surgical approach for diagnostic procedures of mediastinal surgery is via cervical mediastinoscopy or anterior mediastinotomy, while for tumor resection the usual approaches are via median sternotomy or lateral thoracotomy. Careful evaluation of the airway is necessary during pre-operative assessment for surgery within the mediastinum. Myasthenia gravis is commonly associated with other autoimmune disorders. In severe myasthenia, neuromuscular blocking drugs may be avoided completely, as the muscle-relaxing effect of volatile anesthetics is enhanced.
  • Chapter 20 - Significance of age in practice of thoracic anesthesia
    pp 137-144
  • View abstract

    Summary

    Video-assisted thoracoscopic surgery (VATS) has become a vital part of the armamentarium of the surgeon. VATS is associated with shorter length of hospital stay and less use of pain medication than thoracotomy in the treatment of pneumothorax and minor resections. General anesthesia is usually induced with an intravenous agent such as propofol or thiopentone and maintained with an inhalational agent such as isoflurane in an air/oxygen mixture. The isolation and division of the bronchi and pulmonary blood vessels require more accurate and extensive dissection with VATS than conventional surgery. Thoracoscopic lobectomy can be oncologically equal to conventional open procedures with an experienced surgeon and have similar survival for early stage non-small cell lung cancer. Conversion to a thoracotomy is sometimes required if there is an unexpected change in the patient's condition such as chest wall invasion or the need for a sleeve resection.

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