Small Ani. Sx- Pulmonary Sx. 1

wilsbach's version from 2015-11-04 19:10


Question Answer
When is a Complete lobectomy indicated?Disease process involving entire lobe or area near hilus of lobe (Ex: lung lobe torsion, neoplasia, trauma, contamination or infection)
When is a Partial lobectomy indicated?when there are Focal lesions distal in lobe
Dogs and cats may tolerate removal of up to ____% of their lung mass.50%
Which side pneumonectomy is NOT reccomended and why?Dogs and cats may tolerate removal of up to 50% of their lung mass.---> However, Because the right lung possesses slightly greater than 50% of the total lung mass, complete right pneumonectomy is not recommended.
It is ok to do a full Left pneumonectomy if....if the right lung is healthy
what is a pneumonectomy?removal of a full lung
If you perform a pneumonectomy, how might the heart be affected?mediasteinum might migrate, electrical axis of heart might migrate as well if mediasteinum/heart is migrating
explain the surgical technique for a complete lobectomy? (part one-vessels)Isolate and pack off lung lobe to be resected--> Vessels and bronchus are ligated at the hilus *(1) Isolate pulmonary artery (right-angled forceps) and Place 3 ligatures (middle ligature is transfixing). Repeat process with pulmonary vein. Excise vessels between transfixing and distal ligatures (pic is r. angle forceps)
for a complete lobectory, which vessel (pulmonary A or V) do you ligate first, and why? EXCEPTIONS?FIRST ARTERY, THEN VEIN! The exceptions are: (1) small dogs/cats, bc if you ligate the a first, the vein is small and will collapse and be hard to find/ligate. (2) Vein FIRST if neoplasia or abscess (don't want to irritate it and then have it seed and spread through veins)
how is the ligations of the pulmonary aa and vv kinda different from what we're used to?do THREE ligatures, circumfrential-->transfixing-->circumfrential, and transfix between intermediate and distal ligature
explain the surgical technique for a complete lobectomy? (part two- trachea)The bronchus is transected between 2 crushing clamps--> 1 or 2 rows of horizontal mattress sutures, interrupted or continuous are placed through bronchus-->Cut margin of bronchus is over sewn with simple continuous sutures
*aside from pulmonary A and V, what other vessels are you worried about with a complete lobectomy?Bronchial vessels are what supply the lung parynchyma. Must ligate these as well.
what would be the surgical technique for a complete lobecomy if you used a stapler? (what stapler would you use?)TA stapler may be used for complete lobectomy. The hilus of the lobe is isolated--> The entire pedicle is stapled--> The lobe is excised distal to the staples
what is the surgical technique for a PARTIAL lobectomy?Crushing clamps are placed across the lobe proximal to the lesion--> 1 or 2 rows of continuous horizontal mattress sutures placed proximal to the clamps (3-0 or 4-0 absorbable suture, small taper needle)--> cut distal to mattress sutures and prox to clamps--> can run simple cont at end of excision. use small suture.
what important thing must you consider once you've done a partial lobectomy?Make sure no leaks! (do water test via submerging lung in some saline and give breath, look for bubbles) bc leak can lead to pneumothorax-- even hypertensive (tension) penunmothorax
can you use a stapler for a partial lobectomy?yes! TA gives double row of staples which is usually airtight
how do you check the partial lung lobectomy for air leaks?(1) Sterile saline is dripped across the suture line while the lung is inflated (2) In large dogs, the suture line may be placed in a bowl of fluid while the lung is inflated
If there is a leak, how do you fix it?Leaks are closed with interrupted sutures
why might you think a lame animal has a lung prob?Some animals may have lameness because the lung lobe tumor has spread to other sites or has caused swelling and bony reaction along the toes and lower bones of the leg (“hypertrophic osteopathy”). (inflammation of cortex of longbones)
why should you try to limit the amount of stitches in the lung parenchyma to only what is necessary?each hole is a potential leak
leak in lung parenchyma leads to what kinda pneumothorax?tension/hypertensive

