Pulmonary MedSurg Management

Question 1

what are 4 medical management options for pulmonary dysfunction

Answer 1

medications
supplemental O2
monitoring vitals and diagnostics
adjustments to physical activity

Question 2

true or false. any device can be used in any setting

Answer 2

false
certain devices can only be used in a medical setting

Question 3

what is the typical upper limit of flow rate of a portable O2 tanks? where do we see these?

Answer 3

< 12/15 L/min
can be found anywhere

Question 4

what happens if a device needs more than the standard flow rate (> 12-15 L/min) of a portable O2 tank?

Answer 4

the device will be seen in a medical setting with centralized O2 only! (not found outside the hospital)

Question 5

what is non-invasive ventilation (NIV)?

Answer 5

method of breathing support that delivers pressure and volume without the use of an advanced airway (ETT or trach)

Question 6

why is NIV used as the first line therapy in the following acute conditions:
– COPD exacerbation with hypercapnia (inc. CO2)
– cardiogenic pulmonary edema
– pulmonary infiltrates (PNA) for immunocompromised patients
– weaning O2 in extubated COPD patients with hypercapnia

Answer 6

– helps supplement pts breathing to get rid of CO2
– pressure on inhalation helps “push” excess fluid out of alveoli (used with HF patients)
– risk of infection is higher with mechanical ventilation
– used as a transition from MV to other supplemental O2

Question 7

NIV:
heated high flow nasal cannula:
– up to _____ and ____% FiO2
– _____ _______ helps protect airways and keep secretions __(thin/thick)__
– provides some _____ on inhalation and exhalation
– most beneficial pressure is on ______

Answer 7

– 60L/min and 100%
– heated humidification ; thin
– pressure
– exhalation –> device helps keep alveoli inflated at the end of exhalation

Question 8

NIV:
continuous positive airway pressure (CPAP):
– gives pressure on ______ only
– used for _____ breathing patterns that cause sleep apnea
– not effective enough to breathe off excess ____, but is able to keep _____ levels from climbing

Answer 8

– inhalation
– obstructive
– CO2 ; CO2

Question 9

NIV:
BiLevel Positive Airway Pressure: (BiPAP)
– gives one pressure on ______ and one pressure on _____
– used to help rid body of _____
– used for protecting ______ in attempt to avoid ______

Answer 9

– inhalation ; exhalation (can be different pressures)
– excess CO2 build up
– airway ; mechanical ventilation

Question 10

indications for lung surgery

Answer 10

slide 13 (9 things)

Question 11

what is a thoracotomy?

Answer 11

incision cut along the borders of ribs or muscles to access thoracic cavity or lungs

Question 12

which thoracotomy approach is most common and exposes the most amount of space?

Answer 12

posterolateral

Question 13

when would a thoracotomy anterolateral approach be used?

Answer 13

if anterior structures involved
need accesss to heart or esophagus

Question 14

a clamshell thoracotomy approach is used exclusively for?

Answer 14

lung transplant
bilateral incisions

Question 15

what is video assisted thoracic surgery? (VATS)

Answer 15

minimally-invasive approach that doesn’t require separating ribs - may have mini-thoracotomy

Question 16

what are the benefits of performing VATS vs open thoracotomy?

Answer 16

more delicate handling and precision of instruments
decreased blood loss
less incisional pain
less negatively-affected pulmonary functions
decreased inflammatory cytokine reaction to surgery
decreased inflammatory cytokine reaction to surgery
earlier post op mobility
reduced hospital LOS

Question 17

what are thoracotomy precautions?

Answer 17

no lifting > 5 pounds
no twisting or rotational activities
no strenuous activity with surgical side
ROM encouraged as tolerated below 90-90
splinted coughing

Question 18

how long are precautions in place after thoracotomy?

Answer 18

6-8 weeks

Question 19

what is decortication?

Answer 19

removing fibrous visceral pleura from the lung to allow the underlying lung tissue expand

Question 20

when are decortications commonly performed?

Answer 20

lung cancer
empyema
radiation induced pleural fibrosis

Question 21

how are decortications performed?

Answer 21

via VATs or thoracotomy

Question 22

what is pleurodesis?

Answer 22

adheres the pleura together to eliminate the pleural space to prevent air/fluid buildup and entrapment

Question 23

what are the two options for a pleurodesis to be adhered?

Answer 23

surgically or chemically

Question 24

when are pleurodesis commonly performed?

