Pulmonary Assessment Flashcards
What are some questions to inquire about if the patient has an obstructive pulmonary disease?
- Asthma
- Ask about SOB
- chest tightness/wheezing
- Cough
- recent exacerbation
- therapy (esp steroids)
- Hospitalization
- intubation
- COPD
- Ask about smoking hx
- Dyspnea
- Cough
- Wheezing
- Sputum production
- Tachypnea
- Home O2
What are some questions to inquire about if the patient has a restrictive pulmonary disease?
Ask about SOB
Exercise
Home o2 use
What can be found on inspection during pulmonary assessment?
- Assess for respiratory distress
- cyanosis/pallor
- audible sounds of breathing
- inspect neck for accessory muscle use
- trahceal position
- observe shape of chest
- lateral diameter of chest in normal adult is greater than AP diamater
- 0.7-0.9 ratio lateral: AP and increases right age
- lateral diameter of chest in normal adult is greater than AP diamater
Describe the process of auscultating lungs and what you expect to hear on normal auscultation?
- Breathing normally, mouth open
- apply diaphragm to skin
- Listen A&P
- Listen above clavicles
- Alternate and compare sides
- Normal auscultation
- Vesicular- heard over most lung fields
- Quality- lower pitch and softer
- Duration- inspiratory >expiratory
- Bronchovesicular- heard best 1st and 2nd ICS A &P & between scapulae
- Quality- intermediate pitch and sound
- Duration- inspiratory = expiratory
- Bronchial- heard best over the manubrium (larger prox. airways)
- Quality- high, loud and hollow pitch
- Duration- inspiratory < expiratory sounds
- Vesicular- heard over most lung fields
Appropriate candidates for preoperative PFT’s?
(COW SAT 70)
- Pt w/ COPD
- Morbid obesity
- Wheezing or dyspnea on exertion
- Smokers w/ persistent cough
- Open upper abdominal procedure
- Thoracic surgery
- Patients >70 years of age
Who would be at risk for post-op pulmonary complications?/ What are some independent risk factors for pulmonary complications perioperatively?
- Patient (5)
- Age > 60 yrs
- ASA III-V
- CHF
- COPD
- Smoking
- Procedure (AThUNVE)
- Aortic > thoracic > upper abdominal- neuro- peripheral vascular> emergency
- General anesthesia
- Duration of anesthesia >2.5 hrs
- Test
- Albumin < 3.5 g/dL (indicated poor nutritional status)
Ways to maximize pulmonary function?
Goal = ↓ intraop + postop M+M
Methods (4)
- Smoking cessation
* 12-24 hrs:- decreases catecholamine release → decrease HR, BP
- normalizes /decreases carboxyhemaglobin []
* 2-3 weeks: increase mucociliary fx → increases secretions
* 6 weeks: decrease sx
* 8 weeks: reduce post op pulmonary complications
- Smoking cessation
- Mobilize secretions + treat infections
* Abx therapy w/ chronic bronchitis
* Mobilize secretions à mucolytics, hydration, aerosol therapy, mechanical therapy
- Mobilize secretions + treat infections
- Bronchospasm treatment
* B2 sympathomimetic, anticholinergics, corticosteroids, methylxanthines,
- Bronchospasm treatment
- ↑ motivation + stamina = Education + practice w/ IS
Describe West Zone 1 of the lungs.
- Zone 1 = PA > Pa > Pv
- most gravity dependent
- Ventilation, but no perfusion= dead space
- Zone 1 does not occur in normal lung
- Increased by:
- Hypotension
- PE (pulm embolism)
- PPV (positive pressure ventilation)
- To combat Zone 1→ bronchioles of unperfused alveoli constrict to reduce dead space
Describe West Zone 2 of the lungs.
Pa > PA >Pv
- Ventilation and Perfusion
Describe West Zone 3 of the lungs
Pa > Pv > PA
- Venous pressure now exceeds alveolar pressure
- Perfusion > ventilation
- → Physiologic shunt
- Perfusion > ventilation
- To combat Zone 3: hypoxic pulm vasoconstriction reduces pulm blood flow to underventilated areas
What are some dynamic lung volumes obtained during spirometry, their implications and what are the predicted values based on?
Based on:
- Age
- height/weight
- Gender
Dynamic lung volumes
- FVC
- Max inspiration with forced expiration
- Effort and cooperation dependent
- Function volume/time
- Measures resistance to flow
- Interpretation
- 80-120% Normal
- 70-79 mild
- 50-69 moderate
- < 50 severe
- FEV1
- Volume of air forcefully expired from full inspiration in first second
- Normal 75-80%
- Effort and cooperation dependent
- Interpretation of FEV1/FVC
- >80% normal
- 60-79% mild
- 50-59% moderate
- < 49% severe obstruction
- Volume of air forcefully expired from full inspiration in first second
- FEF 25-75% ( forced expiratory flow 25-75%)
- Mean forced expiratory flow during middle FVC
- Most sensitive indicators of small airway disease
- More reliable than FEV1-FVC
- Interpretation of % predicted
- >60% normal
- 40-60% mild
- 20-40% moderate
- < 10% severe
Describe some considerations when interviewing your patient who presents with pectus excavatum.
- Possibility of connective tissue disorder association
- Marfans: MV prolapse, AV dilation, high arched palate
- Ehlers-Danlos: bruising & skin friability
- Noonan’s syndrome
- Symptoms might include: ASK ABOUT…
- Dyspnea
- Loss of endurance
- Chest pain
- Progressive fatigue
- Palpitations, tachycardia
- Syncope
- Assess psychological issues
What are some treatments for bronchospasms?
- beta 2 agonists
- anticholinergics
- methylxanthines - theophylline
- corticosteroids – triamcinolone
- Steriods: not for acute bronchospasm
- FOR PREVENTION
What are some considerations for ventilatory management in a patient with restrictive disease?
AVOID BAROTRAUMA
Susceptible to rapid desaturations - reduced FRC
Smaller Vt 6-8ml/kg
Faster RR 14-18 breaths/mins
Peak pressures < 30cm/H2O
Prolong inspiratory time (I:E - 2:1)
What are some considerations for ventilatory AND ANESTHESIA management in a patient with obstructive disease?
- Tidal volume (6-8 ml/kg) w/slow inspiratory flow rates
- Slow RR (6-10)
- Keep peak pressure < 40 cm/H20
- Increase expiratory time (I:E ratio) to minimize air trapping and auto-peep (aka: dynamic hyperinflation)
- EMERGENCE can be DELAYED d/t air trapping
- Use:
- VA (bronchodilator) → Sevo
- Regional (no higher than T6)
- Lidocaine
- Bronchodilators (Albuterol)
- Alpha 2 agonists (clonidine)
- AVOID:
- Des
- N2O
- Regional > T6
- Respiratory depressants → no benzos
- Use:
