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health assessment exam 2 > Pulmonary Assessment > Flashcards

Pulmonary Assessment Flashcards

1
Q

What are the components of a pulmonary history?

A
  • Baseline pulmonary function
  • History of chronic lung disease
  • History of acute lung disease
  • Previous anesthesia experiences
  • Medical clearance
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2
Q

What are you observing during the observation/inspection part of the pulmonary assessment?

A
  • 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

What should be auscultated during the pulmonary physical exam?

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
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4
Q

Describe normal bronchial auscultation.

A
  • Heard over the tracheobronchial tree
  • Heard best at the trachea, right sternoclavicular joint, posterior right interscapular space
  • Higher pitch quality
  • Inspiration and expiration relatively equal
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5
Q

Describe normal vesicular auscultation

A
  • Auscultation of lung tissue
  • Lower pitch quality, softer
  • Expiration shorter
  • No pause between inspiration and expiration
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6
Q

When are bronchial breath sounds abnormal?

A

When they are heard anywhere other than over the tracheobronchial tree

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7
Q

What is auscultated during consolidation?

A

Low pitched bronchial breathing

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8
Q

What is auscultated during cavitary disease?

A

High pitched bronchial breathing

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9
Q

What are some examples of adventitious breath sounds?

A
  • Wheeze
  • Stridor
  • Crackles
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10
Q

What are indications for pulmonary function testing?

A
  • To assist in diagnosis of disease
  • To evaluate treatment
  • To evaluate disease progression
  • To assess perioperative risk
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11
Q

Who are appropriate candidates for pulmonary function testing?

A
  • Patients with evidence of COPD
  • Smokers with a persistent cough
  • Wheezing or dyspnea on exertion
  • Morbid obesity (restrictive disorder)
  • Thoracic surgery patients
  • Open upper abdominal procedures
  • Patients >70 years of age
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12
Q

What are the two classifications of pulmonary function testing?

A
  1. Tests that assess abnormalities of gas exchange.

2. Tests that assess mechanical dysfunction of the lungs and chest wall.

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13
Q

What pulmonary function tests are classified as tests that assess abnormalities of gas exchange?

A
  • ABGs
  • Pulse Ox
  • Capnography
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14
Q

What pulmonary function tests assess mechanical function of the lungs and chest wall?

A

-Spirometry

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15
Q

What is the normal volume and flow ranges for spirometry?

A
  • Normal volume is 80-120% of predicted value
  • Normal flow is 80% of predicted value
  • Predicted values are based on age, height/weight, gender, ethnicity
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16
Q

What are examples of obstructive diseases?

A
  • Chronic bronchitis or emphysema

- Asthma (chronic inflammatory disorder)

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17
Q

What happens to lung volumes in restrictive disease?

A

Proportional decrease in all lung volumes

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18
Q

What is vital capacity?

A

Maximal inspiration followed by maximal exhalation to RV

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19
Q

What is forced vital capacity?

A

Max inspiration with forced expiration.

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20
Q

What is normal, mind, moderate and severe FVC?

A

Normal: >80%
Mild: 70-79%
Moderate: 50-69%
Severe: <50%

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21
Q

What is FEV1?

A

The volume of air forcefully expired from full inspiration in the first second.

22
Q

What is normal, mild, moderate, and severe FEV1/FVC ratio?

A

Normal: >75%
Mild: 60-75%
Moderate: 50-59%
Severe: <49%

23
Q

What is the FEF 25-75?

A

Forced expiratory flow 25-75:

-Mean forced expiratory flow during middle of FVC

24
Q

What does FEF 25-75 reflect?

A

Effort independent expiration and the status of the small airways.

25
Q

What is normal, mild, moderate and severe values for FEV 25-75?

A

Normal: >60%
Mild: 40-60&
Moderate: 20-40%
Severe: <10%

26
Q

What is MVV?

A

Maximum voluntary ventilation is the largest volume that cane be breathed in one minute by voluntary effort.

27
Q

What are MVV like in obstructive vs restrictive disease?

A
  • MVV is reduced in obstructive disease

- MVV is normal in restrictive disease

28
Q

What is functional residual capacty?

A

The volume of gas in the lungs after passive exhalation

29
Q

How is FRC easured?

A

Indirectly through nitrogen wash-out. A nitrogen analyzer is attached to a spirometer, you wait until alveolar nitrogen falls below 7%, takes about 7-10 minutes.

30
Q

Describe the arterial, venous, and alveolar pressures in the 3 lung zones.

A 
Zone 1:  
PA>Pa>Pv
Zone 2:  
Pa>PA>Pv
Zone 3:  
Pa>Pv>PA
31
Q

When does zone 1 ventilation occur?

