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Anesthesia Concepts 2 > Pulmonary Assessment > Flashcards

Pulmonary Assessment Flashcards

1
Q

Pulmonary History

A

Baseline pulmonary function:exercise tolerance, dyspnea, orthopnea, smoking history, sleep apnea
Chronic lung disease: severity, medications hx, recent hospitalizations, frequency of exacerbations, and effective treatment
Acute lung disease: recent URI’s, abx, current symptoms
Previous anesthesia experiences: procedures, pulmonary complications, anesthesia technique utilized
Medical clearance:evaluations of current status and therapies
availability of laboratory and diagnostic studies
*Smokers

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2
Q

Physical Assessment Observation and Inspection:

A 
Observation / Inspection:
Rate, pattern and effort of respiration
Tracheal position
Expansion of thorax and use of accessory muscles of respiration
Characteristics of skin and soft tissue
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3
Q

Physical Assessment Auscultation:

A

Breathing normally, mouth open
Diaphragm of stethoscope
Auscultate apices, middle and lower lung fields posterior, laterally and interiorly
Alternate and compare sides
Quiet respirations first, then deep breaths
Bronchial

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4
Q

What are Vesicular sounds?

A 
Vesicular
lung tissue
Quality: 
lower pitched
Softer
expiration shorter
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5
Q

What is normal auscultation of the bronchial tree sound like?

A 
Tracheobronchial tree
Heard best: 
trachea, right sternoclavicular joint, posterior right interscapular space
Quality:  
higher pitch
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6
Q

What are abnormal auscultation sounds?

A 
Bronchial Breath Sounds 
Anywhere other than expected
No ventilation into alveoli
Consolidation
low pitched bronchial breathing
Cavitary Disease
high pitched bronchial breathing
Adventitious sounds: Wheeze, Stridor, Crackles
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7
Q

Pulmonary Function Test Purpose and Indication

A 
Purpose
Standardized
Objective
Indication
Assist in diagnosis of disease
Evaluate treatment
Disease progression
Assessing the risk
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8
Q

Who are appropriate candidates for PFTs?

A 
Appropriate candidates for testing:
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 of age
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9
Q

How do we classify Pulmonary function Tests? 2 ways.

A
  1. Tests that assess abnormalities of gas exchange:
    ARTERIAL BLOOD GAS
    PULSE OXIMETRY
    CAPNOGRAPHY
  2. Tests that assess mechanical dysfunction of the lungs and chest wall:
    SPIROMETRY
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10
Q

What are the normal values of Spirometry and what are the predicted values based on?

A 
Spirometry
Volume –Normal 80-120% of predicted value
Flow –Normal 80% of predicted value
Predicted values based on
Age
Height/Weight
Gender
Ethnicity
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11
Q

Obstructive v. Restrictive Pulmonary Disease

A 
Obstructive disease
Airflow obstruction
chronic bronchitis or emphysema 
Asthma 
chronic inflammatory disorder 
Restrictive disease
Proportional decrease in all lung volumes
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12
Q

What is Vital Capacity measured by and what is it, whats the normal?

A

Most commonly measured
Measured by simple spirometry

Maximal inspiration followed by maximal exhalation to RV
Independent of rate of effort

Values decrease as subject goes from sitting to supine position

NORMAL is >/=80% of the predicted value

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13
Q

What is FVC, and what are the interpretations of the percentages predicted?

A 
Forced Vital Capacity (FVC)
Max insp. with forced exp.
Function of volume/time
Measures resistance to flow
Effort and cooperation dependent
Interpretation of % predicted:
80-120%       Normal
70-79%	      Mild 
50%-69%      Moderate
<50%	      Severe
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14
Q

What is FEV1 and what are the interpretations of % of the FEV1/FVC ratios:

A

Forced expiratory volume in 1 second: (FEV1)
Volume of air forcefully expired from full inspiration in the first second
Normal is 75-80% of FVC
Effort and cooperation dependent

Interpretation of % FEV1/FVC:
>75%	    Normal
60%-75%    Mild 
50-59%       Moderate 
<49%	   Severe                 		   obstruction
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15
Q

What is FEF25-75 and what do the vales mean?

A

Forced expiratory flow 25-75% (FEF25-75)
Mean forced expiratory flow during middle of FVC
May reflect effort independent expiration and the status of the small airways
Sensitive in early stages of obstructive disease
More reliable than FEV1/FVC
Interpretation of % predicted:
>60% Normal
40-60% Mild
20-40% Moderate
<10% Severe obstruction

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16
Q

What is Maximum Voluntary Ventilation?

A

Maximum voluntary ventilation (MVV)
MVV is 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 30%
MVV reduced in OBSTRUCTIVE disease
MVV normal in RESTRICTIVE disease

17
Q

What is FRC?

A

Volume of gas in the lungs after passive exhalation (residual volume is the volume of gas in the lungs after forced maximal expiration)
Function:
Point on the pressure-volume curve for resting ventilation
Quantify the degree of pulmonary restriction

18
Q

How is FRC measured?

A

Measured:
Indirectly
Nitrogen wash-out
Nitrogen analyzer attached to a spirometer
End point = alveolar nitrogen concentration falls below 7%, usually takes about 7-10 minutes

19
Q

What does the flow volume curve look like for restrictive?

