Pulmonary Flashcards
1
Q
What to assess for in regards to pulmonary history?
A
- Baseline pulmonary function
- Exercise tolerance, dyspnea, orthopnea, smoking, sleep apnea
- Chronic lung disease
- Severity, meds, recent hospitalizations, frequency of exacerbations, & effective treatment
- Acute lung disease
- Recent URIs, abx, current symptoms
- Previous anesthesia experiences
- Procedures, pulmonary complications, anesthesia technique utilized
- Pts w/ chronic lung dx often have difficulty achieving extubation criteria. a) do you remember if you had a tube inserted into your throat to help you breathe? b) did you have to be placed in ICU after your surgery, 3) did you receive a shot into your back, your hip, or in the surgical area to numb the area and decrease pain? All of these questions provide greater insight into a patient’s medical history.
- Procedures, pulmonary complications, anesthesia technique utilized
- Medical clearance
- Evaluation of current status & therapies
- Availability of lab & diagnostic studies
- “clearance” is not the preferred term. Some pts require optimization prior to sx.Input from a pulmonologist and/or cardiologist might be needed for pts w/ severe respiratory illnesses.
2
Q
What are are some quesitons to ask in regards to obstructive pulmonary disease?
A
problem with getting air out….
- Asthma
- An acute reversible airway obstruction that is accompanied by chronic airway inflammation & hyperreactivity
- Ask about SOB, chest tightness, cough, recent exacerbations, therapy (esp steroids), hospitalizations, intuation
- Chronic Obstructive Pulmonary Disease (chronic bronchitis and emphyema)
- Airflow obstruction – difficulty getting air out
- Ask about smoking hx, dyspnea, cough, wheezing, sputum production, tachypnea, home o2
3
Q
Assessment considerations in restricttive pulmonary disease?
A
- Pulmonary fibrosis, sarcoidosis, obesity
- Reduction in total lung capacity – reduction in all lung capacities
- Proportional decrease in all lung volumes
- Ask about SOB, exercise tolerance, home o2 use
4
Q
Examples of restrictive disease?
A
- Neg press pulm edema
- Kyphoscoliosis
- Pregnancy
- Sarcoidosis
- Pneumothorax
- Pleural effusion
- Ascites
- Neurological disorders (musc dystrophy)
5
Q
Examples of obstructive diseases?
A
Asthma
Chronic bronchitis
Emphysema
6
Q
What to assess for on initial survey of respriation and thorax?
A
Initial survey of respiration & thorax- quickly assess for resp distress
- Inspect color for cyanosis or pallor
- Listen for audible sounds of breathing
- Inspect the neck (accessory muscles)
- Tracheal position
- Observe respirations
- Look directly at the thorax if poss
- Observe the shape of the chest – is it barrel shaped?
- The lateral diameter of the chest in the normal adult is greater than the AP diameter.
- The ratio of its AP diameter to the lateral diameter is ~0.7 to 0.9 and increases w/ age
- Observe for chest deformities – usually present in peds, adolescents, & young adults. Sx avail for excavatum. Both are correctable . even when no corrective action is taken, severe functional limitations rarely experienced
- Pectus carinatum “pigeon chest”
- pectus excavatum” funnel chest”
7
Q
What is pectus carinatum?
A
- Pectus carinatum “pigeon chest”
- Protrusion of sternum.
- Present during adolescent growth spurts ie puberty
- Less common than excavatum
8
Q
What is pectus exacavatum?
A
- Causes a caved in, depressed chest, sometimes the ribs can flare out
- Associated comorbidities & functional limitations rarely exist
- Unbalanced costochondral hypertrophy - exact cause unknown
- ~1 of every 150-1000 births w/ 3:1 male predominance
- Occurs ~ 5-6x more often than pectus carinatum
- Often displays during puberty. Might worsen til ~ 18 yo, although can be present @ birth
- Up to 43% have a family hx of the deformity
- May be associated scoliosis & connective tissue disorders ie Marfans, Ehlers-Danlos, & Noonan’s syndrome
-
Focus on s/s that are assoc w/ these associated dx, can help deter if need addt’l preop testing.
