Short Answer Questions

Anaesthesia
& Intensive Care
Part 8: Thoracic Anaesthesia
:

‫عيداروس‬ THORACIC ANESTHESIA 1

FCAI - FRCA - EDAIC

 ‫بسم الله الرحمن الرحيم‬

For Original Materials and Editors, Please refer to:

North Ireland School of Anaesthesia Website

http://www.nischoolofanaesthesia-finalfrca.org.uk/SAQs/thoracic/
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1- Double Lumen tube and lung resection
a) List the indications for placement of a double lumen tube in anaesthesia and critical care. (5 marks)
b) List, giving appropriate threshold values for each, the methods of pre-operative respiratory
assessment you would use in an adult to decide whether a patient could tolerate lung resection. (5 M)
How would you manage the development of hypoxaemia during one-lung anaesthesia? (10 marks)

 The indications for placement of a Double Lumen Tube in Anaesthesia and Critical Care:

1. To facilitate surgery
a. Lung surgery, e.g. pneumonectomy, lobectomy
b. Non-lung surgery, e.g. pericardial window, diaphragmatic hernia repair, oesophagectomy

2. To prevent cross contamination of contralateral lung

a. Endobronchial haemorrhage
b. Abscess and empyema
c. Bronchiectasis
d. Lavage

3. To control distribution of ventilation

a. bronchopleural fistula

 Pre-operative respiratory assessment you would use in an adult to decide whether a patient
could tolerate lung resection:

1. Spirometry
a. FEV1>1.5L for lobectomy, FEV1 >2.0L for pneumonectomy
b. FEV1 >80% normal predicted for pneumonectomy

2. Quantitive lung scan e.g. V/Q scanning

a. predicted post op FEV1 >40% predicted normal
b. predicted post op TLCO >40% predicted normal

3. Assessment of exercise capacity

a. Gold standard would be cardiopulmonary exercise testing, VO2 max >15 ml/kg/min
b. Shuttle walk test, >400m threshold (BTS guidelines 2010)
c. Number of flights of stairs climbed, historically ≥3 flights for ≥5 flights for pneumonectomy

4. Arterial blood gas

a. preoperative hypoxaemia, saturations <90% and desaturation >4% with exercise have been
associated with increased risk of complications

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 Management of Hypoxaemia during one-lung Anaesthesia:

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2- Preoperative Assessment & Complications of Pulmonary Resection
(a) What tests of lung function can be used to predict whether a patient will tolerate a pulmonary
resection ? (45%)
(b) Indicate minimum values for lobectomy and pneumonectomy. (40%)
(c) List postoperative complications following thoracic surgery (15%)

 Lung Function Tests:

- Spirometry (post bronchodilator) and exercise data are used to predict the perioperative risk and
postoperative respiratory reserve i.e. pulmonary function and risk of respiratory failure.

- The predicted post-operative FEV1 (ppoFEV1) can be estimated from the formula using the total
number of segments in both lungs, 19 (9 in left, 10 in right) and the number of segments to be
resected(y).

ppo FEV1 = FEV1 x (19-y)/19

 Minimum values for Pneumonectomy: FEV1: >80% or >2L

Minimum values for Lobectomy: FEV1>80% or >1.5L

ppoFEV1 <40% and DLCO <40% = HIGH RISK

ppoFEV1 >40% and DLCO >40% and SpO2>90% = AVERAGE RISK

Any other combination requires further exercise testing.

 Complications following thoracic surgery may be classified into early or late complications:
Early (usually within the first 72 hours):
*Respiratory insufficiency
*Mediastinal or subcutaneous emphysema
*Mediastinal shift
*Vocal cord injury
*Haemorrhage
*Arrhythmias

Later complications:
*Pneumonia
*ALI
*Bronchopleural fistula
* DVT
*PE

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3-Thoracic Aneurysm Classification and Cross Clamping of Aorta
(a) What are the relations of the aorta within the thorax (15%)
(b) Describe the classification of thoraco-abdominal aneurysms (TAAs). Why is classification important?
(30%)
(c) Describe physiological changes that occur during aortic cross-clamping (40%)
(d) What are the complications of aortic cross clamping? (15%)

 The aorta is part of the

superior mediastinal structures.
- The contents of the superior
compartment can be divided into
Prevertebral, Central and
Retrosternal.
- The aorta arch and its branches
are part of the central division
with the vagus and phrenic nerve.
- Ascending aorta gives of the
RCA and LCA
- Pierces pericardial sac and
becomes aortic arch at the level
of the manubrio-sternal joint.
- Arch crosses over the
pulmonary trunk and left
pulmonary artery
- At T4/T5 it becomes the descending aorta and passes behind the left main bronchus.
- Upper part of the arch gives of the following branches: Brachiocephalic (Rt. side), left Common
Carotid, left Subclavian arteries.
- Aortic arch is crossed superficially by the left Phrenic and left Vagus nerve.
- Left Vagus gives of the left Recurrent Laryngeal nerve which hooks round the lower part of the
arch.

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 TAA’s are divided into 5 groups based on a modified TAA classification by E. Stanley Crawford.
- Type 1: extends from distal to the Lt. subclavian artery to above the renal arteries
- Type 2: Extends from distal to the Lt. subclavian artery to the aortic bifurcation
- Type 3: Extends from the 6th intercostal space to the aortic bifurcation.
- Type 4: Extends from the diaphragm to the aortic bifurcation (total abdominal aorta)
- Type 5: Extends from the 6th Intercostal space to the aortic bifurcation.

- This

classification does not include aneurysms that involve only the descending aorta.
-Classification is important as it allows risk stratification based on the extent of aorta involved.
-It also gives an idea of what will be encountered in surgery and is important for reporting of results
as more extensive aneurysms are associated with greater mortality and morbidity.
-Type 2 TAA’s carry more risk and complications.

 The physiological changes that occur during aortic cross clamping:

* Crosses
clamping occurs above and below the lesion to allowing the aneurysm to be opened and
replacement with a graft to occur.

* Clamping produces:
- Proximal hypertension; depends on clamp location, degree of collaterals & preocclusion aortic flow.
- Distal hypo-perfusion
- Increase in cardiac filling pressure,  myocardial wall stress and VO2
- Decrease in CO and  EF
- Reflex bradycardia,  contractility and peripheral vasodilation in response to hypertension.

* Distal
to the clamp there is:
- Decrease oxygen consumption
- Conversion to anaerobic metabolism

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- Hepatic and renal hypoperfusion reduces elimination of lactic acid
- End organ hypoperfusion in general

 Complications of Aortic Cross Clamping:

- Significant stress is put on the heart and visceral organs

- Considerable potential for end organ injury for example;

*Bowel ischaemia.
*Renal insufficiency
*Neurological complications

- The risk and extent of complications is related to the duration of cross clamping.

- Most concerning complications are renal failure and paraplegia

- Risk of renal failure increases with longer cross clamp times. Mannitol has been shown to improve
postoperative renal function.

- Risk of ischaemic neurological injury also increases with prolonged cross clamping. It usually
presents with paraplegia but other neurological complications can occur.
The degree of collateral blood supply, renal dysfunction and hyperglycaemia  the risk of injury.