A

Spirometry results
Rapid upstroke
Low volume

20
Q

What is the distribution of blood flow in the zones of the lung?

A 
Zone 1:  
PA>Pa>Pv
Zone 2:  
Pa>PA>Pv
Zone 3:  
Pa>Pv>PA
21
Q

What does Zone 1 in the lung represent?

A

Zone 1
Pulmonary artery (Pa) pressure falls below alveolar pressure (PA)
DOES NOT occur under normal circumstances
Decrease BP < alveolar pressure
Increase in alveolar pressure

22
Q

What does zone 2 and 3 in the lung represent?

A

Zone 2
Pulmonary artery pressure increases due to hydrostatic effect (gravity) and now exceeds alveolar pressure

Zone 3
Venous pressure now exceeds alveolar pressure

23
Q

What is the normal pulmonary blood flow?

A 
UPRIGHT POSITION:
Gravity
SUPINE POSITION:
Uniform blood flow from apices to base
Anterior v posterior
24
Q

When sitting up, awake and breathing spontaneously what the ventilation and perfusion like?

A

When sitting up, awake and breathing spontaneously
Ventilation smallest at highest portion of lung
Ventilation increases in more dependent part of lung
Alveoli most compressed d/t gravity
Good compliance
Perfusion increases in more dependent part of lung.

25
Q

What are the pulmonary physiological effects of PPV?

A

Increased:
Risk for atelectasis
Increase in blood flow to the dependent lung
Ventilation to the independent areas causing an increase in V/Q mismatch.
Dead space
Potential for barotrauma

26
Q

What are treatment options for the pulmonary physiologic effects of PPV?

A 
Peak airway pressure
Deliver an adequate TV
Maintain perfusion pressures to the lung
PEEP
FiO2
Assess & reassess
27
Q

What are the cardiovascular effects of PPV and it’s treatment?

A 
Cardiovascular effects
Decreased 
Preload
Blood pressure
Increase
Right to left shunt with atrial-septal defect
Treatment: Position
Fluid administration
Pharmacology
Alpha & Beta stimulants
Inotropic support
28
Q

What are the goals and methods to maximize pulmonary function?

A

Goal:
Reduce intraoperative and postoperative morbidity and mortality

Methods:
Smoking cessation
Mobilization of secretions/Treat infection
Bronchospasm treatment
Improve motivation and stamina
29
Q

What are the timelines for smoking cessation?

A

12 - 24 hours = will reduce carboxyhemoglobin levels to normal
2-3 weeks mucociliary function returns; increased secretions
4 weeks = reduction in secretions
8 weeks = rate of postoperative pulmonary complications decreases

30
Q

How do you treat infections and mobilize secretions?

A 
Antibiotic therapy in the presence of Chronic bronchitis
Mobilization of secretions
Mucolytic agents ????
Hydration
Aerosol therapy
Mechanical therapy
31
Q

How do you treat bronchospasm?

A

β2 –Sympathomimetic (stimulate)
Anticholinergic compounds
Methylxanthines
Corticosteroids

32
Q

Anesthetic Management for Restrictive Pulmonary Disease

A

Preoperative sedation
titrate carefully due to reduced FRC
Nitrous Oxide +/-
Regional anesthesia
>T10 level = loss of accessory respiratory muscles may be crucial to spontaneous ventilation in these patients
Inhalation agents have accelerated uptake due to decreased FRC
Efficiency
decreased FRC=lower O2 stores = SaO2 drops quickly with apnea despite preoxygenation

33
Q

What do you expect when you are mechanically ventilating someone with restrictive pulmonary disease?

A

Expect increased peak airway pressures
Decrease volume (4-8 ml/kg)
Increase respiratory rate (14-18 bpm)
PEEP

34
Q

What are the anesthesia effects on FRC and VC in the patient with restrictive pulmonary disease?

A

Anesthesia effects on FRC
Normal healthy patients
10-15% reduction in supine position
Additional 5-10% reduction with GA
Plateau develops after 10 minutes regardless of ventilation
May take 3-7days to recover after upper abdominal procedures
VC may have up to a 40% reduction and take up to 14 days to return to normal after an upper abdominal procedure

35
Q

What are things to keep in mind when managing the patient with obstructive pulmonary disease?

A 
1. Reducing airway reactivity 
Aggressive bronchodilator therapy
High alveolar concentrations of IA
IV opioids/lidocaine prior to airway manipulation
Single dose corticosteroids
2. Avoid spontaneous ventilation with GA
3. Regional anesthesia 
>T10 level = loss of accessory respiratory muscles may be crucial to spontaneous ventilation in these patients
4. Use of Nitrous Oxide +/-
36
Q

What do you do with tidal volume and expiratory time with the patient with obstructive pulmonary disease?

A
  1. Positive pressure ventilation:
    Large tidal volume
    slow respiratory rate
    Keep PIP below 40cmH20
  2. Goal = Balance
    Avoid high peak airway pressures; allow longest possible expiratory time
    Intrinsic PEEP may occur due to air trapping

Anesthesia Concepts 2 (10 decks)

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