Thoracic Anesthesia – Learning
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Topics and Concepts
By the end of your two months of thoracic, you should be able to have “at depth” conversations about the following:
- Preop eval: Which patients are suitable for lung resection? What specific risks/outcomes are associated with higher risk patients undergoing lung resection?
- Pulmonary function tests and flow-volume loops: How do you interpret them?
- Exercise testing: What are the different levels of exercise testing and what do they tell you?
- Chest tubes: How does a chest tube work? What is the difference between water seal and suction?
- Thoracic epidurals: Are there any outcome benefits with thoracic epidurals? What about paravertebrals or rib blocks?
- Mediastinal masses: What are the anesthetic risks associated with mediastinal masses?
- Jet ventilation: How do you work the jet ventilator? What are “standard” settings and what situations would prompt adjustment of these settings?
- Lung isolation: How do you place a double lumen tube, and how do you isolate? How do you pick the “sidedness.” What about bronchial blockers? Are there other ways to isolate? What are appropriate tidal volumes during OLV?
- Hypoxemia: What causes hypoxemia during lung isolation? What is HPV and what drugs/conditions impair it? How does positioning impact hypoxemia? How do you manage hypoxemia during OLV?
- V/Q matching and shunt
- Fluid management: When and why are fluid management strategies important in anesthesia for thoracic surgery.
- COPD: Specific considerations and preop optimization for the patient with COPD
- Restrictive lung disease: Specific considerations
- Post-operative arrhythmia: Which patients have higher risk and what to do?
- Special airway devices: Describe different types of tracheostomy, t-tubes, etc.
* Pro-tip: If you’re looking for something for your attending to teach you about, any one of the concepts above can make for a great day of learning!
Anesthesia for Specific Cases
For each of the following cases, you should be able to describe the case, indications, the perioperative risks, and the anesthetic considerations / ideal plan.
- First rib resection
- Rigid bronchoscopy
- VATS/lung resection
- Repair of broncho-pleural fistula*
- Repair of tracheo-esophageal fistula*
- Lung reduction surgery
- Tracheal resection and reconstruction
- Esophagectomies, including the different types
- Repair of esophageal perforation
- Nissen fundoplication
- Heller myotomy
- Thymectomy (and management of myasthenic patients)*
- Suspension microlaryngoscopy
- Cord medialization
- Tracheal stent placement/adjustment
- Airway Laser
- Cryotherapy, TruFreeze
Specific skills to look for on thoracic include:
- Lung isolation (e.g., double lumen placement +/- bronchial blocker placement)
- Thoracic epidural placement
- Paravertebral placement