A

Not under normal circumstances. Can occur when there is decreased blood pressure or an increase in alveolar pressure.

32
Q

Where is ventilation the smallest when a patient is sitting up and breathing spontaneously?

A

Ventilation is the smallest at the highest portion of the lung.

33
Q

What are some pulmonary physiologic effects of PPV?

A
  • Risk for atelectasis
  • Increase in blood flow to the dependent lung
  • Increase in ventilation to the independent areas causing an increase in V/Q mismatch
  • Dead space
  • Potential for barotrauma
34
Q

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

A
  • Set a peak airway pressure alarm
  • Deliver an adequate TV
  • Maintain perfusion pressures to the lung
  • PEEP
  • FiO2
  • Assess and re-assess
35
Q

What are the physiologic effects of PPV on the cardiovascular system?

A
  • Decreased preload and blood pressure

- Increase right to left shunt with atrial-septal defect

36
Q

What are some treatment options for the physiologic effects of PPV on the cardiovascular system?

A
  • Position
  • Fluid administration
  • Alpha and beta stimulants
  • Inotropic support
37
Q

What is the goal of maximizing pulmonary function perioperatively and what are some methods to maximize pulmonary function?

A

Goal is to reduce intraoperative and postoperative morbidity and mortality

Methods:

  • Smoking cessation
  • Mobilization of secretions/Treat infection
  • Bronchospasm treatment
  • Improve motivation and stamina
38
Q

When should smoking be stopped before surgery?

A
  • Stopping 8 weeks before decreases rate of pulmonary complications
  • Stopping 4 weeks before decreases secretions
  • Stoping 2-3 weeks before will increase secretions
  • Stoping 12-24 hours before will reduce carboxyhemoglobin levels to normal
39
Q

What can be done to treat chronic bronchitis perioperatively?

A

Give antibiotics

40
Q

What can be done to mobilize secretions perioperatively?

A
  • Give mucolytic agents
  • Hydration
  • Aerosol therapy
  • Mechanical therapy
41
Q

What are some treatments for bronchospasm?

A
  • B2 Sympathomimetic
  • Anticholinergic compounds
  • Methylxanthines
  • Corticosteroids
42
Q

What precautions should be taken with preoperative sedation for patients with restrictive pulmonary disease?

A

Titrate carefully due to reduced FRC

43
Q

What precautions should be taken with regional anesthesia for patients with restrictive pulmonary disease?

A

At T10 you can have loss of accessory respiratory muscles. Accessory muscles may be crucial to spontaneous ventilation in these patients.

44
Q

What is different about the uptake of inhalation agents in patients with restrictive pulmonary disease?

A

Inhalation agents have accelerated uptake due to decreased FRC

45
Q

What happens to safe apnea time for patients with restrictive pulmonary disease?

A

Safe apnea time decreases because of lower FRC so Sa O2 drops quickly with apnea despite preoxygenation

46
Q

What changes to mechanical ventilation can you expect in patients with restrictive pulmonary disease?

A
  • Expect increased peak airway pressures
  • Decrease volume (4-8 ml/kg)
  • Increase respiratory rate (14-18 bpm)
  • PEEP
47
Q

What are the effects of anesthesia on FRC?

A

In normal healthy patients:

  • 10-15% reduction in supine position
  • Additional 5-10% reduction with general anesthesia
  • Plateau develops after 10 minutes regardless of ventilation
  • May take 3-7 days to recover after upper abdominal procedures
48
Q

What effects does surgery have on VC?

A

Vital capacity may have up to a 40% reduction and take up to 14 days to return to normal after an upper abdominal procedure.

49
Q

What can be done in obstructive pulmonary disease to reduce airway reactivity?

A
  • Aggressive bronchodilator therapy
  • High alveolar concentrations of IA
  • IV opioids/lidocaine prior to airway manipulation
  • Single dose corticosteroids
50
Q

When under general anesthesia how should patients with obstructive pulmonary diseases be ventilating?

A

Spontaneous ventilation should be avoided with these patients under GA.

51
Q

What precautions with regional anesthesia should be taken for patients with obstructive pulmonary diseases?

A

If the block goes above the level of T10 you may get loss of accessory respiratory muscles that are crucial to spontaneous ventilation in these patients

52
Q

What vent changes will you need to make for patients with obstructive pulmonary disease?

A
  • Large tidal volumes
  • Slow respiratory rate
  • Keep PIP below 40 cmH20
  • Avoid high PAP
  • Allow longest possible expiratory time
  • Intrinsic PEEP may occur due to air trapping

health assessment exam 2 (6 decks)

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