Lecture 22: Pulmonary Medical and Surgical Management Flashcards
possible medical management options for pulmonary dysfunction
medications
supplemental O2
monitor vitals/diagnostics
adjustments to PA
why can certain O2 delivery devices only be used in a medical setting
portable tanks have upper limit of flow rate (<12-15L/min)
if device requires >12-15L/min of flow, that device will be seen in a medical setting with centralized O2
some devices used in high acuity settings for acute support can be used at home for maintenance therapy, at different levels of supplementation
some exceptions (i.e. home vents)
general rule = higher flow devices in hospital, lower flow devices can be used anywhere
what is non-invasive ventilation and conditions it is used as first line therapy for
method of breathing support that delivers pressure and volume wo the use of advanced airway (ETT or trach)
NIV used at first line therapy in 4 main acute conditions
- COPD exacerbation with hypercapnia
- cardiogenic pulm edema
- pulm infiltrates for immunocompromised pts
- weaning O2 in extubated COPD pts with hypercapnia
how does NIV help with COPD exacerbation with hypercapnia
helps pull off excess CO2
how does NIV help with cardiogenic pulmonary edema
pressure on inhalation helps “push” excess fluid out of alveoli
how does NIV help with pulmonary infiltrates for immunocompromised pts
risk of infection is higher with mechanical ventilation (MV)
how does NIV help with weaning O2 in extubated COPD patients with hypercapnia
used as a transition from MV to other supplemental O2
describe heated high flow nasal cannula as a non-invasive ventilation option and how it helps
up to 60 L/min and 100% FiO2
heated humidification helps protect airways and keep secretions thin
provides some pressure on inhalation and exhalation
most beneficial pressure on exhalation (device helps keep alveoli inflated at end of exhalation)
describe continuous positive airway pressure (CPAP) as a NIV
gives pressure on inhalation only
used for obstructive breathing patterns that cause sleep apnea
not effective enough to breathe off excess CO2 but is able to keep CO2 levels from climbing
describe BiLevel Positive Airway Pressure (BIPAP) as a NIV
gives one pressure on inhalation and one pressure on exhalation (may be different pressures)
used to help rid body of excess CO2 build up
can be used for protecting the airway in an attempt to avoid mechanical ventilation
indications for lung sx
remove tumor
remove part of lobe, entire lobe, or entire lung due to disease
remove lymph nodes
remove/repair unhealthy tissue
remove fluid in chest cavity
remove device or drain
to reduce lung volume
removal of blood clot
transplant donor lungs
what is a thoracotomy
incision along borders of ribs or mm to access thoracic cavity or lungs
posterolateral = more common; exposes most space
anterolateral = used if anterior structures involved; access heart or esophagus
clamshell = lung transplant
what is a video assisted thoracic sx (VATS)
minimally invasive
doesn’t require rib separation
may have mini thoracotomy or other small incision somewhere
benefits of VATS instead of open thoracotomy
more delicate handling and precision of instruments
decreased blood loss in sx
less incisional pain
less negatively affected pulmonary functions
decreased inflammatory cytokine reaction to sx
earlier post op mobility
reduced hospital LOS
thoracotomy precautions
usually 6-8 weeks
no lifting > 5 lbs
no twisting or rotational mvmts
no strenuous activity with surgical side
ROM encouraged as tolerated below 90-90
splinted coughing
what is decortication
removing fibrous visceral pleura from lung to allow the underlying lung tissue to expand
often performed in cases of lung cancer, emphysema or radiation induced pleural fibrosis
can be performed via VATS or thoracotomy
often have chest tube post op
what is pleurodesis
adheres the pleura together to eliminated pleural space to prevent air/fluid buildup and entrapment
can be surgically or chemically adhered
performed to treat recurrent or malignant effusion, recurrent pneumothorax
post op drain or chest tube used to keep pleural space drained
what is a wedge resection
removal of a wedge shaped portion of the lung
most commonly utilized for removal of Tumors close to the periphery
can also be used to remove granulomas or isolated areas of lung damage from various diseases
performed via VATS
what is a lobectomy and pneumonectomy
removal of entire lobe of the lung or entire lung
performed for advanced lung cancer if other surgical removal is not possible
larger the tissue removed, the higher the likelihood a full thoracotomy will be used
what is a lung reduction
procedure to reduce lung volume do to hyperinflation from COPD/emphysema
subpleural emphysema has an increased risk of worsening and creating a tension pneumothorax
done after other less invasive measures have failed
stats for lung transplants
average wait time = 2 years for single lung and 3 years for double
~1% of national transplant lists are lung pts
estimated 1st year expense = $1.2 million
80-85% 1 year survival rate
50-60% 5 year survival rate
history of lung transplant
1963 = 1st human lung transplant in US
1980s = successful long term lung transplants
1990s = use of ECMO in adults help pts survive lung transplant
2019 = peak number annual lung transplants prior to pandemic
still have not returned to pre pandemic number of lung transplants
indications for lung transplant
IPF
CF
sarcoidosis/amyloidosis
COPD
contraindications to lung transplant
> 72 years old
severe mental/psychological instability
drug/tobacco/ETOH use w/I 6 months
BMI >35
malnourishment
uncontrolled DM
PVD
hepatitis B/C
renal failure
autoimmune disease with multi system
AIDS
current/recent malignant cancer
systemic illness + short life expectancy
process of a lung transplant
evaluation = CVP imaging, PFTs, VQ scan, exercise testing
pt placed on waitlist after being deemed candidate
geographic waiting list maintained by UNOS
organ available = matched to pt based on characteristics
organ preserved and transported
medications for lung transplants
immunosuppressants = prevent rejection
corticosteroids = reduce inflammation and risk of rejection
antibiotics/antivirals = prevent bacterial/viral illness due to immunosuppression
anti-hypertensives = counteract side effects of SLT/DLT meds that cause HTN; prevent pulmonary HTN
insulin = counteract side effects of SLT/DLT meds that cause hyperglycemia
bronchodilators = prevent bronchoconstriction/bronchospasm in donor lung airways
mucolytics = ensure secretion clearance
complications of lung transplants
infection = highest 12 months post; high risk due to immunosuppression
rejection = 20-50% in first 12 months; S&S include never, fatigue, N&V, myalgias
challenging to balance risk of rejection with risk of infection
describe a chest tube and its use
often placed with thoracic sx
evacuate fluid and air that can impede breathing and cause lung collapse
inserted at optimal intercostal space to target fluid/air accumulation then advanced several inches into the pleural space
may also be used in traumatic injuries and other pathologies
post sx management of chest tube
usually connected to 3 chamber water seal drainage device
attached to wall suction initially and progressed to gravity only as the air leak reduces in size or the drainage amount subsides
drainage collection systems provide a means to verify presence of an air leak and monitor amount of drainage and intrathoracic blood loss
what is a pleurX drain
indwelling drain that continually drains pleural space
indicated for recurrent pleural effusions; done in place of repeated thoracentesis procedures
commonly seen in palliative or hospice situations
can be managed at home