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- Cross clamping can also cause mesenteric ischaemia.

- Other complications include:

- Blood loss
- Depletion of coagulation factors
- DIC
- Hypothermia
- Hypocalcaemia after hepatic hypoperfusion
- Respiratory insufficiency.

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4- Paravertebral Block
Paravertebral blockade is an acceptable alternative to an epidural for analgesia following thoracotomy
or rib fractures,
(a) Describe the anatomy of the paravertebral space (25%)
(b) Describe the technique of paravertebral blockade (25%)
(c)What are the indications? (25%)
(d) and contraindications (25%) for paravertebral blockade.

 Anatomy of The Paravertebral Space:

Boundaries:
- Medially, bounded by vertebral bodies
and intervertebral discs
- Anterolaterally by parietal pleura
- Posteriorly by transverse processes
and heads of the ribs.

Contents:
Spinal nerves, Sympathetic chain, Intercostal
vessels, fat and Rami communicantes.
 The Technique of Paravertebral Blockade:
- Consent, equipment preparation, monitoring,
assistance, asepsis.
- Position: sitting if awake, lateral if asleep
(operative site up), head and neck flexed.
- Mark skin at spinous processes of level required, and corresponding transverse processes 2.5cm
laterally. Local to skin if awake.
- 18G Tuohy inserted at TP perpendicular to skin until bony contact obtained, depth 3.5-4.5cm.
- Needletip ‘walked off’ TP caudally until 1cm deeper than bony contact and local anaesthetic
injected after aspiration.
- 15ml blocks roughly 3 dermatomes (sympathetic block 8 dermatomes).
- Loss of resistance may assist in finding this point but is not a complete loss.
- Peripheral nerve stimulator will elicit intercostal muscle contraction.
*If ultrasound guidance is used:
- linear probe 5cm from midline craniocaudally and moved medially to identify rib/TP join and needle
inserted ‘out-of-plane’.
- A catheter may be inserted after 10ml LA to expand the space; advance catheter 2cm into space.
Surgical placement of paravertebral catheters also possible and reliable.

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 The indications of Paravertebral Blockade:

- Surgical Anesthesia
(Unilateral):

*Breast / Thoracic Surgery;

*Cholecystectomy;
*Renal Surgery;
*Appendicectomy;
*Inguinal Hernia Repair.

Acute pain relief:

*Fractured Ribs; Liver Capsule
Pain; Labour

Chronic pain relief:

*Post-surgical or post-herpetic
neuropathic chest or abdominal pain
*Complex regional pain syndrome
*Refractory angina pectoris
*Relief of cancer pain including mesothelioma.

Sympathetic block:
*Relief of hyperhidrosis / SVT

 Not usually advantageous over epidural analgesia for bilateral procedures.

 The contraindications for paravertebral blockade

Absolute:
-Patient refusal
-Allergy to agents
-Empyema.
-Local sepsis
-Tumour spread to space

Relative:
-Coagulopathy
-Severe respiratory disease where intercostal muscle block inadvisable.
-Distorted anatomy such as Spinal Scoliosis.

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5- Endoscopic Thoracic Sympathectomy
(a) List the indications for endoscopic thoracic sympathectomy (ETS) (25%)
(b) Outline the general (30%) and airway (15%) implications of managing a patient for ETS under general
anaesthesia
(c) What are the most likely problems to be encountered in the intraoperative (15%) and
(d) postoperative (15%) period?

 The indications for endoscopic thoracic sympathectomy (ETS)

- Palmar hyperhidrosis (most common)
- Craniofacial hyperhidrosis
- Facial blushing
- Complex regional pain syndrome
- Upper limb ischaemic pain
- Refractory angina pain
- Congenital long QT syndromes
- Historically was used to treat Raynaud’s disease but it is no longer performed for this indication
 Anesthetic Management
General
- Usually performed under general anaesthesia but the use of regional anaesthesia has been
described- thoracic epidural or intercostal nerve block
- Patients are generally young with few co-morbidities (except angina and limb ischaemia patients)
- Elective non-essential surgery
- Through discussion with patient about potential
complications is required
- Rarely converted to open procedure
- Usually bilateral
- Patient positioned supine with head up tilt and
arms abducted
- Carbon dioxide insufflated into pleural cavity
- One or two lung ventilation techniques can be
used
- Large bore IV access required due to risk of
bleeding
- Consider arterial line for monitoring- especially in
patients with comorbidities

Airway
- Surgical access to pleural cavity is required. Various techniques have been described-
* Use of double lumen endotracheal tube- one lung isolated and then the other for bilateral
surgery- this gives very good surgical conditions with collapsed lung
* Single lumen ETT with bronchial blocker
* Single lumen ETT with two lung ventilation- CO2 in pleural cavity- high pressures generated
within pleural cavity can cause haemodynamic compromise and operating conditions not as good
as with one lung ventilation

* LMA technique has been described but is not frequently used

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 Intra-operative Complications:
- Haemorrhage due to damage to blood vessels- Subclavian and Intercostal vessels are particularly
at risk- deaths have been reported due to haemorrhage during ETS
- Hypoxia due to shunt, atelectasis or hypoxic pulmonary vasoconstriction when switching from
ventilation of one lung to the other
- Conversion to open thoracotomy
- Cardiovascular compromise due to capnothorax impairing venous return

 Post-operative Complications:
- Pneumothorax- may or may not require drainage
- Horner’s syndrome
- Compensatory sweating
- Gustatory sweating
- Pleural effusions
- Haemothorax

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6- One Lung Anaesthesia and Management of Hypoxaemia
Hypoxaemia during one-lung ventilation may be a major problem during thoracic operations.
(a) What are the indications for one lung anaesthesia? (30%)
(b) What are the physiological changes associated with one lung ventilation? (30%)
(c) How could you manage the development of hypoxaemia during one lung anaesthesia (40%)

 The indications for one lung anaesthesia:

Absolute indications
- Isolation of one lung from the other to avoid spoilage in unilateral infection or massive he.
- Control of distribution of ventilation-
- Giant unilateral lung cyst or bulla
- Bronchopleural fistula, bronchopleural cutaneous fistula
- Open surgery on main bronchus
- Life threatening hypoxia due unilateral lung disease
- Tracheobronchial tree disruption
- Bronchoalveolar lavage- risk contamination to other lung

Relative
- Surgical access- pneumonectomy, lobectomy, oesophagectomy, VATS, mediastinal exposure, Spinal
surgery, Thoracic aneurysm repair

- Post cardiac bypass after removal of totally concluding chronic unilateral PE.

 The physiological changes associated with one lung ventilation:

Depending on position of patient:

- ICU pts remain supine however most surgical operations the pt is in the decubitus position with
surgical side upper most therefore non- ventilated.

- Blood flow to the non-dependent lung does’t take part in gas exchange & this shunt causes hypoxia.
- The (lower) dependent lung; has increased perfusion compared non-dependant lung due gravity
and surgical compression and lung retraction on the non-dependent lung therefore receives a
greater percentage of CO this therefore decreases shunt.
If pneumonectomy and vessels are ligated entirely then this will decrease shunt further.
- Hypoxic pulmonary vasoconstriction (HPV) diverts blood flow from the non-ventilated to the
ventilated lung, thereby reducing venous admixture and ameliorating the decrease in PaO2.
It involves the constriction of small arterioles (and to a lesser degree, venules and capillaries) in
response to alveolar hypoxia.

- Expansion of the dependent lung is restricted by the weight of the mediastinum, the cephalad
displacement of the diaphragm and abdominal organs, and non compliance of the hemi-thoracic
chest wall.

- The alveolar compliance curve is shifted down and to the left in the dependent lung. This leads to
atelectasis of the dependent lung, decreasing the ventilated lung surface. This causes HPV, increased
resistance to flow in the dependent pulmonary artery, and diversion of flow to the non-dependent

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lung, increasing the shunt fraction
further.
- PaCO2 can rise with lower volumes,
can increase respiratory rate to increase
minute volume.
- Secretions can pool in dependent lung,
difficult to remove through DLT.
CVS
- Arrhythmia especially AF can develop
-  venous return and CO if significant
peep given to dependant lung

 Management of Hypoxemia:
- Recognise hypoxaemia
- ABC approach anf Place FiO2 1.0
- Check tube disconnection / ventilator working
- Check ventilator settings
- Check DLT movement with fibre-optic scope
- Check secretions/ debris - suction
- Maintain PaCO2 5.3kpa as lower can decrease HPV
- Place O2 flow into dependant lung
- Place CPAP to dependant lung - tell surgeon
- Add peep 5 cmH2O to non-dependant lung
- Tell surgeon need to reinflate lung
- Clamp pulmonary artery

 Check other observations - haemodynamically HR , BP if unstable - need fluid or vasopressors

to ensure adequate CO.

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7- Double Lumen Tubes and Tracheal Anatomy
(a) Describe the anatomy of the trachea and main bronchi (25%)
(b) List the methods of providing one lung ventilation (30%)
(c) How is the correct size of double lumen tube selected? (10%)
(d) Describe the correct positioning of a double lumen tube (35%)

 The anatomy of the trachea and main bronchi:

- The trachea is a tubular structure composed of C-shaped cartilaginous rings anterolaterally.

- Extends downwards from cricoid cartilage at level of C6 vertebra in the midline to the level of T5-6.
- 10-11cm in length and 20mm in diameter.

- The trachea bifurcates into the right and left main bronchi.

The Right Main Bronchus:

It is positioned more vertically than the left main. The Rt. main bronchus is shorter and wider than
the left main bronchus, 3cm VS 5cm. At 2.5cm along the right main bronchus arises the right
upper lobe bronchus. At 3 cm the Rt. main bronchus bifurcates into the right middle and lower
lobe bronchi.

- The bronchopulmonary segments of the right main bronchus:

- Rt. upper lobe bronchus; Apical, Posterior and Anterior segments

- Rt. middle lobe bronchus; Lateral and Medial segments (APALM)
- Rt. lower lobe bronchus; Apical, Medial Basal, Anterior Basal, Lateral Basal & Posterior Basal Seg.

The Left Main Bronchus:

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 It divides into the Lt. upper lobe bronchus and Lt. lower lobe bronchus. The Lt. upper lobe
bronchus bifurcates into the superior division and lingular bronchus.

-The bronchopulmonary segments of the Lt. main bronchus:

- Lt. upper lobe bronchus;

-Superior division Apical, Posterior and Anterior Segments
-Lingular bronchus; Superior and Inferior segments (APASI)
-Lt. lower lobe bronchus; Apical, Anterior Basal (medial basal segment arises from here), Lateral
Basal, and Posterior Basal segments.
 Thus the right lung has 10 bronchopulmonary segments and the left lung has 9.

 Methods of providing OLV:

I- Double Lumen Tubes:

-Left and right DLTs cannulate the trachea and the appropriate main bronchus.
-Right sided bronchial limbs have side hole to ventilate right upper lobe.

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-Inserted via conventional laryngoscopy.
- Checked clinically and with fibreoptic bronchoscope (FOB) at insertion and on turning.

-Large external diameter, small internal diameter (39 F” DLT has ED of 13mm & ID of 6mm).
-Usually Lt. sided tubes selected except when surgery involves Lt. main bronchus, due to difficulty in
ventilation of Rt. upper lobe bronchus.

-Tube has 2 lumens allowing lung isolation and collapse of either lung. This is achieved by clamping
the desired lumen and opening to the atmosphere.
-Various types of DLT: Robsertshaw, Bronchocath, Sheribronch, Carlens (Rt. sided), Whites (Lt. sided)

II- Bronchial blockers

-Fine bore catheter with a distal cuff.

-It is passed down a tracheal tube under FOB and placed in the main bronchus of the lung to be
collapsed.
-Its cuff is inflated and the lung collapses through escape of gas through the blocker’s lumen.
-Arndt blocker has loop of nylon thread which ensnares the FOB.
-Blockade of Rt. main bronchus more problematic than Lt. main bronchus due to position of Rt.
upper lobe bronchus.
-Selective lobar blockade possible.

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Indications:
-Isolation of lobar bronchus required
-Difficult intubation
-Permanent tracheostomy
Various types:
-Arndt, Cohen, Uniblocker, Coopdech blockers.
-Univent tube – tracheal tube with small second lumen containing stiff directable bronchus blocker.
-Papworth Bivent tube and blocker – DLT which rests on the carina, blocker passed blindly down side
to be blocked. Not designed for use with FOB.

Advantages over DLTs:

*Useful for lung isolation in difficult intubation
*Tube change at end of operation unnecessary in those requiring post op ventilation
*Paediatric use possible
*Selective lobar collapse possible
*Theoretically lower tube resistance for ventilating one lung

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Disadvantages over DLTs:
Positioning takes longer
Migrates more easily
Lung deflation slow and limited suction due to small lumen
Lung reinflation requires deflation of cuff with possible cuff movement
Repeated rapid lung deflation and reinflation may be difficult
Stapling of blocker parts into bronchial stump possible during lung resection

III-Single lumen endobronchial tubes

-Intubation of desired bronchus allowing ventilation of that bronchus alone. Rarely used.

 Sizing of DLT:

-Patient height most accurate reflection of size of tube to be used.

-General rule is use the largest tube that will pass, as the internal diameter of DLTs is small.
-Bear in mind that the Lt. main bronchus is narrower than the Rt. main.
-Robsertshaw DTLs come as small, medium and large tubes.
-Other DLTs are sized according to French Gauge (FG).
-In women use a small Robertshaw tube or 35 or 37 FG tube.
-In men use a medium or large Robsertshaw, 39 or 41 FG tube.

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 Correct positioning of a DLT:

- The DLT is inserted via normal laryngoscopy passing the bronchial portion through the cords with
the tip pointing anteriorly.
-Rotate the tube through 90° to intended side of cannulation. Advance tube as far as it will go
without undue force.
-Average depth of 29cm in adults has been estimated.
- Inflate tracheal cuff to achieve a seal.

- Manual ventilation is commenced with the tracheal cuff inflated.

-Auscultate the chest to confirm equal air entry on both sides and there should be no leak around
the tracheal cuff.

- The tracheal side of the adapter is then clamped and the tracheal port is opened distal to the
clamp.

-The bronchial cuff is inflated; so as to just eliminate air leak from the tracheal lumen - 1ml at a time
until leak stops. If a reasonable seal cannot be achieved with less than 4ml of air the tube is either
too small or incorrectly placed.

- Auscultate the chest - breath sounds should be heard only on the side of endobronchial intubation.
-Look for unilateral chest expansion. Assess compliance via manual ventilation. Also note a change in

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airway pressure on tracheal clamping.
-The tracheal limb is then unclamped, the tracheal port closed and the bronchial limb of the adapter
is clamped and the bronchial port opened to air. Breath sounds should only be heard on the
contralateral side with unilateral chest expansion seen. Assess compliance via manual ventilation.

- Fibreoptic Bronchoscopy; down the tracheal lumen should reveal the carina. The top edge of the
blue bronchial cuff should be just visible in the intended main stem bronchus. When a right-sided
tube is used, the fibrescope should be used to visualise the orifice of the right upper lobe bronchus.
- Repeat checks after positioning in the lateral decubitus position.

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8- Intercostal Chest Drains and Pleural Fluid Analysis
(a) Describe your technique for insertion of a chest drain in this patient. (30%)
(b) Describe the principle features of underwater seal drainage devices. Illustrate with a basic diagram
(30%)
(c) Describe investigations that assess the size of a pleural fluid collection (15%)
(d) Describe investigations that assess the nature of a pleural fluid collection (15%)
 Insertion of a chest drain:
- Consent if possible or assent from relatives
- Preparation - check coag, ensure G+H or X-match, check
platelets
- Trained assistant
- Patient position: arm internally rotated & abducted to
90o with forearm on bed
- USS guided if clinical situation permits
- Prepare equipment: if viscosity of pleural effusion
thought to be low could use a seldinger drain eg 14
French, but if unclear as to how viscous the fluid then use
a larger french drain eg 28 french
- Increase FiO2 to 1, increase sedation and paralyse patient
- Triangle of safety:
-Lateral border of Pectoralis major, ant border of Latissmus dorsi, 3rd to 5th ICS
-Aim for just above rib to avoid neurovascular bundle injury.

- Full asepsis/Anaesthetise skin,muscle &

periosteum
- Use blunt forceps to dissect through chest wall
- Use finger to further blunt dissect into pleural
cavity, ensure there are no adhesions
- Attach forceps to drain and use them to direct
drain along the chest wall into pleural space and
inferior
- Attach to underwater seal
- Suture in place and do CXR

 The features of under-water seal drainage:

- Airtight system to maintain subatmospheric intrapleural pressures to
enable reexpansion of lung
- Requirements - chest drain with minimal resistance, underwater seal
and collection chamber.
-Chest drain is submerged to 1-2cm to ensure minimal resistance to
drainage of air and maintains the seal even in the face of a large
inspiratory effort.
- Chamber should be 100cm below chest to ensure when during
obstructed respiration the negative pressures generated are not more
negative than that in the drain
- Drains under gravity or suction

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Types of Chest Tube Drainage:

*One Bottle *Two BottleS *Three BottleS Chest Drainage System

 The investigations that assess the size of a pleural fluid collection:

- Chest X-ray:

-AP/lateral/olique/decubitus
- fluid will gather in most dependent part of chest. Meniscus formed.
-On erect AP 75ml of fluid is needed to obscure the costophrenic angle, 500ml to obscure the
diaphragm, 1000ml to reach 4th anterior rib.
-On decubitus films may see apical capping which disappears on erect film

- CT scan:
-Split pleura sign (enhancement of visceral and parietal pleura after injection of iv contrast).
-Can distinguish an empyema from an abscess

- Ultra-sound scan:
-Identifies free or loculated pleural effusions.
-Can be used for chest drain insertion and thoracocentesis.

- MRI: can characterise the content of pleural effusions

 The investigations that assess the nature of a pleural fluid collection:

- Radiological - CT can indicate if exudate or transudate is more likely

- MRI can give an idea of the nature of an effusion
- Thoracocentesis with pleural fluid analysis:
- Gross appearance eg; turbid may be empyema, haemorrhagic may be malignant
- Transudate has <25g/dl protein whereas an exudate has >35g/dl
- Cytology - neutrophils may be parapneumonic, or PE. Lymphocytes may indicate malignancy
- Low glucose and low pH indicates Malignancy or Empyema
- Immunological investigations eg; Rheumatoid factor positive suggest rheumatoid arthritis.

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9- Anaesthesia for Bronchoscopy
(a) What are the diagnostic and therapeutic indications for bronchoscopy? (40%)
(b) List the major contraindications for bronchoscopy. (15%)
(c) How is a fibre optic flexible bronchoscope processed after use? (20%)
(d) How may anaesthesia be maintained during bronchoscopy? (25%)

 The diagnostic and therapeutic indications for bronchoscopy:

- Diagnostic
* Assess patency of upper airway
* Localizing lesion of unknown etiology on CXR
* Localizing/assess extent of toxic inhalation/ aspiration
* Assess/ check placement of airway stent
* Recurrent pneumonia/atelectasis/infiltrate
* Investigation of haemoptysis/persistent cough/dyspnoea/localized wheeze/stridor
* Obtain washings/biopsy for cytologic/histologic/microbiology
* Suspicious sputum cytology result
* Problems with endotracheal tube or tracheostomy.

- Therapeutic
* Aid tracheostomy procedure and difficult intubation/difficult airway
* Retrieval of foreign body from airway
* LASER tissue removal/basket/forceps
* Endobronchial toilet in VAP
* Aid in placement of DLT and bronchial blocker in selective intubation of bronchus
* Airway balloon dilatation in tracheobronchial stenosis

 The major contraindications for bronchoscopy:

- Absolute
*Patient refusal
*Inexperienced operator
*Lack of emergency setup for CPR and management of pneumothorax/bleeding
*Patient cannot adequately be oxygenated

- Relative
*Coagulopathy
*Refractory hypoxaemia
*Unstable haemodynamics/Dysarrythmias/recent MI/CCF
*Pulmonary hypertension

 How is a fibre optic flexible bronchoscope processed after use? (20%)

* Inspect all parts for damage, perform leak test
* All parts/channels/lumens thoroughly cleaned/brushed with soap and water immediately after use
to prevent drying of secretions
* Thoroughly dry
* Soaked with high level disinfectant for 20 mins.
* Gluteraldehyde/peracetic acid/hydrogen peroxide
10 hrs for sterility

‫عيداروس‬ THORACIC ANESTHESIA 30

* Rinse 3 times with sterile water/ bacteriological filtered water (water filtered through 0.1-0.2
micron filters)
* Dry internal channels of reprocessed bronchoscope using 70% alcohol followed by forced air
treatment
* All heat stable parts/ accessories e.g biopsy forceps reprocess by ultrasonics followed by autoclave/
sterilization
* Hang up to dry and not placed in a case.

