Intra-Operative Discussion Topics for Thoracic Anesthesia Rotation

1. Anatomy of the respiratory tract - structure of the trachea and its relationships in neck and chest; lung divisions, bronchial and pulmonary circulations.

2. Lung volumes - methods of measurement, normal values, and time constant.

3. Lung mechanics - compliance, resistance, work of breathing, flow-volume loop and hysteresis.

4. Ventilation – perfusion – distributions of ventilation and perfusion, West’s lung zones, hypoxic pulmonary vasoconstriction, measurements of V/Q ratio, implications of V_D/V_T, Q_S/Q_T.

5. Control of breathing – central respiratory center, central sensors, peripheral chemoreceptors, lung receptors, and the effects of anesthesia on the control of breathing.

6. Pre-operative evaluation of the patient for thoracic surgery including operative criteria for pneumonectomy and criteria for extubation.

7. Indications for lung isolation and different techniques (bronchial blocker, UniVent tube, mainstem intubation … etc) for achieving it.

8. Indications and contraindications of double lumen tube (DLT) placement, left-sided versus right-sided DLT, selection of the proper DLT based on CXR and/or other methods, technique in its placement, verification, and trouble shooting, and complications.

9. Effect of the lateral decubitus position on respiratory mechanics in the awake and anesthetized state, and with positive pressure ventilation.

10. Physiology of one lung ventilation with regards to V/Q matching, hypoxic pulmonary vasoconstriction, and the effect of different anesthetics on them.

11. Hypoxemia during one lung ventilation – etiologies, diagnosis, and treatment.

12. Anesthetic considerations in a patient with a mediastinal mass.

13. Paraneoplastic syndromes and the anesthetic considerations.

14. Post-op complications – pulmonary edema, bronchopleural fistula, herniation of heart intra-operative hemithorax, bleeding, torsion of lobe, and paraplegia.

15. Post-pneumonectomy pulmonary edema/ARDS – etiologies, diagnosis, pathophysiologies, and management.

16. Management of the patient with massive pulmonary hemorrhage.

17. Stridor and intrathoracic vs extrathoracic obstruction – etiologies, diagnosis, and management.

18. Anesthesia management of patients with tracheal stenosis or tracheal trauma for tracheal resection and reconstruction.

19. Anesthetic considerations and management of patient for pulmonary stenting.

20. Anesthetic considerations and management of patient for thoracoscopy.

21. Anesthetic considerations and management of patient for broncholalveolar lavage.

22. Anesthetic considerations for and management of patient for esophageal surgery.

23. Anesthetic considerations for and management of patient for lung volume reduction surgery.

24. Epidural (thoracic versus lumbar) anesthesia for thoracic surgeries – impact on perioperative lung functions and outcome.