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Health Assessment > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

What information do you want to gather during the history of a pulmonary pt?

A
  • Baseline pulmonary function
    • exercise tolerance
    • dyspnea
    • orthopnea
    • smoking
    • OSA
  • chronic lung disease
    • severity
    • medications
    • recent hospitilizations
    • frequency of exacerbations
    • effective treatments
  • Acute lung disease
    • recent URIs
    • antibiiotics
    • current symptoms
  • Previous anesthesia
    • complications?
  • Medical clearance
    • evaluate for current status
    • labs/diagnostic tests
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2
Q

What are the components of physical assessment?

A
  • inspection/ observation
  • auscultation
  • palpation
  • percussion
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3
Q

What can you observe about your pts pulmonary status?

A
  • rate, pattern, effort of respiration
  • tracheal position
  • expansion of thorax and use of accessory muscles
  • characteristics of skin and soft tissues
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4
Q

What do you hear with normal auscultation?

A
  • First you will hear the tracheobronchial tree
    • where: heard best over trachea, right sternoclavicular joint, posterior right interscapular space
    • Quality: higher, hollow pitch; equal on inspiration and expiration w/ short pause
  • Vesicular
    • Where: lung tissue
    • Quality: lower pitched, softer, shorter expiration
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5
Q

You shouldn’t hear bronchial air sounds anywhere other than the bronchial tree. What does it mean if you do?

A
  • It means that there is no ventilation into the alveoli
  • Could be caused by:
    • Consolidation- sounds like low pitched bronchial breathing (pulm edema, etc)
    • Cavitary disease- sounds like high pitched bronchial breathing. (tb, malignant, etc)
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6
Q

What are the abnormal adventitious sounds?

A
  • Wheeze (high pitched), Rhonchi (low pitched)
    • musical, usually on expiration but may be on inspiration
  • Stridor
    • high pitched, usally inspiration
  • Crackles/Rales
    • tearing velcro open
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7
Q

What is the purpose of pulmonary function tests?

When are they indicated?

A
  • Purpose:
    • standardized
    • objective
  • Indication
    • assist in diagnosis of a disease
    • to evaluate a treatment
    • to monitor disease progression
    • Assess the risk- will they tolerate removal of part of lung, etc.
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8
Q

Who would be appropriate patients to do PFTs on?

A
  • Patients with evidence of COPD
  • smokers with a persistent cough
  • wheezing or dyspnea on exertion
  • morbid obesity
  • thoracic surgery patients
  • open upper abdominal procedures
  • patients >70 years
  • Routine PFTs are NOT recommended
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9
Q

What are tests that assess abnormalities in gas exchange?

Mechanical dysfunction?

A
  • Abnormalities of gas exchange
    • ABG
    • pulse oximetry
    • capnography
  • Mechanical dysfunction of lungs and chest well
    • spirometry
  • **All are considered PFTs
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10
Q

What are the normal values for Volume and flow?

How are these determined?

A
  • Spirometry
    • Volume- normal 80-120% of predicted value
    • Flow- normal is 80% of predicted value
  • Predicted values based on:
    • age
    • height/weight
    • gender
    • ethnicity
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11
Q

Quick review of pulmonary disease:

Obstructive

Restrictive

A
  • Obstructive
    • airflow obstruction- chronic bronchitis or emphysema; progressive
    • Asthma- chronic inflammatory disorder; reversible
  • Restrictive
    • proportional decreases in ALL lung volumes
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12
Q

What is Vital capacity?

A
  • Most commonly measured; measured by simple spirometry
  • Maximal inspiration followed by maximal exhalation to RV
    • independent of rate of effort
    • values should decrease as person goes from sitting to supine
  • Normal is >/=80% of predicted value
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13
Q

What is Forced Vital Capacity (FVC)?

How do you interpret the results?