 Anaesthesia maintenance during bronchoscopy:

* Flexible bronchoscopy can be done under sedation and Local Anaesthesia to mucosa.
* Rigid bronchoscopy requires GA induction with IV Propofol or Gas induction.
* Short acting opiate to obtund profound pressor response, Fentanyl/ Remifentanil infusion
* Muscle relaxant Suxomethonium or Rocuronium with Suggamaddex reversal
* Anaesthesia is maintained by either intermittent blouses of Propofol, TIVA or TCI when using jet
ventilation.
* Volatile agents can be used when using ventilating bronchoscope.

https://www.youtube.com/watch?v=VLsXe5oB2W0
http://www.thoracic-anesthesia.com/?page_id=2

https://www.youtube.com/watch?v=ThYHLG50pH0

https://bronchoscopy.org/

https://www.youtube.com/watch?v=phRv73Ik7fI&lr=1

‫عيداروس‬ THORACIC ANESTHESIA 31

‫عيداروس‬ THORACIC ANESTHESIA 32
‫عيداروس‬ THORACIC ANESTHESIA 33
http://www.ccam.net.au/handbook/the-fibre-optic-bronchoscope/

‫عيداروس‬ THORACIC ANESTHESIA 34

10- Indications and Anaesthesia for Airway Stenting
(a) Describe the systemic and local effects of intrathoracic malignancy
(b) What are the indications for airway stenting?
(c) Describe the anaesthetic management of airway stenting procedures

 The systemic and local effects of intra-thoracic malignancy:

Systemic
-Cachexia and malnutrition
-Eaton-Lambert syndrome: an autoimmune disease a/w malignancy that affects the pre-synaptic
release of ACh and renders patients very sensitive to neuromuscular block
-Endocrine abnormalities such as hyperparathyroidism, SIADH, Cushing’s syndrome
-Previous chemotherapy can lead to venous thrombosis and produce cardiac side-effects
-Immunosuppression

Local
-SVC obstruction
-Airway obstruction
-Damage of vocal cord’s innervation (e.g. stretching of the recurrent laryngeal nerve on the left)
-Previous radiotherapy can cause fibrosis of the soft tissues around the upper airway causing
difficulty with laryngoscopy

 The indications for airway stenting:

Stents are placed into the airway for both benign and malignant disease.

Benign
-Tracheo/bronchomalacia
-Goitre
-Webs
-Granulation tissue (ETT, foreign body, Wegener’s granulomatosis 
post-transplant)
-Lymphadenopathy (infectious, sarcoid)
-Tracheal- or bronchial- oesophageal fistula

Malignant
-Primary endoluminal carcinoma
-Metastatic carcinoma
-Oesophageal carcinoma
-Mediastinal tumours (thymus,
thyroid, teratoma)
-Lymphadenopathy (malignancy)
-Lymphoma

 The anaesthetic management of

airway stenting procedures.
Pre-operative
-Anaesthetic history and examination
(medical and anaesthetic history, medications, allergies)
‫عيداروس‬ THORACIC ANESTHESIA 35
-Airway assessment and check for airway obstruction; stridor, tracheal tumour on CT scan, FB.
-In appropriate patients can be done as day-case
-Warn about post-op coughing and haemoptysis
-Discuss with surgeons their technique (rigid or flexible) as this has consequences for anaesthesia

An emergency surgical airway will not resolve a crisis of ventilation if the stenosis cannot be
passed intraluminally

Intra- operative
-Full pre-oxygenation
-Confirm surgeon is in theatre before inducing patient
-Teamwork between anaesthetist, surgeon and theatre staff is important as airway is shared

If rigid bronchoscopy is used:

- IV induction coupled with neuromuscular block provides best operating conditions
- Requires intermittent jet ventilation via a side port of the bronchoscope
- Severe surgical stimulus occurs therefore short acting opiates such as Remifentanil
- Anaesthesia can be maintained IV with either boluses, simple infusions, orTCI of Propofol +/-
Remifentanil and a short acting muscle relaxant
- BIS monitoring has been suggested as there is a high risk of awareness

If flexible bronchosopy is used:

- This can be passed down a tracheal tube or possibly an LMA
- Some favour intubation after inhalational induction as all volatile agents give potentially useful
bronchodilation (sevoflurane causes least coughing)
- Maintenance with volatile anaesthetic agent is possible
-Gas trapping distal to lesion should be minimised by limiting inspiratory pressure and allowing
adequate expiratory time

Post- operative
-After manipulation, the airway may bleed or become oedematous
-The patient should be fully awake with normal neuromuscular function & be given supplemental O2
-A useful endpoint to signal suitability for discharge to a recovery unit is the presence of all parts of
the cough reflex
-Post-op pain is minimal AND long acting opiates are unhelpful when a fast & full recovery is needed
-Close monitoring is important
-Post-op respiratory compromise 2ry to oedema can respond to nebulised adrenaline & iv steroids
-Heliox should be available as it can improve gas flow in situations of critical airflow limitation due to
its low density making laminar flow more likely

Beware of post-op central airway obstruction

- Central airway may become completely obstructed (can also occur intra-op)
- Characteristically patient fails to re-establish effective spontaneous ventilation
- Can mimic partial reversal of neuromuscular block
- Worsening hypoxia and hypercarbia can lead to CV collapse
- Re-intubation with the rigid bronchoscope and vigorous airway suction is required
- Surgeon should remain present and the rigid bronchoscope still available until recovery is deemed
satisfactory
‫عيداروس‬ THORACIC ANESTHESIA 36
11- COPD and Lung Volume Reduction Surgery
(a) Describe the pathophysiology of COPD? (30%)
(b) What is VATS? (10%)
(c) What is the mechanism of improvement post lung volume reduction surgery (LVRS)? (20%)
(d) What is the anaesthetic management of LVRS? (40%)
 The pathophysiology of COPD:
- COPD is a progressive inflammatory disease in the lungs characterised by airflow limitation which is
only partially reversible.
- It affects small airways of the lungs (bronchitis) and causes parenchymal destruction (emphysema).
The result is obstruction and air trapping/hyperinflation and reduced gas transfer causing V/Q
mismatching.
- Extrapulmonary manifestations e.g. Cor-pulmonale, respiratory muscle wasting and weight loss can
occur. As the condition progresses expiration becomes active requiring positive pressure to
overcome airway resistance.
 VATS
- Video assisted thoracoscopic surgery is a minimally invasive surgical technique allowing a
thoracoscopic view inside the thoracic wall using small incision ports (0.5-2 cm long incisions).
- It is used for:
*Diagnostic biopsies *Lymph node removal
*Minor resections *Treatment of recurring pneumothoraces and lobectomy.
-It is mandatory to collapse the lung for this.

 The mechanism of improvement post lung volume reduction surgery (LVRS):

- Removal of emphysematous lung tissue will improve residual pulmonary and chest wall mechanics.
- Remaining lung tissue will be on a more favourable part of the compliance curve, with
length/tension relationship of respiratory muscles optimised reducing the work of breathing.