- Ie cardiac manifestations – MV prolapse, AV dilation, & BBB
- Observe for bruising & skin friability which is a sign of ED
- Look for high arched palates –> point to associated syndrome which may need more testing
-
Focus on s/s that are assoc w/ these associated dx, can help deter if need addt’l preop testing.
- In addition to cosmetic considerations, severe PEX may result in cardiac compression & cardiopulmonary impairment
- Symptoms might include:
- Dyspnea
- Loss of endurance
- Chest pain
- Progressive fatigue
- Palpitations, tachycardia
- Syncope
9
Q
What should be considered when evaluating pectus exacavatum
A
Psychological issues can be SIGNIFICANT, esp in adolescents & young adults
- Don’t focus too much attention at the defect. Don’t stare and ask direct questions about it, espeically if a teen or young adult; especially if surgery is unrelated to the defect!
- body image very important at this age
- However, don’t overlook the disorder. If pediatric, ask questions to patient and parent. Do you have pediatrician that you see regularly? Do you play sports? are you able to run around with your friends? have you ever passed out or had chest pain?
- Sx - Nuss procedure & cosmetic procedures commonly used to correct.
- Evaluation:
- Individually tailored to pt’s symptoms & responses to aforementioned questions
- Noncontrast CT–> extent of deformity
- EKG –> arrhythmias
- ECHO –>cardiac compression, MVP
- PFTs
- Exercise stress testing
10
Q
What to assess for on palpation during pulmonary exam?
A
- Areas of tenderness
- Crepitus
- Tactile/ vocal fremitus – palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the pt is speaking. Vibrations should be symmetrical
- Tactile frem- place palms or ulnar surfaces of hands on chest while pt says 99 repeteadly. Alterations in vocal fremitus could suggest PNA, pleural effusion, COPD, etc
11
Q
What to assess for during percussion portion of pulmonary asessment?
A
- Helps you to establish whether the underlying tissues are air filled, fluid filled, or consolidated & ID the pathology to them
- Healthy lungs are resonant
- Fluid filled cavities and solid tissues percuss dullness & can indicate PNA, tumor, or pleural effusion
12
Q
How do you auscultate the lungs?
A
- Breathing normally, mouth open
- 1) apply Diaphragm of stethoscope – directly to pts skin bc over clothes or gowns can alter breath sounds
- 2) listen to ant & post chests
-
3) listen above the clavicles bc the lung apices extend above them
- Apices, middle & lower lung fields, posterior, lateral, & anterior
- 4) Alternate & compare sides- ie if listen to R clavicle, 2nd pt of ausc should be above the L clav & continue stair step technique for all fields
- Quiet respirations first, then deep breaths
13
Q
What are normal breath sounds heard during auscultation?
A
-
Vesicular – heard over most lung fields
- Quality – lower pitch & softer
- Duration – inspiratory sounds last longer than expiratory sounds
-
Bronchovesicular- heart best @ 1st & 2nd ICS anteriorly & between scapulae
- Quality- intermediate pitch & sound
- Duration – expiratory & inspiratory sounds almost equal
-
Bronchial- heard best over the manubrium (larger prox airways)
- Quality – higher, loud, hollow pitch
- Duration – expiatory sounds last longer than inspiratory sounds
14
Q
What are vesicular breath sounds?
A
- heard over most lung fields
- Quality – lower pitch & softer
- Duration – inspiratory sounds last longer than expiratory sounds
15
Q
What are bronchovesicular breath sounds?
A
- heart best @ 1st & 2nd ICS anteriorly & between scapulae
- Quality- intermediate pitch & sound
- Duration – expiratory & inspiratory sounds almost equal
16
Q
What are bronchial breath sounds?
A
- heard best over the manubrium (larger prox airways)
- Quality – higher, loud, hollow pitch
- Duration – expiatory sounds last longer than inspiratory sounds
17
Q
What are adventitious breath sounds?
A
Abnormal breath sounds
-
If bronchial breath sounds are auscultated anywhere other than expected (manubrium is expected)
- Suspect replacement of air-filled lung tissue by consolidation - ex PNA
Adventitious sounds – umbrella term for abnormal breath sounds
-
Wheeze (high pitched), rhonchi (low pitched)
- Musical, usually on expiration but may be heard on inspiration
-
Stridor
- High pitched, usually on inspiration
-
Crackles/ rales – less distinct
- Tearing Velcro open
- Crackles of HF are best heard in the posterior lung fields
- Pulm edema- crackles
- Clearing of crackles, wheezes, or rhonchi after coughing or position change –> inspissated (mucoid) secretions –> present in bronchitis, atelectasis
- Beware of the silent chest (no air mvmt) –> clinical emergency
18
Q
What is a wheeze? rhonchi?
