Exam 2: Pulmonary Flashcards
Observation pieces of pulmonary assessment:
Rate/pattern/effort of breathing Tracheal position Thorax expansion Skin/soft tissue appearance Trach scar/stoma
Bronchial breath sounds are normally heard:
In the tracheobronchial tree
Trachea, R sternoclavicular
Characteristics of bronchial breath sounds:
I/E components equal with a pause between
Higher pitch, louder
Vesicular breath sounds are normally heard:
In the lung tissue
Characteristics of vesicular breath sounds:
Lower pitched and softer
Expiration shorter than inspiration without a pause between breath sounds
Consolidation sounds like:
Low pitched bronchial breathing
Cavitary disease sounds like:
High pitched bronchial breathing
Three adventitious sounds:
Wheeze
Stridor
Crackles
Seven appropriate candidates for PFTs:
COPD Smokers with persistent cough Wheezing/dyspnea on exertion Morbid obesity Thoracic surgery Open upper abdominal surgery > 70 y/o
Two categories of PFT:
Abnormalities of gas exchange (ABG, pulse ox, capnography)
Mechanical dysfunction of lungs/chest wall (spirometry)
Normal %s of volume & flow in spirometry:
Volume: 80-120% of predicted
Flow: 80% of predicted
Examples of obstructive lung disease:
COPD
Asthma
Examples of restrictive lung disease:
Pregnancy
NM disease
Obesity
Normal vital capacity result:
> 80% of predicted value
Type of disease that affects VC:
Restrictive diseases ↓ VC
Interpretation of FVC results:
80-120% Normal
70-79% Mild
50-69% Moderate
FVC measures:
Resistance to flow; max inspiration with forced expiration
FEV1 measures:
Volume of air forcefully expired from full inspiration in the 1st second
Interpretation of % FEV1/FVC:
> 75% Normal
60-75% Mild
50-59% Moderate
Type of disease that affects FEV1/FVC:
Obstructive disease will ↓ ratio
FEF25-75 measures:
The effort independent middle portion of expiration and the status of the smaller airways
Interpretation of % FEF25-75:
> 60% Normal
40-60% Mild
20-40% Moderate
Type of disease that affects FEF25-75:
Obstructive disease, even in early stages
FRC is measured by:
Nitrogen wash-out with an analyzer on spirometer; end-point is when alveolar nitrogen concentration falls below 7%
Relative PA, Pa, and Pv in Zone 1:
PA > Pa > Pv
Relative PA, Pa, and Pv in Zone 2:
Pa > PA > Pv
Relative PA, Pa, and Pv in Zone 3:
Pa > Pv > PA
Best V/Q match is in Zone:
Zone 2
Describe Zone 1:
Arterial pressure falls below alveolar pressure so capillaries are compressed, alveoli are enlarged; does not happen under normal circumstances, only when BP drops below alveolar pressure; more ventilation than perfusion.
Describe Zone 2:
Pulmonary artery pressure exceeds both venous pressure and alveolar pressure, so good flow past alveoli and good V/Q match
Describe Zone 3:
Venous pressure exceeds alveolar pressure, so capillaries are engorged and crushing alveoli; more perfusion than ventilation.
Distribution of pulmonary blood flow upright/supine:
Upright: flow strongest bases –> apex
Supine: flow equal bases to apex, but strongest in posterior/weakest anterior
Pulmonary effects of PPV:
Increases in: Zone 1 Blood flow to dependent lung Ventilation to independent lung Dead space
CV effects of PPV:
Decreased preload and BP
Can increase R to L shunt with atrial septal defect
Counteracting CV effects of PPV:
Positioning TED hose Fluid administration to ↑ volume load/preload ɑ/β agonists Inotropic support
Effects of smoking cessation at 12-14 hours:
↓ carboxyhemoglobin levels to normal
Effects of smoking cessation at 2-3 weeks:
Mucociliary function returns
↑ secretions!!
Effects of smoking cessation at 4 weeks:
Reduced secretions
Effects of smoking cessation at 8 weeks:
↓ rate of post-op pulmonary complications
Tx for bronchospasm:
β-agonists
Anticholinergics
Methylxanthines
Corticosteroids (for inflammation)
Restrictive pulmonary disease and anesthetics:
Titrate sedation carefully d/t ↓ FRC
Careful with NO and sats
Inhaled agents have accelerated uptake d/t ↓ FRC
SaO2 will drop quickly due to lower stores
Restrictive disease and regional anesthesia:
Regional anesthesia > T10 may impair ventilation (accessory muscles)
Restrictive disease and mechanical ventilation:
↑ PAP ↓ volumes (4-8 ml/kg) ↑ respiratory rate (14-18) Use PEEP Pressure control mode better than volume
FRC change in supine position:
10-15% ↓
FRC change with GA:
5-10% ↓ additional
VC changes after upper abdominal procedure:
Up to 40% ↓ and up to 14 days to recover
Strategies for obstructive pulmonary disease and anesthesia:
Reduce airway reactivity
Avoid spontaneous ventilation under GA
Keep regional anesthesia low-level
Careful with NO
Strategies for reducing airway reactivity:
Bronchodilator therapy
High alveolar concentrations of inhalation agents
IV opioids/lidocaine prior to airway manipulation
Single dose corticosteroids
PPV for obstructive disease:
Large TV
Slower rate to allow full expiration
Low I:E ratio
Keep PIP below 40