 The anaesthetic management of LVRS

- Preoperative assessment; pulmonary function tests (PFTs), calculate PPO, Shuttle Walk Test, cardiac
investigation if deemed high risk, period of pulmonary rehabilitation, smoking cessation
- Maximal treatment with long acting bronchodilators including on day of surgery
- Adequate pre-oxygenation
- Short acting anaesthetic agents, avoid Nitrous Oxide
- OLV, lung isolation and pressure control ventilation to limit damage to isolated lung
- Euvolaemia and normothermia
- Excellent post operative pain control; thoracic epidural , multimodal
- IABP monitoring and CVP line insertion
- BIS monitoring as awareness risk is high
- Extubation post op- prevent air leak secondary to suture line disruption if IPPV
- Close post operative monitoring in HDU/ thoracic ward capable of caring for these patients post op

‫عيداروس‬ THORACIC ANESTHESIA 37

‫عيداروس‬ THORACIC ANESTHESIA 38
12- Lung Transplantation and Anaesthesia
(a) List the indications for unilateral and bilateral lung transplantation (25%)
(b) Describe the routine tests performed prior to transplant. Indicate why these are required ?
(c) List the key features of preoperative management of these patients (i.e. from induction of
anaesthesia to emergence) (50%)

 The indications for unilateral and bilateral lung transplantation:

- Some indications are common to both single and bilateral lung transplantation; Emphysema (or
COPD), ideopathic pulmonary fibrosis, alpha-1 antitrypsin deficiency, sarcoidosis and primary
pulmonary hypertension
* Bronchiectasis and cystic fibrosis are indications for bilateral lung transplant only
* The most common of reason for lung transplantation is COPD, which accounts for 35% of
transplant surgery. FEV1 must be <25% predicted
* Ideopathic pulmonary fibrosis is the second most common cause accounting for 23% of surgeries
* Primary pulmonary hypertension is the most common indication in the under 5 age group
- The nature of the disease process may determine whether the patient receives a single or double
lung transplant e.g. suppurative lung diseases do not lend themselves to single lung transplants for
risk of contamination
- The age limit for both differs slightly; the upper age limit for SLT is 65, DLT is 60

 The routine tests performed prior to transplant

- Thorough preoperative work up required

Functional status, exercise tolerance etc must be elicited on careful history taking

- The following list encompasses some of the important investigations:

* Height and weight
* Bloods including full blood picture, Electrolytes/renal function, blood and tissue typing, group and
cross matching of blood, thyroid function testing and viral screen.
* Chest xray, lung function tests and V/Q scan
* Arterial blood gas
* ECG and 24 hour holter monitor
* Echocardiogram
* 24 hour urine collection
* Exercise stress testing

- Some patients may warrant further investigations depending on the surgery they are undergoing
and underlying co morbidities, e.g. cardiac catheterisation
- Some of these investigations are paramount in deciding if a patient is fit to undergo major surgery,
such as exercise stress testing
- Investigations are useful in optimising patients for surgery, e.g. treating anaemia, optimising lung
function and treating undiagnosed comorbidities e.g. thyroid disease
- Symptoms/functional status may deteriorate if recipient has been waiting for a long time for
surgery and these need to be revaluated

- Donors need to investigated also, needing to meet the following criteria: PaO2 > 30Kpa on an FiO2
1.0, minimal infiltrates on CXR, negative culture of sputum.

‫عيداروس‬ THORACIC ANESTHESIA 39

 Anesthetic Management :
- Drug and equipment preparation as for any anaesthetic, including emergency drugs, ventilator
check, equipment check including fiberoptic scope

- IV access. Large bore peripheral cannula, e.g. 14G x2. Arterial line, consider pre induction given
likelihood of significant comorbidities. Central venous access. Either before or after induction
depending on patient condition. Site; Internal Jugular vs Subclavian: Internal Jugular may be most
appropriate in midline sternotomy. Consider insertion of PA catheter.

- Fasting state and induction. Often a RSI or modified RSI technique should be considered as surgery
often occurring on a “full stomach” due to unanticipated nature of surgery

- Airway devices: Double lumen tube and fiberoptic scope to confirm placement

- Use of Cardiopulmonary bypass should be considered…even if not planned for may be required if
hypoxia is unmanageable when one lung ventilation is instituted and should be readily available

- Awareness of potential airway and breathing complications intraoperatively;

*Movement of DLT requiring repositioning/repeat fiberoptic.
*Risk of hypoxaemia with one lung ventilation; initial plan of management, including ruling out
airway problems, recruitment manoeuvres, increasing Fi02, NO, phosphdiesterase inhibitors, good
communication with surgeons at all times, should pulmonary artery clamping or CPB be required
as a last resort. Ventilatory measures to reduce increase in PVR ie avoidance of hypoxia and
hypercarbia

- Haemodynamics: May be compromised with induction agents, reduced CO with a high PEEP
(decreased venous return). Inotropes such as Dobutamine and vasopressors e.g. Noradrenaline
should be readily available. Measures for patients with pulmonary hypertension should be available
such as nebulised Prostacyclin.

- Monitoring: Standard AAGBI monitoring as for all anaesthetics. Arterial blood pressure monitoring
and CVP monitoring as discussed above. Consider CO monitoring devices such as TOE, or PA catheter
as mentioned above

- Analgesia: Commonly a thoracic epidural is sited preoperatively and used intra and post
operatively

- Drugs: Consider use of early premedication due to high levels of anxiety. Choice of induction agent
and dose dependent on anaesthetist and patient specifics, e.g. Opioid induction for cardiac stability if
history of significant IHD. No specific muscle relaxant of particular benefit, but a long acting agent
such as Pancuronium may suit nature of surgery

- Early use of Immuno-suppressants, either pre operatively or after induction. Agents such as
Steroids, Cyclosporin A and Azathioprine commonly used agents.

‫عيداروس‬ THORACIC ANESTHESIA 40

- Emergence and post operatively: Most patients extubated early (even within a number of hours).

- Awareness of early post operative complications that can arise and early management of these. E.g.
respiratory failure requiring ongoing ventilation/reintubation. Early rejection, due to tissue mistyping

- Sterility and antimicrobial therapy. Consider Prophylactic Antiobiotic therapy, in conjunction with
surgical team and those used specifically in that unit. Sterility and prophylaxis of particular
importance in this patient group as they are often commenced on immunosuppressants at an early
juncture for protection of the newly implanted organ.

- General measures such as pressure point prophylaxis, temperature control, eye protection ….etc.

‫عيداروس‬ THORACIC ANESTHESIA 41

13- Anatomy of Upper Airway and Fibre Optic Intubation
(a) Which nerves supply sensation to i) The Nasal air passages ii) The Oropharynx iii) The Larynx?
(b) Outline the techniques for achieving local anaesthesia of these areas? (15%)
(c) What are the indications (30%) and contraindications (25%) for fibre optic intubation?

 The nerves supply sensation to the nasal air passages :

*Naso-ciliary nerve of V1.

