Lecture 22: Pulmonary Medical and Surgical Management

Question 1

possible medical management options for pulmonary dysfunction

Answer 1

medications
supplemental O2
monitor vitals/diagnostics
adjustments to PA

Question 2

why can certain O2 delivery devices only be used in a medical setting

Answer 2

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

Question 3

what is non-invasive ventilation and conditions it is used as first line therapy for

Answer 3

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

Question 4

how does NIV help with COPD exacerbation with hypercapnia

Answer 4

helps pull off excess CO2

Question 5

how does NIV help with cardiogenic pulmonary edema

Answer 5

pressure on inhalation helps “push” excess fluid out of alveoli

Question 6

how does NIV help with pulmonary infiltrates for immunocompromised pts

Answer 6

risk of infection is higher with mechanical ventilation (MV)

Question 7

how does NIV help with weaning O2 in extubated COPD patients with hypercapnia

Answer 7

used as a transition from MV to other supplemental O2

Question 8

describe heated high flow nasal cannula as a non-invasive ventilation option and how it helps

Answer 8

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)

Question 9

describe continuous positive airway pressure (CPAP) as a NIV

Answer 9

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

Question 10

describe BiLevel Positive Airway Pressure (BIPAP) as a NIV

Answer 10

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

Question 11

indications for lung sx

Answer 11

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

Question 12

what is a thoracotomy

Answer 12

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

Question 13

what is a video assisted thoracic sx (VATS)

Answer 13

minimally invasive

doesn’t require rib separation

may have mini thoracotomy or other small incision somewhere

Question 14

benefits of VATS instead of open thoracotomy

Answer 14

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

Question 15

thoracotomy precautions

Answer 15

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

Question 16

what is decortication

Answer 16

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

Question 17

what is pleurodesis

Answer 17

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

Question 18

what is a wedge resection

Answer 18

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

Question 19

what is a lobectomy and pneumonectomy

Answer 19

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

Question 20

what is a lung reduction

Answer 20

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

Question 21

stats for lung transplants

Answer 21

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

Question 22

history of lung transplant

Answer 22

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

Question 23

indications for lung transplant

Answer 23

IPF
CF
sarcoidosis/amyloidosis
COPD

Question 24

contraindications to lung transplant

Answer 24

> 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

Question 25

process of a lung transplant

Answer 25

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

Question 26

medications for lung transplants

Answer 26

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

Question 27

complications of lung transplants

Answer 27

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

Question 28

describe a chest tube and its use

Answer 28

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

Question 29

post sx management of chest tube

Answer 29

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

Question 30

what is a pleurX drain

Answer 30

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