A
  • Pt takes in maximum inspiration and forces exhalation
  • Function of volume/time
  • measures resistance to flow
  • depends on pts effort and cooperation
  • Interpretation:
    • normal: 80-120%
    • Mild: 70-79%
    • Moderate: 50-69%
    • Severe: <50%
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14
Q

What is the Forced expiratory volume in 1 second (FEV1)?

A
  • Volume of air forcefully expired from full inspiration in the first second
  • Normal is 75-80% of FVC
  • Depends on effort and cooperation
  • Interpretation:
    • Normal: >75%
    • Mild: 60-75%
    • Moderate: 50-59%
    • Severe: <49%
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15
Q

How do pulmonary function tests compare btw obstructive and restrictive disease?

(table)

A
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16
Q

What is the Forced expiratory flow 25-75% (FEF25-75%)?

How is it interpreted?

A
  • Mean forced expiratory flow during the middle of the FVC
  • May be independent of effort and shows status of the small airways
  • Sensitive to early stages of obstructive disease
  • More reliable than FEV1/FVC ratio
  • Interpretation:
    • Normal: >60%
    • Mild: 40-60%
    • Moderate: 20-40%
    • Severe: <10%
17
Q

What is Maximum voluntary ventilation (MVV)?

What happens to the MVV with obstructive disease?

Restrictive?

A
  • the largest volume that can be breathed in one minute by voluntary effort
    • test is actually performed over 10, 12, or 15 seconds
  • Normal results may vary up to 3%
  • MVV reduced is obstructive disease
  • MVV normal is restrictive disease
    • might be reduced with muscular disorders due to progressive weakness
  • **not often used anymore, too much variability in results
18
Q

What is the Functional residual capacity (FRC)?

What is its function?

A
  • Volume of gas in the lungs after passive exhalation
    • RV is the volume of gas in lungs after forced maximal expiration
  • Function:
    • It is a poing on the pressure-volume curve for resting ventilation
    • Quantify the degree of pulmonary restriction
19
Q

How is FRC measured?

A
  • Measured indirectly
    • Nitrogen wash-out (breath 100%FiO2
    • Nitrogen analyzer attached to a spirometer
      • Nitrogen measured w/each breath
    • End point is when the alveolar nitrogen concentration falls below 7%, usually takes about 7-10 minutes
      • measure total volume required for wash-out
20
Q

Describe a flow volume loop

A
  • Top part is exhalation, bottom is inhalation
  • steep climb is the effort dependent exhalation
  • flow is L/sec- y axis
  • volume is L- x axis
21
Q

Why is there a curve on the flow volume loop for obstructive disease?

A

because after you force the initial air out, the airways are starting to collaps, decreasing the rate of the rest of the air

???

22
Q

What would you expect a flow volume look like for restrictive disease?

A
  • same shape as normal, but lower volume
23
Q

What does the blood flow through the lungs depend on?

A
  • Blood flow in lungs largely gravity dependent
    • alveolar- capillary beds are softer, less rigid
    • surrounding tissues can cause resistance through the capillaries- can be squished
  • Flood flow depends on relationship btw:
    • pulmonary artery pressure (Ppa)
    • Alveolar pressure (PA)
    • Pulmonary venous pressure (Ppv)
24
Q

What are the different zones of the lungs?

What is different between them?

A
  • Zone 1: PA > Pa> Pv
    • ​most independent on gravity
    • Alveolar pressure is atmospheric
      • Pa < PA does not occur under normal circumstances- seen in shock when pressure isnt high enough to perfuse
      • ventilation, but little perfusion (dead space)
  • Zone 2: Pa >PA > Pv
    • ​Pa pressure increased d/t hydrostatic effect gravity)
    • best matched ventilation and perfusion
    • most alveoli are here
  • Zone 3: Pa >Pv > PA
    • ​Pv >PA
    • perfusion greater than ventilation (shunt)
    • greater change in pressure here during inspiration that at the top, more gas sucked into bases
25
Q

When sitting up and awake,

Where is perfusion lowest?

where are the alveoli compressed?

What do you see when somebody has good compliance?

