Pulmonary Flashcards
What are some basic questions you can ask to a patient with chronic lung disease?
when were they diagnosed? how severe is it? what medications are they on? do they have flare-ups? when do they have flare-ups? what triggers flare-ups? effective treatments for flare-ups?
What are some basic questions to ask to assess acute respiratory disease?
any recent infections? are you on atnibiotics? what are your current symptoms?
What kinds of basic questions could you ask your patient to assess previous anesthesia complications?
have you had any complications in the past? prolonged intubations? what kind of anesthesia have you had? family history of anesthetic complications?
What are the components of the observation/inspection portion of the pulmonary assessment?
look at the skin and soft tissues, shape of the chest, tracheal position
rate and pattern of respiration
effort of respiration
use of accessory muscles
What are the components of the auscultation portion of pulmonary assessment?
quiet respirations first, then deep breaths
listen top to bottom, right to left
listen anterior, posterior, lateral lung fields
use the diaphragm of the stethoscope
Where are bronchial breath sounds heard best?
trachea
right sternoclavicular joint
posterior R interscapular space
What is the pitch of bronchial breath sounds?
high pitch
Where are vesicular breath sounds normally heard?
over the lung tissue
What do vesicular breath sounds sound like?
low pitched, softer, with shorter expiration
What are abnormal findings when auscultating a patients lungs?
hearing bronchial breath sounds anywhere other than normal
absent ventilation in the alveoli
low pitched bronchial breathing (consolidations)
high pitched bronchial breathing (cavitary disease)
What are examples of adventitious breath sounds?
wheezing, rales, stridor
Who is an appropriate candidate for pulmonary function tests?
patients with evidence of COPD smokers with persistent cough wheezing dyspnea on exertion morbid obesity thoracic surgery open upper abdominal surgery patients >70
What types of diagnostic tests would assess for abnormalities in gas exchange?
ABG
pulse ox
capnography
What type of diagnostic tests assess mechanical dysfunction of the lungs and chest wall?
spirometry
What are the limitations of spirometry testing?
it can be subjective
it is patient effort and cooperation dependent
What are normal values for spirometry?
volume - should be 80-120% of predicted values
flow - should be 80% of predicted values
How are normal values for spirometry determined?
based on age, gender, height/weight and ethnicity
Vital Capacity
most commonly measured using simple spirometry
it is maximal inspiration followed by maximal expiration, and is independent of the rate
values will decrease as the subject lies down
normal = 80% of predicted value
What are some questions you can ask to assess baseline pulmonary function?
SOB, dyspnea, orthopnea, functional level, smoking history, sleep apnea
FORCED VITAL CAPACITY (FVC)
maximal inspiration with a forced exhalation
measures resistance to flow
determines difference between restrictive and obstructive disease
it is effort and cooperation dependent
a normal value is 80-120% of predicted
Forced expiratory volume over 1 second (FEV1)
measures the volume of air forcefully expired in the first second
effort and cooperation dependent
normal value is >80% of the FVC
How do lung volumes change in restrictive disease?
FVC, FEV1, FRC and TLC all decrease!!
FEV1/FVC ratio and FEF25-75 will not change!!
How will lung volumes change in obstructive disease?
normal or slightly increased FVC, FRC and TLC
normal or slightly decreased FEV1
INCREASED residual volume
DECREASED FEV1/FVC ratio and FEF25-75, VC and ERV
What is FEF25-75?
mean Forced Expiratory Flow during the middle of the FVC
can be effort independent
most sensitive in the early stages of obstructive disease
more reliable than FEV1/FVC
normal value is >60%
What is MVV?
maximum voluntary ventilation: largest volume that can be breathed in one minute by voluntary effort
measures pulmonary endurance and the elastic properties of the lung
normal results can vary by up to 30%
MVV is reduced in obstructive disease
MVV is normal in restrictive disease
FRC - functional residual capacity
volume of gas remaining in the lungs after passive exhalation
used to quantify the degree of pulmonary restriction
measured indirectly using nitrogen washout attached to a spirometer
Residual volume
volume of gas left in the lungs after forceful maximal expiration
Describe pressure changes in the 3 zones of the lung in respect to blood flow and ventilation?
Zone 1 - PA > Pa > Pv
Zone 2 - Pa > PA > Pv
Zone 3 - Pa > Pv > PA
Where does the best ventilation/perfusion matching occur in the lung?
in zone 2
What are the pulmonary effects of PPV?
increased V:Q mismatch increased barotrauma increased dead space increased risk of atelectasis increased perfusion to the dependent lung
How can you combat the pulmonary physiologic effects of PPV?
increased PEEP and FiO2
decrease peak airway pressures
deliver appropriate tidal volumes
maintain perfusion pressures to the lung
What are the cardiovascular effects of PPV?
decreased preload, CO and blood pressure
increased R to L shunt in patients with an atrial septal defect
How can you combat the cardiovascular responses to PPV?
increase fluid volume as required
position them appropriately to increase venous return to the heart
intropes, ALPHA and BETA support as necessary
How can the CRNA maximize pulmonary function in the patient pre-operatively?
quit smoking
mobilize secretions and treat infections
treat bronchospasm (should start 2-3 days before)
improve motivation and stamina with IS
What are the guidelines for smoking cessation?
quitting 12-24 hours before will decrease carboxyHGB levels
2-3 weeks before will actually increase secretions
4 weeks will reduce secretions
8 weeks is IDEAL to decrease rate of post op pulmonary complications
What are some ways to mobilize secretions?
mucolytic agents
hydration
mechanical chest PT
aerosol therapy
What are the 4 treatments for bronchospasm?
B2 agonists
anticholinergic
methylxanthines (theophylline or aminophylline)
corticosteroids
What are the treatments for a reactive airway?
increase concentration of anesthetic gas
bronchodilators
corticosteroids
lidocaine with epi into the airway
How does your anesthetic management change in a patient with restrictive lung disease?
carefully titrate sedatives r/t reduced FRC
nitrous oxide isn’t indicated
regional anesthesia may knock out accessory muscle use
inhaled agents have accelerated uptake r/t reduced FRC
O2 sat will drop quickly r/t decreased FRC so preoxygenate well
How are your vent settings changed in restrictive disease?
plan for higher peak airway pressures
decrease tidal volume (4-8mL/kg) and increase ventilation rate (14-18)
add PEEP to improve oxygenation
How does having an obstructive respiratory disease affect your anesthetic management?
implement the 4 methods to reduce airway reactivity
avoid spontaneous ventilation under general anesthesia r/t air trapping
regional anesthesia may inactivate their accessory muscles
use of nitrous oxide is not indicated
How should your ventilator settings change in managing a patient with obstructive lung disease?
larger tidal volumes, slower respiratory rate, keep PIP below 40, increase your I:E ratio
