mean PAP > 25 mm Hg
- Pulmonary arterial e.g. IPAH, systemic sclerosis, congenital heart disease
- Secondary to left heart disease
- Secondary to chronic lung disease
- Chronic thromobo-embolic
- Estimation of sPAP in Apical 4-Chamber view. PH likely if estimated sPAP>50 mm Hg
- Other features of PH: dilated right side chambers, reduced RV function, RVH, enlarged PA, abnormal inter-ventricular septum motion
- Ca-channel blockade
- Endothelin receptor antagonists
- PDE-5 inhibitor
- TREAT PRIMARY CAUSE
- consider (CTPA) +/- treat VTE
This method allegedly reduces the risk of puncturing apex of pleura and causing pneumothorax.
(Usual pre-procedure steps and positioning)
– Place finger (A) in supra-clavicular notch at junction of medial 1/3 and lateral 2/3 of clavicle
– Entry point 1.5-2.0cm below junction of medial 2/3 and lateral 1/3 of clavicle
– Angle needle towards finger (A) just under clavicle, walking off if necessary. Often hit subclavian vein in this trajectory.
– If no puncture then systematically re-orientate needle towards supra-sternal notch in stepwise fashion.
This method should avoid breaching the pleura
– JB, GGH
Always loose lots of fluid and they tend to be relatively under-resuscitated by end of op.
+/- pre-med temazepam 10-20mg
Peripheral access 14/16G
Start remi at 0.1mcg/kg/min
Sit up for thoracic epidural
Supine, full monitoring inc. BIS
co-induction with propofol + sevo. 1mg/kg roc.
Miniman bagging. DLT using asleep fibre optic intubation technique.
Top-up epidural 10ml of 0.25% l-bupivicaine.
Intra-op: O2/air/desflurane. Remi at 0.1mcg/kg/min.
IVI + arterial line
Propofol & remi TIVA induction -> maintenance
(or remi in mcg/kg/min or ml/hr)
Insert ventilating bronchoscope. Attach Sanders Jet Ventilator. Beware of loose connection, kinks in tubing
Jet ventilate 10-12 bpm. Allow expiration
Pause as needed e.g. laser
Suction + Insert LMA
Laparotomy – usually umbilicus to pubis, may be longer
Potential major blood loss
Xmatch 4 units/fluid warmer/cell salvage
Large bore IV
Awake epidural @ T10. Test does 3ml of mix (of 20ml 0.25% levobupivicaine + 100mcg/2ml fentanyl)
GA/ETT ( – 2mcg/ml fentanyl, less propofol)
Asleep art line/CVC +/- CO monitor
Adv: Best for ventilation/control of each side.
Dis: bulky therefore not in difficult intubation, tracheostomy
2. Single lumen ETT with bronchial blocker
Adv: Use in (pot.) difficult airway, tracheostomy, if ETT already in situ e.g. ICU.
Dis: More specialised kit and technique. Needs fibreoptic scope.
3. Single lumen ETT advanced into main bronchus ( + fibreoptic if left sided)
Adv: Useful in emergency with most simple/available kit.
Dis: no control over non-intubated lung.
Left-sided DLT: less likely to be malpositioned (obstruct RUL)
Right-sided DLT: easier to insert, necessary if proximal left main bronchus is occluded
Stylet in bronchial lumen
Remove stylet once tip is through the cords
Left-sided DLT: rotate to the left. Right-sided DLT rotate to the right
Checking – Clinically
1. Treat as single lumen tube. Inflate tracheal cuff and check for equal air entry, normal compliance, no leak
2. Test bronchial lumen. Clamp tracheal limb of catheter mount. Open port to feel leak diasappear. While ventilating inflate bronchial cuff (2ml) until leak disappears. Single lung should ventilate.
3. Test isolated ventilation of contra-lateral lung. Clamp bronchial limb and open port. Opposite lumb should ventilate.
Checking – Bronchoscope
1. Tracheal lumen. Observe bronchial cuff just distal to carina in proximal main bronchus
2. Bronchial cuff. Observe correct placment of Murphy’s eye at RUL orifice.