A
  • Perfusion is lowest at the highest portion of the lung
    • Perfusion increases in more dependent part of lung
  • Alveoli are compressed in the lower parts d/t gravity
  • With good compliance, large TV will reach the bases, which is important b/c the dependent lung has the greatest ventilation and perfusion (gas exchange)
26
Q

What happens to blood flow when supine?

A
  • uniform blood flow from apices to base
  • Anterior : zone 1
  • posterior: zone 3
27
Q

What are the physiologic effects of PPV?

A
  • Increased dead space
    • increase in intrathoracic pressure causes decrease in venous return and CO
    • ventilation with low perfusion causing an increase in V/Q mismatch
  • Potential for alveolar over distension and rupture (barotrauma)
  • risk for atelectasis- with inadequate TVs
28
Q

How can you avoid the negative side effects of PPV?

A
  • Maintain Peak airway pressures < 40 cm H2O
  • Increase FiO2
  • deliver an adequate TV
  • maintain perfusion pressures to the lung
    • fluids
    • pressors
    • comprssion socks
    • trendelenberg- not ideal
  • PEEP
  • assess and reassess
29
Q

How can we maximize pulmonary function for our patients?

A
  • Goal to reduce intraop M&M
    • smoking cessation
      • can reduce carboxyHgb within 24 hrs
    • mobilization of secretions/treat infections
    • bronchospasm treatment
    • improve motivation and stamina
      • deep breathing, IS
30
Q

Timeline of changes after cessation of smoking

A
  • 12-24 hours: will reduce carboxyHgb to normal levels
  • 2-3 weeks: mucociliary function returns; may have increased secretions
  • 6 weeks: reduction in secretions
  • 8 weeks: rate of post-op pulmonary complications decreases
31
Q

How can you help mobilize secretions?

A
  • hydration
  • aerosol therapy
  • mechanical therapy- percussion/vibration
  • mucolytic agents- sometimes cause more problems than it is worth; not good if they dont have a good cough
  • Abx for chronic bronchitis- should be dealt with way before surgyer
32
Q

How can bronchospasm be treated?

A
  • B2 agonists- have them take before surgery
  • anticholinergic compounds
    • ipratroprium- can help prolong effect of B2
  • methylxanthines
  • Corticosteroids
    • minimal systemic absorption from the inhaled steroids
    • wont need stress dose
33
Q

Anesthetic management of Restrictive pulmonary disease?

A
  • Titrate pre-op sedation carefully d/t reduced FRC
  • Nitrous oxide +/-
  • Regional is good unless it goes about T10 b/c they would lose accessory muscles that they probably depend on
  • Inhalation agents have accelerated uptake d/t decreased FRC
  • Must be efficient, will not tolerate long apneic time d/t small FRC
34
Q

How should you plan to ventilate a pt with RLD?

A
  • expect increased peak airway pressure
  • decrease volume to 4-8 ml/kg
  • increase rate 14-18
  • PEEP
35
Q

How does FRC decrease in normal health patients?

when supine

when under GA

how long to recover?

A
  • 10-15% reduction in FRC in supine position
  • addition 5-10% reduction with GA
    • plateau after 10 minutes
  • May take up to 3-7 days to recover FRC after upper abdominal procedure
  • VC may have up to 40% reduction and take up to 14 days to return to normal after an upper abdominal procedure
36
Q

Anesthetic management of Obsturctive lung disease?

A
  • reduce airway reactivity
    • bronchodilator
    • IA good
    • Opioids and lidocaine to prevent problems with manipulation
    • steroids
  • LMAs are good
  • Otherwise avoid spontaneously ventilation under GA
    • may start hyperventilating, may not be able to exhale adequately, causing intrinsic peep
  • Regional anesthesia
    • >T10 will lose accessory muscles that they might depend on
  • Use of nitrous oxide +/-
  • Larger TV
    • keep PIP <40
  • longer expiratory time
    *
37
Q
A

Health Assessment (14 decks)

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