Leo-Pulmonary Assessment Flashcards
What are the 3 main things to consider for pulmonary Assessment?
1.Determine patient’s baseline
2.Recent changes in patient’s pulmonary
status:How would these changes affect the anesthetic
plan
3.Assess risk for pulmonary complications
Length of Surgery – risk
Increase after 2-3hrs
What further increases risk of pulmonary complications?
Increase Risk when incision approaches diaphragm
What is decrease after long surgery (pulmonary)?
FRC and postop VC
Pulmonary assessment
CCC SSSSS REM
– Current or Recent upper respiratory infection?
– Cough – productive? Need to be optimized before surgery?
– Coexisting diseases
– Shortness of breath (dypsnea/orthopnea) – Sleep apnea – Snoring – Stridor, wheezing – Smoking: Tobacco Use
– Recently hospitalized fordisease/infection – Exercise tolerance –Medications ■ What meds and their actions ■ Effectiveness for patient
Even in smokers, with no chronic
lung disease, Effect of smoking?
Smoking increases carboxyhemoglobin levels, decreases ciliary function, increases sputum production, stimulates CV system
Smoke-free interval of 12-18 hours shows
significant declines in carboxyhgb & normalization of
oxygen-HGB dissociation curve
■ 8 wks smoke free:
improves ciliary & small airway function; & decreases
risk of post-op pulm. complications.
– Increased reactivity
CXR and anesthetic plan
Only 5% had an impact on surgical/anesthetic plan
Physical Pulmonary Assessment (RCASSSWCT)
Respiratory rate (RR) ■ Conversation ■ Auscultation of Lung Sounds ■ Skin color ■ Size/shape of chest ■ Work of breathing ■ Clubbing/ nail color ■ Tongue & Sublingual area
Surgical Physiologic Changes in Pulmonary Function mainly 2 types of surgeries
Abdominal and Thoracic surgeries
Surgical Physiologic Changes in Pulmonary Function Diaphragm change?
Diaphragmatic dysfunction
Surgical Physiologic Changes in Pulmonary Function TV
Decreased
Surgical Physiologic Changes in Pulmonary Function RR
Increased
Surgical Physiologic Changes in Pulmonary Function FRC FRC
Decreased FRC (up to 60-70%)
Surgical Physiologic Changes in Pulmonary Function TLC
Decreased TLC
Surgical Physiologic Changes in Pulmonary Function alveolar -arterial O2 tension
Increased Alveolar-to-arterial O2 tension gradient
________should be treated with antibiotics before undergoing surgery
■ Infections
How does Chest physiotherapy help–
improve sputum clearance & bronchial drainage
Treat cor pulmonale with
diuretics, dig, oxygen
Preop Assessment Goals
■ Bronchodilation therapy ■ Stop smoking ■ Steroid therapy ■ Correct hypoxemia ■ Relieve bronchospasm
Other things to consider
Procedure ■ Position ■ Estimated & Allowable Blood loss ■ Pain Control ■ Need for paralysis
General Anesthesia: on airway
Provides controlled airway to deliver desired oxygen
concentration
What are the benefits of Volatile Anesthetics
– Good bronchodilators
– Can even be used to treat status asthmaticus
– Beta2-adrenergic stimulation
■ Good choice for respiratory compromised patient
Local / Regional Anesthesia
Good choice when trying to avoid possibility
of bronchospasm d/t instrumentation
Local / Regional Anesthesia
High levels of blockade can produce
severe anxiety & initiate bronchospasm
LA Can block sympathetic input to lungs leading
even leading to increased airway resistance
Patients at Increased Risk for Pulmonary Complications
COUPLES
COPD /Cardiac disease Obese Upper abdominal surgery Prolonged bed rest Long surgery Elderly Smokers
Patients at greatest risk for complications are
those with
preop pulmonary function measurements less than 50% of predicted
Vesicular
■ NORMAL
– inspiration/expiratory ratio of 3 to 1 (I:E of 3:1)
Over most of both lungs Which bronchial sounds
Vesicular
■ Inspiratory sounds last longer then expiratory
Vesicular
Soft sound with relatively low pitch
Vesicular
Distinct pause between I/E
Bronchial
Expiratory sounds last longer than inspiratory (1:3)
Bronchial
Bronchial breath sounds other than close to the trachea
may indicate
pneumonia, atelectasis, pleural effusions
High pitch
Bronchial
Breath sounds with high intensity
Bronchial
Abnormal in the lung periphery and may indicate an early infiltrate or partial atelectasis
Bronchovesicular
Inspiratory & expiratory almost Equal
Bronchovesicular
Mixture of the pitch of the bronchial breath sounds
heard near the trachea and the alveoli with the vesicular sound
Bronchovesicular
Medium intensity
Bronchovesicular
Medium Pitch
Bronchovesicular
Heard between scapula & in 1st & 2nd interspaces
anteriorly
Bronchovesicular
Signs of Inadequate Airway pediatric
Stridor
■ Noisy respirations
■ Flaring of nares
■ Labored breathing with use of accessory
muscles (Supraclavicular& intercostalretractions
Signs of Inadequate Gas Exchange
Tachypnea ■ Decreased PaO2 ■ Increased dead space ■ Central cyanosis ■ Chest infiltrates on x-ray evaluation
Inadequate Ventilation manifestations of
Obstructed airway
Chest wall and inadequate ventilation
Paradoxical motion involving significant portion of chest
wall
PaO2, PaCo2, pH
PaO2 decreased
PaCo2 increased
pH decreased
Central cyanosis associated with
inadequate ventilation
Normal FRC =
30 mL/Kg (2-2.5L inaverage person)
Associated with decreased FRC
FRC ↓ in supine position during general anesthesia & ARDS
PEEP: How does it help in supine position
↑ FRC & ↓ airway closure
Preoxygenate/ denitrogenate to keep Expired oxygen
> 90%
After general anesthesia, how long does it take for FRC to return to normal
FRC can take 2 weeks to return to baseline after GETA
Asthma is a
Chronic airway inflammation characterized by exacerbations & remissions
Can cause bronchospasm
Manipulation &/or intubation of airway can cause
Bronchospasm
Asthma and CO2 retention
CO2 retention is late finding in these patients
– May be hypocarbic with respiratory alkalosis d/t
hyperventilation
Solubility of CO2 vs O2
– 20X more soluble than O2
Asthma : What is universal finding during attack
hypoxemia
During interview for asthma; Determine?