*Nasopalatine and post-nasal branches of Maxillary nerve of V2; branches of the trigeminal nerve.

ii) The

nerves supply sensation to the oropharynx :

* Glossopharyngeal nerve provides

sensory innervation to the oropharynx,
supraglottic area, base of tongue and
vallecula.
* Superior Laryngeal nerve (branch of
Vagus) provides sensation to the inferior
aspect of the epiglottis and laryngeal
inlet above the vocal cords

iii) The nerves supply sensation to the

larynx:  Vagus

-The Vagus divides into the Superior

and Recurrent Laryngeal nerves.
-The superior branch divides into the
Internal and External Laryngeal nerves
-The Internal Laryngeal nerve innervates the superior surface of the epiglottis and the supraglottic
region as far as the mucous membrane of the vocal folds
-The Recurrent Laryngeal nerve supplies the laryngeal mucosa below the vocal cords
‫عيداروس‬ THORACIC ANESTHESIA 42
 Local anaesthesia for Bronchoscopy:
Nasal anaesthesia
-Cocaine (4–5%)
-Lignocaine 5% combined with phenylephrine 4% (as a spray or on
cotton-wool-tipped swabs).
Oral analgesia
- 4% lignocaine spray, 2 ml (the patient should swirl it around the mouth
and then gargle with it)
- Additional 10% lignocaine spray, 100 mg directed into the posterior
oropharynx at the back of the
tongue to the left, right and in the mid-line
Anaesthesia of the lower Airway
- Topical anaesthesia of the lower airway may be used alone or supplemented with nerve blockade
- Spray-as-you-go:
-Following topical anaesthesia of the mouth or nose, the endoscope is advanced into either orifice
until the posterior aspect of the tongue or the epiglottis can be seen.
-From a distance, 1 ml aliquots of Local Anaesthetic (4% lignocaine) are administered through the
working port of the endoscope, first towards the back of the tongue. If the epiglottis is not seen,
the endoscope is advanced further until it is visible overlying the glottis.
-The epiglottis and glottis are then sprayed in turn until the vocal cords cease reacting to local
anaesthetic administration. The endoscope is then advanced closer to the larynx and additional
local anaesthetic is delivered between the vocal cords until coughing ceases.
-Subsequently, the passage of an endoscope into the trachea through the mouth or nose is usually
well tolerated.

NB; the British Thoracic Society recommends an upper dose limit of 8.2 mg/kg for fibre-optic
bronchoscopy with topical lignocaine

- Translaryngeal or transtracheal administration:

*Direct injection of local anaesthetic into the airway precipitates coughing, thus dispersing the local
anaesthetic. This provides tracheal anaesthesia and also a significant degree of anaesthesia of the
laryngeal inlet and epiglottis. Lignocaine 4%, 2–4 mls
*Nebulisation of 10% lignocaine is reported to be effective.

- Nerve blocks:
-Glossopharynegeal
-Superior Laryngeal
-Recurrent Laryngeal nerve blocks

- General anaesthesia:
-Volatile agents or TIVA.

‫عيداروس‬ THORACIC ANESTHESIA 43

 The indications and contraindications for fibre optic intubation:

Indications
-Known difficult mask ventilation and/or difficult intubation
-Expected difficult mask ventilation e.g. head and neck tumours
-Patient at risk of aspiration with a difficult airway
-Neurological assessment required following intubation, e.g. cervical spine injury
-Morbid obesity
Contraindications (relative and absolute)
-Local anaesthetic allergy
-Patient refusal/uncooperative patient
-Lack of experience of anaesthetist
-When rapid airway control is required
-Critical airway; the flexible endoscope may obstruct the narrow airspace
-Blood in the airway - this may obscure vision making FOI impossible
-Prion disease
-Difficult anatomy; it may be impossible to access the glottis
-Airway obstruction at the level of the glottis may be exacerbated by both endoscopy and topical .
anaesthesia and therefore FOI should be used with caution

Contraindications to nasal intubation

-Bleeding/coagulopathy
-Severe intranasal disease
-Basal skull fracture
-Cerebrospinal fluid (CSF) leak

‫عيداروس‬ THORACIC ANESTHESIA 44

‫عيداروس‬ THORACIC ANESTHESIA 45
14- Anatomy of First Rib and Subclavian Central Line Insertion
(a) Illustrate the anatomy of the first rib. Include a sketch (20%)
(b) Describe the course of the subclavian artery and vein (20%)
(c) Describe the technique of insertion of a subclavian central line (50%)
(d) Why is the infraclavicular approach preferred (10%)

 The anatomy of the first rib

 The Subclavian Artery and Vein:

Right subclavian artery :
* originates from right
brachocephalic artery just behind
the sternoclavicular joint, posterior
to subclavian vein and anterior to
the anterior head of sterno-
cleidomastoid.
* It runs over the cervical pleura
and lung apex to lateral border of
1st rib (grooved) where it becomes
right Axillary Artery.

* It gives off five branches

Left subclavian artery:

Third branch of aortic arch.
* Grooves the first rib posteriorly
before terminating as axillary
artery at its lateral border.

‫عيداروس‬ THORACIC ANESTHESIA 46

Subclavian Vein:
* Originates from continuation of axillary vein which itself is made by joining cephalic and basilic
veins of arm.
* It forms behind the first rib anterior to subclavian artery and joins by internal jugular and external
jugular vein and forms brachiocephalic vein on both sides.

 Subclavian Vein Cannulation:

- Aseptic procedure. Pt should be consented, assess the indication and rule out any contraindications
- Full monitoring (ECG, Sats , NIBP or IBP, depending on if patient is anaesthetised or not EtCO+, ET
sev,..),IV access, Emergency drugs, Assistant.
- CVC line should be flushed and all the lines should be assessed for patency.
- Point of entry: between middle and medial 2/3 of clavicle. Feel for the notch underside of clavicle.
- Local anaesthetics at the point of entry.
- Aim for sternal notch and advance the needle while aspirating. Stop advancing when aspirating free
flow of blood. Insert the guide wire and while checking monitor.
- All the lines should be aspirated and flushed, the CVC line should be sutured and chest X-ray should
be requested.

 Infraclavicular approach is more desirable approach: There is less chance of accidental puncture
of pleura.

‫عيداروس‬ THORACIC ANESTHESIA 47

Types of Chest Tube Drainage

I- One Bottle Chest Drainage System:

This is one bottle collects the fluid and the same time seals air leak (
water seal is barrier). A rigid straw is immersed into the bottle, tip is
located 2 cm below the surface of normal saline solution into the
bottle.
The other end of this rigid straw is connected to the pleural cavity
of thoracic drainage tube. Decompression valve which decompress
the pressure from the air leak, an opening of one-way
decompression valve. It is mportant to remove this valve cover
before connecting the system to the client side.
When the pleural pressure is positive, the rigid straw
pressure becomes positive, and if the positive pressure in straw is greater than the depth to which
the tube is immersed in the saline solution, then air will enter in the bottle and then depressurized
by vent into the atmosphere.
If the pleural pressure is negative, it would move liquid from the bottle to the rigid straw and air
would not be entered in the pleural cavity or the rigid straw. This system is called water seal because
the water bottle seals the pleural cavity from the air or liquid from the outside of the body.
It just like a straw in a drink, air can push through the straw, but air can not be drawn back up the
straw.
when the rigid straw is above the liquid level in the bottle, the system would not be operated
consistently developing pneumothorax.
However, when a significant quantity of liquid would be drained from the pleural cavity of the client,
the liquid level would be rose, thus requiring a greater pressure on the rigid straw to remove
effectively additional air from the pleural cavity to the bottle.
This system works when air is leaving the chest, because if fluid is draining, it would be added to the
fluid in the water seal, it increase the depth, and as the depth increases, it becomes harder for the
air to push through a higher level of water, could result in air stays in the chest. As a result, the one-
bottle system works efficiently for uncomplicated pneumothorax.
*Disadvantage of this system is that the position of the bottle at a level higher than the client’s
chest causes liquid passing into the pleural cavity.

