Respiratory & Thoracic 00 / 24 , all cards and bookmarks
Sheet 07 Anaesthesia
Respiratory & Thoracic Breathing reserve before surgery, lung isolation and the double-lumen tube, hypoxaemia on one lung, ventilating obstructed lungs, spirometry, loops and blood gases, and the thoracic emergencies.
Cards 24
Minutes about 13
Scenarios 24 Start at card 1 Or start again from the beginning Review the rules
Hypoxaemia on one lung: the ladder 03 / 24 Gradual fall: oxygen, bronchoscope, positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP); precipitous: two-lung ventilation.
Proceed, postpone or treat first 04 / 24 Postpone active untreated disease; treat first (bronchodilator on the day, CPAP beforehand), then proceed.
Which test 05 / 24 Match the test to the question: reference test to confirm, echocardiography to screen pulmonary hypertension.
Patient Test Suspected obstructive sleep apnoea → , open its explanation Overnight polysomnography, the reference test Suspected pulmonary embolism, haemodynamically stable → , open its explanation CT pulmonary angiography; raised D‑dimer cannot confirm Pulmonary hypertension: the lung‑function clue → , open its explanation Low carbon monoxide diffusing capacity (DLCO) Suspected pulmonary hypertension → , open its explanation Echocardiography screens; right heart catheterisation confirms Systemic sclerosis, new or changed breathlessness → , open its explanation Transthoracic echocardiogram for pulmonary arterial hypertension, not repeat spirometry Worsening pulmonary sarcoidosis → , open its explanation Full lung function tests; echo only for pulmonary hypertension Echo: moderate–severe pulmonary hypertension before major surgery → , open its explanation Confirm with right heart catheterisation before operating
Report a problem with card 5: Which test
Choosing the anaesthetic 06 / 24 Spare lung and airway: regional, short-acting opioid, CPAP at induction, total intravenous anaesthesia (TIVA) to protect mucociliary clearance.
Patient Anaesthetic choice Obstructive sleep apnoea, knee replacement → , open its explanation Spinal, light sedation, opioid‑sparing; deeper sedation: secure airway Obese obstructive sleep apnoea, day case → , open its explanation Short‑acting opioids Obese obstructive sleep apnoea, at induction → , open its explanation CPAP/PEEP added to mask preoxygenation Chronic obstructive pulmonary disease (COPD): preserving mucociliary clearance → , open its explanation Propofol‑opioid TIVA, not volatiles or nitrous oxide
Report a problem with card 6: Choosing the anaesthetic
The leaking lung: induction and ventilation 07 / 24 Leaking lung (fistula, bulla): no positive pressure until it is isolated; favour spontaneous breathing.
Leaking lung What to do Bronchopleural fistula: induction → , open its explanation Inhalational or awake; spontaneous breathing until healthy lung isolated Bronchopleural fistula: airway device → , open its explanation Double‑lumen tube isolating the healthy lung before positive pressure Fistula, normal airway, bronchoscope at hand → , open its explanation Modified rapid sequence acceptable; bronchoscope‑guided double‑lumen isolation Post‑pneumonectomy bronchopleural fistula: ventilation → , open its explanation Endobronchial tube in remaining lung, or high‑frequency jet ventilation Fistula with empyema → , open its explanation Double‑lumen, bronchial limb opposite side: right fistula, left tube Bullous lung disease → , open its explanation Spontaneous breathing until bulla lung isolated; no nitrous oxide
Report a problem with card 7: The leaking lung: induction and ventilation
Ventilating obstructed lungs 08 / 24 Give obstructed lungs time to empty; try mask ventilation first unless the airway is unguarded.
Ventilator settings in airway obstruction Mask ventilation or intubation Glasgow Coma Scale (Stoelting): best eye + verbal + motor response, total 3 to 15 Report a problem with card 8: Ventilating obstructed lungs
Lung volumes and spirometry 09 / 24 Low FEV1 to forced vital capacity (FVC) ratio: obstruction; low total lung capacity (TLC): restriction.
Spirometry patterns by condition Condition What the volumes show Obstructive lung disease → , open its explanation FEV1/FVC below 70%; use the ratio, not FEV1 alone Restrictive lung disease on spirometry → , open its explanation FEV1 and FVC both fall; ratio preserved Restrictive lung disease → , open its explanation Defined by reduced TLC Restrictive lung disease: other volumes → , open its explanation Functional residual capacity (FRC), vital capacity, tidal volume and FEV1 fall Restrictive lung disease: FEV1/FVC → , open its explanation Normal or raised; reduced volumes, not ratio, show restriction Scoliosis → , open its explanation Restrictive: vital capacity, TLC, FRC fall; FEV1/FVC normal Scoliosis: FRC versus FEV1 → , open its explanation FRC falls directly; FEV1 only tracks the smaller vital capacity Obesity → , open its explanation Expiratory reserve volume most sensitive; FRC falls later, less
Lung volume definitions Report a problem with card 9: Lung volumes and spirometry
Loops and curves 10 / 24 Read the shape: flattened limbs locate the obstruction; the pressure-volume slope is compliance.
The sleep study 11 / 24 Grade apnoea by events per hour; name the sleep stage by its EEG band.
Blood gases: name the mechanism 12 / 24 Raised PaCO2 with normal A–a gradient is hypoventilation; otherwise name mismatch, shunt or dead space.
The double-lumen tube by ear 13 / 24 Clamp one lumen and listen: the pattern says too shallow, correct, or wrong bronchus.
Capnography and airway pressures 14 / 24 Wider arterial–end-tidal gap means dead space or shunt; peak without plateau rise means resistance.
Monitor finding Cause Wider arterial–end‑tidal CO2 gap → , open its explanation Dead space: embolism, hypovolaemia, low output, high V/Q Modestly wider arterial–end‑tidal CO2 gap → , open its explanation Right‑to‑left shunt Narrower arterial–end‑tidal CO2 gap → , open its explanation High cardiac output Peak pressure up, plateau unchanged → , open its explanation Raised airway resistance, such as bronchospasm Peak and plateau pressures both up → , open its explanation Reduced compliance
Report a problem with card 14: Capnography and airway pressures
Sudden change in thoracic theatre 16 / 24 Name the cause from what changed and when: tube, pneumothorax or a compressed vessel.
Sudden change Cause and action Lost right‑hand pulse trace in mediastinoscopy, normal ECG → , open its explanation Innominate artery compression, not cardiac arrest Bullae, positive pressure, rising airway pressure, hypotension → , open its explanation Pneumothorax from bulla rupture Bullae, opioid‑only induction, spontaneous breathing, tachycardia, hypertension → , open its explanation Hypercapnia from opioid hypoventilation Sudden airway‑pressure rise after lateral turn, double‑lumen tube → , open its explanation Tube malposition: confirm position with fibreoptic bronchoscopy One‑lung ventilation: high pressure, hypoxaemia, hypotension, falling EtCO2 → , open its explanation Dependent‑lung pneumothorax: decompress now; pressure alone: bronchoscope tube
Report a problem with card 16: Sudden change in thoracic theatre
After pneumonectomy 17 / 24 New bilateral infiltrates with refractory hypoxaemia after pneumonectomy: post-pneumonectomy oedema, mortality 30-50%.
Alveolar proteinosis 18 / 24 Proteinosis fills alveoli: treat worsening hypoxaemia with whole-lung lavage, not more PEEP.
Pulmonary embolism: the signs 20 / 24 No sign or symptom predicts embolism; dyspnoea is the commonest symptom, tachypnoea the commonest sign.
FRC, atelectasis and positive pressure 21 / 24 Anaesthesia collapses dependent lung; PEEP restores FRC but lowers venous return.
Oxygen, carbon dioxide and the drive to breathe 22 / 24 Oxygen content rides on haemoglobin; ventilation follows carbon dioxide and chemoreceptor drive.