Trachea Sx

Question Answer
what is tracheal collapse?An acquired end-stage disease of the tracheal cartilage, leading to mechanical collapse of the trachea on inspiration and/or expiration
hx of a tracheal collapse sufferer?Chronic history of coughing, Chronic bronchial disease, Coughing with excitement
big clinical signs of tracheal collapse“Honking” cough, Cyanosis, Syncope (when their faint they relax and it actually gets better for a bit, but uh, not a good long term plan)
what are the grades for tracheal collapse?GRADE 1: 25% collapse. GRADE 2: 50% collapse. GRADE 3: 75% collapse. Grade 4: 100% collapse. <img sr=""height="350">
what are the 2 types of tracheal collapse based on region?cervical or thoracic
when does collapse happen if it's in the cervical trachea?inspiration
when does collapse happen if it's in the thoracic trachra?expiration
why is tracheal collapse kinda like a vicious cycle?inspire harder bc having trouble breathing, leads to more pressure, which increases flattening of trachea..etc
4 types of surgical tx for tracheal collapse?(1) Dorsal membrane plication (2) Ventral ring chondrotomy (not in use anymore) (3) External tracheal splints (ring or spiral) (4) external tracheal stents
medical management methods for tracheal collapse?Weight loss, cough suppressants, bronchial dilators, sedation
what are you doing in a dorsal membrane plication? WHEN do you want to do this procedure? What is the suture pattern you use?C-shaped cart, where there isnt cart there is a membrane-- try to bring membrane close together and cart rings closer together. mattress stitches. keep membrane together and circumference of trachea can be regained. Only when you still have good architecture of trachea( Not helpful in grade 3/4 when rings are weakened or flat)
what are you doing in the tracheal ring splint technique?use a splint to support cart. membrane and maintain carts open. Place around ouside of trach, maintain with sutures. (was first done by cutting syringe cases and drilling holes in them for the suture to go through. Now there are things you can buy)
Diagram for tracheal splint
what are the two major precautions you must keep in mind when doing a tracheal ring splint technique?(1) the recurrent laryngeal nn runs on dorsal aspect of trachea-- DON'T damage it (2) trachea has SEGMENTAL blood supply-- do not disrupt this
what is the "domino effect" you risk when you do a tracheal splint?if you enforce on area...the adj area might become weakened
explain the approach you take to place the tracheal splintdorsal recum, VM approach, displace mm like eso sx.... delicately dissect around trach rings and try to pass splints and place sutures
do you want to suture into the lumen when placing your tracheal splint? if you do, what do you do?Don't want to, but if you, will have to improve diameter of lumen...might elicit some more coughing, support pt with meds (cough suppressants) and might need some humidifiers bc if too dry mucosa, more coughing
Disadvantages of external tracheal splints?Extensive surgical approach, Anesthetic risks, Prolonged postoperative care and pain, High cost of anesthesia and aftercare, Trachea adjacent to supported trachea may be at higher risk of collapse
Advantages of external tracheal splints?Most animals improve postop
Where do Internal Tracheal STENTS go? What must you do to place them?instead of outside, these go inside. place with cath--place with ruler (need to use fluroscopy)
potential advantages of internal tracheal STENTS? (5)(1) Catheter delivery - no surgery required (2) Shorter anesthesia (3) Reduced postoperative pain (4) Reduced cost (?) (5) Entire trachea is treated at one time
potential disadvantages of internal tracheal STENTS? (2)(1) Endoscopy or fluoroscopy required (2) Stent cannot be retrieved back into delivery catheter if error in placement or sizing is made (<--questionable, depends on if it is an old or new model)
If your stent isn't long enough, should you put in two?Overlapping 2 is not the best idea. ciliary cells- move w/ goblets cells to remove shit. if too much pressure will damage goblet cells and cilliar-muco cells
Is surgery on the trachea for tracheal collapse a cure?NO- just a tx to improve pulmonary fxn
which is generally more successful- the tracheal SPLINTS or the tracheal STENTS?stents
3 possible complications of stenting?(1) Decreased mucociliary clearance (2) Inflammation and exuberant granulation tissue formation (still a FB-- can have hypertrophy to tissues in response to the FB ) (3) Pressure necrosis
6 things you can do for post-op care after tracheal stent (can apply to splint too, im sure..)(1) perioperative abx (2) corticosteroids for 7d (3) sedation (4) cough suppression (5) 24hrs O2 if needed (6) humidification


Question Answer
how can intubation cause trach trauma?act of intubation itself can cause damage, rotate pt without deflating cuff...
If there is severe damage to the trach, what is your rad gonna look like?AIR EVERYWHUR (SQ emphysema)
if there is a bunch of tracheal damage, what salvage procedure should you try? What if the hyoid apparatus is involved? (think: bit by dog)tracheostomy- remainder of trachea is applied to skin as a tube-- if hyoid is involved, this swallowing apparatus is also compromised, so may have to do esophagostomy or gastrostomy tube also
Tracheal Resection and Anastomosis--> how many rings can you usually take away with this, and why?resection of 3-5 rings easily done, but up to 8-10 rings (25%) can be resected (however in class this might be too many)....Only can do LIMITED amount of rings bc the trachea DOES NOT LIKE TENSION! If more than 3-5, you will need harnass to keep dogs head down to prevent stress on trach (neck flexion)
2 ways to minimize tension on the trachea after you have performed a tracheal resection and anastomosis?(1) use tension relief sutures (bridging by going around carts so not all tension on primary wound) (2) Use a harness that keeps the head down to reduce tension
what are two ways to resect the trachea (based on where you cut) and which is probably preferred (why?)(1) cut through the membrane between each ring (easier but not the best) (2) *Resect trachea between rings (split cartilage) (more demanding but better and strong apposition and no membrane that might get inverted too)
explain sx technique for Tracheal Resection and AnastomosisResect trachea between rings (split cartilage)--> Handle trachea with umbilical tape or traction sutures--> Suture dorsal tracheal membrane first--> Place sutures around rings, add tension sutures if necessary
which part of he trach do you sew first in a resect/anastomosis?Suture dorsal tracheal membrane first
If there is a small hole/you arent so sure about your anastomoses of the trach, how can you help?can sometimes use patching technique- if hole can use mm in vicinity (like for eso) and tracheal mucosa will rapidly cover that (*still be aware there is a weak point where there is no cart), A pleural patch may be placed over the suture line
how do you place tension sutures for your resect+anasto?Tension sutures are placed 2-3 rings from the suture line on each side
what tool might be useful to help with a trach resect and ana?can use a tube (not sure if ET or bain or what) kinda acts like a stink, helps you place and guide stitches, etc.
If there is a small leak in your repair of the trach, aside from patching, what else can you do?leave 1-2 stitches on skin not closed so allow drainage (otherwise can cause SQ emphysema)