Answer 24

to treat recurrent or malignant pleural effusion
recurrent pneumothorax

Question 25

how do we keep the pleural space drained post op?

Answer 25

post op drain or chest tube

Question 26

what is a wedge resection?

Answer 26

removal of a wedge-shaped portion of the lung

Question 27

when are wedge resections commonly used?

Answer 27

removal of lung tumors that are close to the periphery
remove granulomas or isolated areas of lung damage from various diseases

Question 28

how are wedge resections performed?

Answer 28

VATS

Question 29

lobectomy =
pneumonectomy =

Answer 29

removal of entire lobe of the lung
removal of entire lung

Question 30

when are lobectomy/pneumonectomy performed?

Answer 30

advanced lung cancer if other surgical removal is not possible

Question 31

lobectomy/pneumonectomy:
– the larger the tissue removed, the _____

Answer 31

higher the likelihood a full thoracotomy will be used

Question 32

what is lung reduction?

Answer 32

procedure to reduce lung volume due to hyperinflation from COPD/emphysema

Question 33

_________ has an increased risk of worsening and creating a tension PNX

Answer 33

subpleural emphysema

Question 34

what surgical management technique is used as a last resort and after less-invasive measures have failed?

Answer 34

lung reduction

Question 35

avg time on lung transplant list for:
– single lung transplant:
– double lung transplant:

Answer 35

– 2 years
– 3 years

Question 36

when was the first human lung transplant in US?

Answer 36

1963

Question 37

first successful long term lung transplant?

Answer 37

1980s

Question 38

use of ECMO in adults help patients survive to transplant:

Answer 38

1990s

Question 39

what medical management protocols are patients who are candidates for a lung transplant?

Answer 39

severe functional deficits
limited life expectancy
some must remain hospitalized until transplant becomes available

Question 40

indications of lung transplants:
** put in order of # of transplants performed

Answer 40

IPF
CF
sarcoidosis/amyloidosis
COPD

Question 41

contraindications for lung transplant:

Answer 41

age > 72
severe mental/psychological instability
drug, tobacco, ETOH use within 6mo
BMI > 35
malnourishment
uncontrolled DM
PVD
hepatitis B/C
renal failure
autoimmune disease with multisystem involvement
AIDS
current/recent malignant cancer
other systemic illness with shortened life expectancy

Question 42

a lung transplant evaluation includes:

Answer 42

CVP imaging
PFTs
VQ scan
exercise testing

Question 43

what is the process of getting a lung transplant?

Answer 43

evaluation
put on wait list after being deemed candidate
when organ becomes available, it is matched to the patient
preserved and transported to recipient

Question 44

what do the following medications that are used for lung transplants do?
– immunosuppressants
– corticosteroids
– antibiotics/antivirals
– anti-hypertensives
– insulin
– bronchodilators
– mucolytics

Answer 44

– prevents organ rejection
– reduces inflammation, reduces risk of rejection
– prevention of bacterial or viral illnesses in the setting of immunosuppression
– counteracts side effects of SLT/DLT meds that cause HTN ; prevents pulmonary hypertension
– counteracts side effects of SLT/DLT medications that cause hyperglycemia
– prevents bronchoconstriction/bronchospasm in donor lung airways
– ensures secretion clearance

Question 45

what are two common complications of a SLT/DLT?

Answer 45

1. infection –> highest risk 12 months post op
2. rejection –> 20-50% in first 12 months

Question 46

what are symptoms of organ rejection?

Answer 46

fever
fatigue
N/V
myalgias

Question 47

when are chest tubes often placed?
where?

Answer 47

during thoracic surgical procedures
inserted at optimal intercostal space to target the accumulated fluid/air and then advanced several inches into the pleural space

Question 48

what does a chest tube do?

Answer 48

evacuate fluid or air that can impede breathing and cause the lung collapse

Question 49

chest tubes are usually connected to:
– what does this help tell us?

Answer 49

three-chamber water seal drainage devices
– provides a mean to verify presence of an air leak and monitor amount of drainage and intrathoracic blood loss

Question 50

post-surgery, where is the chest tube attached?

Answer 50

to wall suction initially
progressed to gravity only as the air leak reduces in size or the drainage amount subsides

Question 51

what is a PleurX Drain?

Answer 51

indwelling drain that continously drains pleural space

Question 52

when are PleurX drain’s indicated?

Answer 52

recurrent pleural effusions, done in place of repeated thoracentesis procedures

Question 53

where are PleurX drains’ commonly seen?

Answer 53

palliative or hospice situations – can be manageed at home