Oxygen and carbon dioxide values Quantity Value Alveolar ventilation → , open its explanation Gas reaching alveoli and respiratory bronchioles Alveolar volume, spontaneous breathing → , open its explanation Tidal volume minus dead space (about one third) Haemoglobin back‑calculated from oxygen content → , open its explanation (Arterial oxygen content − PaO2 × 0.003) ÷ (constant × saturation) Oxygen‑binding constant per gram haemoglobin → , open its explanation 1.34 (Miller), 1.36 (Barash) or 1.39 (Faust) mL/g PaO2 on FiO2 1.0, healthy lungs → , open its explanation Above 400 mmHg; haemoglobin already saturated near 100 Mitochondrial oxygen tension on room air → , open its explanation 4–22 mmHg, cascade's lowest; arterial about 100 PaCO2 rise in apnoea (absent ventilation) → , open its explanation 6–10 mmHg first minute, then 3–3.5 mmHg each minute
What drives or changes breathing Stimulus Effect Rising PaCO2 or hypoxaemia, general anaesthesia → , open its explanation Raises intraocular pressure: keep PaCO2 normal, avoid hypoxaemia Ascent to altitude, low inspired oxygen → , open its explanation Sustained hypoxic rise in ventilation; kidneys excrete bicarbonate Carbon monoxide poisoning, rapid breathing → , open its explanation Lactic acidosis, not hypoxaemia; carotid bodies unstimulated Metabolic acidosis vs opioids, barbiturates, volatiles → , open its explanation CO2 curve left; depressants shift right or flatten
Report a problem with card 22: Oxygen, carbon dioxide and the drive to breathe
Traps Check these before you finish 1 card · about 1 min 24 Traps
Traps 24 / 24 The tempting choice matches the side, the number or the reflex; the books name another.
Tempting Right call One‑lung desaturation: deepen the volatile above 1 MAC → , open its explanation Reduce volatile below 1 MAC; never deepen it Gradual one‑lung desaturation: resume two‑lung ventilation → , open its explanation FiO2 1.0, bronchoscope; two‑lung if precipitous; then PEEP/CPAP Left DLT too shallow: stop at cuff deflation → , open its explanation Deflate, then advance into the left main bronchus Alveolar proteinosis hypoxaemia: increase PEEP to 10 → , open its explanation Whole‑lung lavage through a double‑lumen tube Right lung transplant: right‑sided DLT → , open its explanation Left‑sided DLT; right‑sided only for diseased or operated left bronchus Pneumonectomy as absolute lung isolation indication → , open its explanation Relative, exposure only; absolute: soiling, fistula, bulla, torn airway, lavage Pulmonary embolism defect: hypoperfusion → , open its explanation Dead space; oxygen‑refractory hypoxaemia means shunt Untreated active asthma wheeze, elective: proceed with salbutamol → , open its explanation Postpone; refer to restart treatment Wide arterial–end‑tidal CO2 gap: hypoventilation → , open its explanation Dead space (embolism, low cardiac output) or right‑to‑left shunt Diagnosing obstruction with FEV1 alone → , open its explanation FEV1/FVC ratio below 70%; restriction keeps ratio normal Emphysema low PaO2, normal PaCO2: membrane damage → , open its explanation Ventilation–perfusion mismatch, not diffusion defect or hypoventilation Ventilated COPD hypercapnia: increase respiratory rate → , open its explanation Lengthen expiration; tolerate mild hypercapnic acidosis High one‑lung airway pressure: resume two‑lung ventilation → , open its explanation Alone: bronchoscope tube; with shock: decompress dependent‑lung pneumothorax Right fistula with empyema: right‑sided DLT → , open its explanation Left‑sided double‑lumen tube, bronchial limb in healthy bronchus
Report a problem with card 24: Traps
Quiz Check yourself 24 practice scenarios · one to a screen Quiz Check yourself 24 practice scenarios Answers checked against the books and guidelines.
The quiz needs JavaScript. Every answer is also in the reference.
Sheet 07 · Respiratory & Thoracic 24 / 24
That is Respiratory & Thoracic, all 24 cards.
Your answers from this session Use my answers to improve Butters. Saying yes sends what you did in this session, which until now stayed on your phone. From then on, while this is on, we keep which cards and entries you open and for how long, your quiz picks and how sure you were, and the days you come back. They are stored with Neon in Frankfurt under a code made from your email, never the email itself, and used to find which beliefs residents hold and which cards need work. Turn it off at any time; nothing more is kept after that.
Yes, use my answers Keep them on my phone
What the quiz asks
Your answers:
Back to the sheets The 24 rules One rule per card, in the sheet's order. Tap one to open its card.