Pulmonary Assessment Flashcards by Elizabeth Borissow

What are the components of a pulmonary history?

Baseline pulmonary function
History of chronic lung disease
History of acute lung disease
Previous anesthesia experiences
Medical clearance

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

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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What should be auscultated during the pulmonary physical exam?

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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Describe normal bronchial auscultation.

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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Describe normal vesicular auscultation

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

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When are bronchial breath sounds abnormal?

When they are heard anywhere other than over the tracheobronchial tree

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What is auscultated during consolidation?

Low pitched bronchial breathing

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What is auscultated during cavitary disease?

High pitched bronchial breathing

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What are some examples of adventitious breath sounds?

Wheeze
Stridor
Crackles

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What are indications for pulmonary function testing?

To assist in diagnosis of disease
To evaluate treatment
To evaluate disease progression
To assess perioperative risk

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Who are appropriate candidates for pulmonary function testing?

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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What are the two classifications of pulmonary function testing?

Tests that assess abnormalities of gas exchange.

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

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

ABGs
Pulse Ox
Capnography

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

-Spirometry

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What is the normal volume and flow ranges for spirometry?

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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What are examples of obstructive diseases?

Chronic bronchitis or emphysema

- Asthma (chronic inflammatory disorder)

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What happens to lung volumes in restrictive disease?

Proportional decrease in all lung volumes

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What is vital capacity?

Maximal inspiration followed by maximal exhalation to RV

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What is forced vital capacity?

Max inspiration with forced expiration.

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What is normal, mind, moderate and severe FVC?

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

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What is FEV1?

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

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

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

What is the FEF 25-75?

Forced expiratory flow 25-75:

-Mean forced expiratory flow during middle of FVC

What does FEF 25-75 reflect?

Effort independent expiration and the status of the small airways.

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

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

What is MVV?

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

What are MVV like in obstructive vs restrictive disease?

- MVV is reduced in obstructive disease | - MVV is normal in restrictive disease

What is functional residual capacty?

The volume of gas in the lungs after passive exhalation

How is FRC easured?

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.

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

``` Zone 1: PA>Pa>Pv Zone 2: Pa>PA>Pv Zone 3: Pa>Pv>PA ```

When does zone 1 ventilation occur?

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

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

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

What are some pulmonary physiologic effects of PPV?

- 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

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

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

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

- Decreased preload and blood pressure | - Increase right to left shunt with atrial-septal defect

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

- Position - Fluid administration - Alpha and beta stimulants - Inotropic support

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

Goal is to reduce intraoperative and postoperative morbidity and mortality Methods: - Smoking cessation - Mobilization of secretions/Treat infection - Bronchospasm treatment - Improve motivation and stamina

When should smoking be stopped before surgery?

- 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

What can be done to treat chronic bronchitis perioperatively?

Give antibiotics

What can be done to mobilize secretions perioperatively?

- Give mucolytic agents - Hydration - Aerosol therapy - Mechanical therapy

What are some treatments for bronchospasm?

- B2 Sympathomimetic - Anticholinergic compounds - Methylxanthines - Corticosteroids

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

Titrate carefully due to reduced FRC

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

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

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

Inhalation agents have accelerated uptake due to decreased FRC

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

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

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

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

What are the effects of anesthesia on FRC?

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

What effects does surgery have on VC?

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

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

- Aggressive bronchodilator therapy - High alveolar concentrations of IA - IV opioids/lidocaine prior to airway manipulation - Single dose corticosteroids

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

Spontaneous ventilation should be avoided with these patients under GA.

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

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

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

- 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