Inciting factors o Severity o Reversibility o Current status o Last attack (May be hyperreactive for weeks!)
For asthma know the last time they
Hospitalizations, bronchodilator use, systemic
steroid use
What are the 3 Early signs of an asthma attack under general anesthesia
- Increased peak airway
pressure - Alteration of expiratory plateau on capnography
- Hypoxemia occurs as the attack progresses and
worsens
COPD Criteria to postpone surgery
Elective surgery is postponed: – Severe dyspnea – Wheezing – Pulmonary congestion – Hypercarbia (paCO2>50 mm Hg)
“Pink-puffers” - ________appearance
acyanotic
Exhale thru pursed lips (PEEP)
Pink Puffers
Pink puffers are COPD with
– Advanced disease, yet preserved arterial O2 tension until very late in disease
What is the hallmark of chronic air flow obstruction?
Decrease in Forced Expiratory Volume (FEV1)/Forced Vital Capacity ratio
In COPD there is diminished flow in
Diminished airflow at all lung volumes
May have hyperinflation & gas trapping
COPD
CXR- COPD changed
flat diaphragms, hyperlucent lung fields, heart appears
small, decreased pulm. vasculature
COPD patients May have pulm. bullae which put them at risk
– high risk of pneumothoraxes intraop, especially with positive pressure
Characteristics of Blue Bloaters
“Blue-Bloaters” – cyanotic
– Arterial O2 desaturation (even early in disease)
– Bloated appearance
Chronic Bronchitis
Copious secretions → occlude airways
– d/t proliferation & hypertrophy of bronchial goblet cells; hyperreactivity of bronchial smooth muscle
– Chronic productive cough/wheeze
Blue bloaters may have RHF with
Possible right-sided failure, cor pulmonale
– Peripheral edema
– Increased hepatojugular reflux
In chronic Bronchitis: Lung volume
– Near normal in chronic bronchitis (except acute
exacerbation)
In emphysema :lung volume
Increased TLC, Increased FRC, Increased RV in
emphysema
Beware of too much oxygen for COPD why?
– Can dangerously elevate PaO2 if pts are CO2 retainers
■ Depend on chemoreceptors to make them breathe when hypoxic
– Elevating PaO2 above 60 mmHg can lead to respiratory failure
Acute Intrinsic Pulmonary Disorders
– Pulmonary edema
– ARDS
– Infectious pneumonia
– Aspiration pneumonitis
Chronic Intrinsic Pulmonary Disorders
– Interstitial lung disease
– Chronic inflammation of alveolar walls, & progressive
pulmonary fibrosis.
Acute Intrinsic Pulmonary Disorders: surgery
no, postpone elective
Preop treatment of:
– Heart failure – Fluid overload – Optimize oxygenation & ventilation – Decompress abdomen, drain ascites – Use PEEP (helps c/restrictive airway disease)
Chronic Intrinsic pulmonary disorders you will see on CXR
– CXR –”Ground-glass to honeycomb”
Late stage of chronic intrinsic pulmonary disorders
In late stages, signs of right ventricular failure/cor pulmonale
Extrinsic Restrictive Pulmonary Disorders
–Pleural effusions – Pneumothorax – Mediastinal mass – Kyphoscoliosis – Pectus excavatum – Neuromuscular disorders – Marked obesity – Increased intraabdominal pressure ■ Ascites, pregnancy, bleeding, pneumoperitoneum
FEV1: What is it?
forced expiratory volume in one second
– total volume of air a patient can exhale in the first second during maximal effort
FVC: What is it
forced vital capacity: total volume of air a patient can exhale for the total duration of the test during maximal effort
The percentage of the FVC expired in one second
FEV1/FVC ratio
FEF25–75%:
forced expiratory flow over the middle one-half of the FVC
FEF25–75%: is the average flow from the point at which
– Average flow from the point at which 25% of the FVC has been exhaled to the point at which 75% of the FVC has been exhale
Determine If the FEV1/FVC Ratio Is Low
Obstructive?
National Asthma Education and Prevention Program
Gold Criteria <0.70 (70% obstructive)
< 85% (0.85)
What is the best test for early stage COPD
■ FEF25-75% Decreased
Obstructive: VC is
Normal or Decreased
Restrictive what is decreased
VC, TLC, RV
Obstructive: RV is
Increased
FEV1/FVC in obstructive
Decreased
FEV1/FVC in Restrictive
normal or INCREASED
TLC in obstructive
Normal or increased
Restrictive Disease
TLC - < 80% of predicted in age