A
Wheeze= high pitched
rhonchi= low pitch
- musical, usually on expiraiton but may be heard on inspiration
19
Q
What is stridor?
A
high pitched, usually on inspiration
20
Q
What are crackles/rales?
A
- Tearing Velcro open
- Crackles of HF are best heard in the posterior lung fields
- Pulm edema- crackles
- Clearing of crackles, wheezes, or rhonchi after coughing or position change à inspissated (mucoid) secretions à present in bronchitis, atelectasis
21
Q
What additional testing may be required in obstructive or restrictive disease?
A
- O2 saturation w/ pulse oximetry
- Chest radiograph
- Arterial blood gases
- Pulmonary function testing
- Chest computed tomography
- Lab testing – CBC, CMP
- EKG
24
Q
Who is at risk for postop pulmonary complications?
A
Categorized as:
- patient related
- age >60
- ASA 3-4
- CHF
- COPD
- Cigarette smoking
- procedure related
- aortic >thoracic> upper abdominal- neuro-peripheral vascular> emergency
- duration of anesthesia >2.5 hours
- general anesthesia
- diagnostic testing related
- only albumin <3.5 is at increase risk for increased pulmonary risks.
32
Q
What is seen in obstructive vs restrictive dx?
FVC?
FEV1?
FEV1/FVC?
FEF25-75%
RV
FRC
TLC?
A
33
Q
What are flow volume loops?
A
- FVL = plots of insp & exp flow on the Y axis against vol on X axis, during the performance of max forced insp & exp maneuvers.
- The contour of the loops assist in dx & localization of airway obsxn bc diff lung disorders produce easily recognized patterns
- Events occurring in the loop:
- 1.) The pt inhales from RV to TLC
- 2.) Then the pt exhales back to RV as fast as possible
34
Q
What does a normal flow volume loop look like?
A
upside down ice cream cone
35
Q
What does an obstructive flow volume loop look like?
A
- In obstructive ds the expiratory limb has a concave shape
- Ex: COPD
- “Someone took a bite of my ice cream cone”
36
Q
What is seen in flow volume loop in restrictive leasions?
A
- In restrictive disease the shape of the loop is similar to the normal loop, just smaller and right shifted
- Ex: Pregnancy
- ”on a restrictive diet you’ll have to eat a smaller ice cream cone”
37
Q
What is seen in flow volume loop with fixed leasions?
A
- With a fixed lesion, the inspiratory and expiratory limbs are flat
- Ex: tracheal stenosis
- “Someone smashed my ice cream cone and it needs to be fixed”
45
Q
What happens in Zone 1 of West Lung Zones?
A
- PA>Pa>Pv
- There is ventilation, but no perfusion= dead space
- Zone 1 does not occur in normal lung
- Is increased by hypotension, PE, or PPV
- To combat Zone 1, the bronchioles of unperfused alveoli constrict to reduce dead space
46
Q
What is Zone 2 of West’s Lung Zones?
A
- Pa>PA>Pv
- There is ventilation and perfusion
“waterfall”
- Think of a waterfall flowing over a dam.
- Pa= height of upstream river
- PA= height of dam
- A greater height of the upstream river = higher rate of water flow over the dam. Like waterfall, BF = directly proportional to differences in Pa – PA. the greater the diff b/w art & alv prs, the greater the BF
53
Q
- A patient is mechanically ventilated. Which interventions will improve the patient’s condition? (Select 2)
- A) disconnect the circuit
- B) decrease respiratory rate
- C) increase inspiratory time
- D) increase inspiratory flow
A
- A & B
- The waveform indicates “breath stacking” (auto-peep). Pts who have obstructive disease require prolonged time to exhale. So this condition could be improved by decreasing RR. If peep rises to dangerous levels. The patient should be disconnected from the ventilator.
- Increasing inspiratory time is another way of saying reducing expiratory timeà would not be beneficial