II- Two Bottles Chest Drainage System:

This is one bottle collects the fluid and the same time seals
air leak (water seal is barrier). A rigid straw is immersed
into the bottle, tip is located 2 cm below the surface of
normal saline solution into the bottle.
The other end of this rigid straw is connected to the
pleural cavity of thoracic drainage tube. Decompression
valve which decompress the pressure from the air leak, an
opening of one-way decompression valve.

‫عيداروس‬ THORACIC ANESTHESIA 48

-It is mportant to remove this valve cover before connecting the system to the client side.
- If the pleural pressure is Positive, the rigid straw pressure becomes positive, and if the positive
pressure in straw is greater than the depth to which the tube is immersed in the saline solution,
then air will enter in the bottle and then depressurized by vent into the atmosphere.
-If the pleural pressure is Negative, it would move liquid from the bottle to the rigid straw and air
would not be entered in the pleural cavity or the rigid straw.
This system is called water seal bec. the water bottle seals the pleural cavity from;
the Air or Liquid from the outside of the body.

-It just like a straw in a drink, air can push through the straw, but air can not be drawn back up the
straw.
-When the rigid straw is above the liquid level in the bottle, the system would not be operated
consistently developing pneumothorax.
-However, when a significant quantity of liquid would be drained from the pleural cavity of the client,
the liquid level would be rose, thus requiring a greater pressure on the rigid straw to remove
effectively additional air from the pleural cavity to the bottle.

III- Three Bottles Chest Drainage System:

-The suction is always required to
pull air and fluid out of the pleural
space and pull the lung up against
the parietal pleura.
-If suction is required, a third bottle is
added.
The first chambers:
Connects the drainage unit directly
to the chest tube, drainage flows into
this chamber. The collection
chamber has to be calibrated and has
a easy measurement and recording
of the time, date, and amount of
drainage.
The middle chamber
The water seal. The main purpose of the water seal is to allow air to exit from the pleural space on
exhalation and it prevent air from entering the pleural cavity or mediastinum on inhalation.
When the water seal chamber is filled with sterile fluid up to the 2 cm line, to maintain an effective
seal, it is important to keep the chest drainage unit upright at all times and to monitor the water
level in the water seal to check for evaporation.

‫عيداروس‬ THORACIC ANESTHESIA 49

-Sometimes negative pressure is necessary to apply in the pleural cavity in order to facilitate re-
expansion of the underlying lung parenchyma or accelerate air removal from the pleural cavity.
The third chamber
-A suction control bottle allows the controlled application of suction and it is connected to the water
seal bottle. The two bottles are interconnected.
-The suction control bottle has a rigid straw, which is similar to the water-seal bottle.
-The amount of negative pressure within the suction system is equal to the depth of immersion of
the rigid straw below the liquid surface of the bottle. This size can be changed by adjusting the
position of the rigid straw to the suction control bottle or by changing the depth of liquid in the
bottle.
- Bubbling in the water seal chamber which indicates an air leak.
-The water seal chamber has a calibrated manometer to measure the amount of negative pressure
within the pleural cavity. The as intra-pleural pressure becomes more negative when the water level
in the small arm of the water seal rises
-If there is not leaking of air, the water level would rise and fall with the client’s respirations, and it
reflecting normal pressure changes would be in the pleural cavity.
-During spontaneous respirations, the water level would rise during inhalation and fall during
exhalation.
- During positive pressure ventilation, the oscillation would be just the opposite the water level,
should fall with inhalation and rise with exhalation. This oscillation is called tidaling and it is an
indicator of a patent pleural chest tube.
-Some units of system have an anti-siphoning float valve in the water seal fluid column which
prevents the water from being siphoned out of the water seal chamber and into the collection
chamber during situations which create high negative pressures, such as chest tube stripping.
-At the top of the chamber system is having the float valve which permits uncontrolled vacuum
levels to accumulate in the client’s chest with each subsequent stripping of the client tube. To
eliminate this pressure, system is having manual high negative pressure relief valves to chest drain
system which allow filtered atmospheric air to enter the system to prevent any accumulation of
negative pressure in the client.
Three situations can cause high negative pressure
1. Respiratory distress, coughing vigorously, or crying;
2. Chest tube stripping; Decreasing or disconnecting suction.
3. Vigorous milking or stripping can create dangerously high negative pressures.

Features
 Air/fluid leaves pleural cavity through tubing into drain and into water
o Air cannot flow back into pleural cavity as water impedes it
o Fluid cannot flow back into pleural cavity as long as the drain is kept adequately lower
than insertion site to prevent siphoning
 May have multiple chambers

‫عيداروس‬ THORACIC ANESTHESIA 50

  May be attached to suction
o Assists lung re-expansion
o Expediates drainage
o Single chamber suction requires low suction controller and set to around 20cmH2O
 Heimlich or flutter valve can be used to achieve a similar effect
 Components
o Chest tube attachment
o Rod from chest tube into chamber
 Rod cannot be in contact with bottom on chamber
 End of rod must be submerged 2-4cm in water to create one-way valve for air
 More fluid creates too much resistance
 Water in rod rises and falls with inspiration and expiration = swinging
 Mirror effect to the pleural cavity
 Will be revered if ventilated
 Normally rises 2-4cm
o Chamber
 Air expelled from a pneumothorax presents as bubbles in the water of the
chamber
o Vent to allow trapped air to escape and prevent pressure build up
o Second chamber
 Placed in series between first chamber and ICC
 Collects fluid from pleural cavity
o Third chamber
 Placed in series after the first chamber
 Level of fluid in chamber limits the amount of suction applied from external
suction
 20cm of water limits suction to -20cmH2O
 Excess suction draws air into chaber through vent rod which is then suctioned
out

Indications
 ICC
o Pneumothorax
o Large pleural effusion or empyema

Contraindications
 Airomedical retrieval
o Cannot assure chamber will be below level of chest and fluid/air may siphon back into
pleural cavity

Procedure
 Connect ICC to conector of UWSD
o Tape connections
 Drain should be secured >80cm lower than insertion site of intercostal catheter
 +/- apply suction
o Wall suction if 3 chambered
o Suction with low suction regulator if 1 or 2 chambers
 Document and monitor

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 o Swinging
o Bubbling
o Drainage output and character
 1.5L in first hour
 Then max 500ml/hr or less
o Drain position and fluid levels
o Tubing patency

Complications
 Tension pneumothorax
o If vent or tubing is blocked
 No bubbling on respiration
o Pneumothorax resolved: CXR
o Inadequate pressure to expel remaining air: get patient to cough to check for bubbles
o ICC not in pleural cavity or clamped: so check location, remove clamp
o Vent from chamber blocked: unblock
 No swinging
o Displaced ICC
o Disconnected ICC
o Blocked ICC
 Re-expansion Pulmonary Oedema

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