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Advanced Health Assessment > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

What are some basic questions you can ask to a patient with chronic lung disease?

A

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?

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2
Q

What are some basic questions to ask to assess acute respiratory disease?

A

any recent infections? are you on atnibiotics? what are your current symptoms?

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3
Q

What kinds of basic questions could you ask your patient to assess previous anesthesia complications?

A

have you had any complications in the past? prolonged intubations? what kind of anesthesia have you had? family history of anesthetic complications?

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4
Q

What are the components of the observation/inspection portion of the pulmonary assessment?

A

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

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5
Q

What are the components of the auscultation portion of pulmonary assessment?

A

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

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6
Q

Where are bronchial breath sounds heard best?

A

trachea
right sternoclavicular joint
posterior R interscapular space

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7
Q

What is the pitch of bronchial breath sounds?

A

high pitch

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8
Q

Where are vesicular breath sounds normally heard?

A

over the lung tissue

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9
Q

What do vesicular breath sounds sound like?

A

low pitched, softer, with shorter expiration

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10
Q

What are abnormal findings when auscultating a patients lungs?

A

hearing bronchial breath sounds anywhere other than normal

absent ventilation in the alveoli

low pitched bronchial breathing (consolidations)

high pitched bronchial breathing (cavitary disease)

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11
Q

What are examples of adventitious breath sounds?

A

wheezing, rales, stridor

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12
Q

Who is an appropriate candidate for pulmonary function tests?

A 
patients with evidence of COPD
smokers with persistent cough
wheezing
dyspnea on exertion
morbid obesity
thoracic surgery
open upper abdominal surgery
patients >70
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13
Q

What types of diagnostic tests would assess for abnormalities in gas exchange?

A

ABG
pulse ox
capnography

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14
Q

What type of diagnostic tests assess mechanical dysfunction of the lungs and chest wall?

A

spirometry

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15
Q

What are the limitations of spirometry testing?

A

it can be subjective

it is patient effort and cooperation dependent

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16
Q

What are normal values for spirometry?

A

volume - should be 80-120% of predicted values

flow - should be 80% of predicted values

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17
Q

How are normal values for spirometry determined?

A

based on age, gender, height/weight and ethnicity

18
Q

Vital Capacity

A

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

19
Q

What are some questions you can ask to assess baseline pulmonary function?

A

SOB, dyspnea, orthopnea, functional level, smoking history, sleep apnea

20
Q

FORCED VITAL CAPACITY (FVC)

A

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

21
Q

Forced expiratory volume over 1 second (FEV1)

A

measures the volume of air forcefully expired in the first second

effort and cooperation dependent

normal value is >80% of the FVC

22
Q

How do lung volumes change in restrictive disease?

A

FVC, FEV1, FRC and TLC all decrease!!

FEV1/FVC ratio and FEF25-75 will not change!!

23
Q

How will lung volumes change in obstructive disease?

A

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

24
Q

What is FEF25-75?

A

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%

25
Q

What is MVV?

A

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

26
Q

FRC - functional residual capacity

A

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

27
Q

Residual volume

A

volume of gas left in the lungs after forceful maximal expiration

28
Q

Describe pressure changes in the 3 zones of the lung in respect to blood flow and ventilation?

A

Zone 1 - PA > Pa > Pv

Zone 2 - Pa > PA > Pv

Zone 3 - Pa > Pv > PA

29
Q

Where does the best ventilation/perfusion matching occur in the lung?

A

in zone 2

30
Q

What are the pulmonary effects of PPV?

A 
increased V:Q mismatch
increased barotrauma
increased dead space
increased risk of atelectasis
increased perfusion to the dependent lung
31
Q

How can you combat the pulmonary physiologic effects of PPV?

A

increased PEEP and FiO2
decrease peak airway pressures
deliver appropriate tidal volumes
maintain perfusion pressures to the lung

32
Q

What are the cardiovascular effects of PPV?

A

decreased preload, CO and blood pressure

increased R to L shunt in patients with an atrial septal defect

33
Q

How can you combat the cardiovascular responses to PPV?

A

increase fluid volume as required
position them appropriately to increase venous return to the heart
intropes, ALPHA and BETA support as necessary

34
Q

How can the CRNA maximize pulmonary function in the patient pre-operatively?

A

quit smoking
mobilize secretions and treat infections
treat bronchospasm (should start 2-3 days before)
improve motivation and stamina with IS

35
Q

What are the guidelines for smoking cessation?

A

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

36
Q

What are some ways to mobilize secretions?

A

mucolytic agents
hydration
mechanical chest PT
aerosol therapy

37
Q

What are the 4 treatments for bronchospasm?

A

B2 agonists
anticholinergic
methylxanthines (theophylline or aminophylline)
corticosteroids

38
Q

What are the treatments for a reactive airway?

A

increase concentration of anesthetic gas
bronchodilators
corticosteroids
lidocaine with epi into the airway

39
Q

How does your anesthetic management change in a patient with restrictive lung disease?

A

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

40
Q

How are your vent settings changed in restrictive disease?

A

plan for higher peak airway pressures
decrease tidal volume (4-8mL/kg) and increase ventilation rate (14-18)
add PEEP to improve oxygenation

41
Q

How does having an obstructive respiratory disease affect your anesthetic management?

A

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

42
Q

How should your ventilator settings change in managing a patient with obstructive lung disease?

A

larger tidal volumes, slower respiratory rate, keep PIP below 40, increase your I:E ratio

Advanced Health Assessment (10 decks)

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