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

what 4 conditions is NIV used as the first line of treatment?

Answer 6

1. COPD exacerbation w/ hypercapnia
2. cardiogenic pulmonary edema
3. pulmonary infiltrates (PNA) for immunocompromised patients
4. weaning O2 in extubated COPD patients with hypercapnia

Question 7

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 7

– 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 8

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 8

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

Question 9

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 9

– inhalation
– obstructive
– CO2 ; CO2

Question 10

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 10

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

Question 11

indications for lung surgery

Answer 11

slide 13 (9 things)

Question 12

what is a thoracotomy?

Answer 12

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

Question 13

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

Answer 13

posterolateral

Question 14

when would a thoracotomy anterolateral approach be used?

Answer 14

if anterior structures involved
need accesss to heart or esophagus

Question 15

a clamshell thoracotomy approach is used exclusively for?

Answer 15

lung transplant
bilateral incisions

Question 16

what is video assisted thoracic surgery? (VATS)

Answer 16

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

Question 17

what are the benefits of performing VATS vs open thoracotomy?

Answer 17

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 18

what are thoracotomy precautions?

Answer 18

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 19

how long are precautions in place after thoracotomy?

Answer 19

6-8 weeks

Question 20

what is decortication?

Answer 20

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

Question 21

when are decortications commonly performed?

Answer 21

lung cancer
empyema
radiation induced pleural fibrosis

Question 22

how are decortications performed?

Answer 22

via VATs or thoracotomy

Question 23

what is pleurodesis?

Answer 23

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

Question 24

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

Answer 24

surgically or chemically

Question 25

when are pleurodesis commonly performed?

Answer 25

to treat recurrent or malignant pleural effusion recurrent pneumothorax

Question 26

how do we keep the pleural space drained post op?

Answer 26

post op drain or chest tube

Question 27

what is a wedge resection?

Answer 27

removal of a wedge-shaped portion of the lung

Question 28

when are wedge resections commonly used?

Answer 28

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

Question 29

how are wedge resections performed?

Answer 29

VATS

Question 30

lobectomy = pneumonectomy =

Answer 30

removal of entire lobe of the lung removal of entire lung

Question 31

when are lobectomy/pneumonectomy performed?

Answer 31

advanced lung cancer if other surgical removal is not possible

Question 32

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

Answer 32

higher the likelihood a full thoracotomy will be used

Question 33

what is lung reduction?

Answer 33

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

Question 34

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

Answer 34

subpleural emphysema

Question 35

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

Answer 35

lung reduction

Question 36

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

Answer 36

-- 2 years -- 3 years

Question 37

when was the first human lung transplant in US?

Answer 37

1963

Question 38

first successful long term lung transplant?

Answer 38

1980s

Question 39

use of ECMO in adults help patients survive to transplant:

Answer 39

1990s

Question 40

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

Answer 40

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

Question 41

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

Answer 41

IPF CF sarcoidosis/amyloidosis COPD

Question 42

contraindications for lung transplant:

Answer 42

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 43

a lung transplant evaluation includes:

Answer 43

CVP imaging PFTs VQ scan exercise testing

Question 44

what is the process of getting a lung transplant?

Answer 44

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 45

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

Answer 45

-- 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 46

what are two common complications of a SLT/DLT?

Answer 46

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

Question 47

what are symptoms of organ rejection?

Answer 47

fever fatigue N/V myalgias

Question 48

when are chest tubes often placed? where?

Answer 48

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 49

what does a chest tube do?

Answer 49

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

Question 50

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

Answer 50

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 51

post-surgery, where is the chest tube attached?

Answer 51

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

Question 52

what is a PleurX Drain?

Answer 52

indwelling drain that continously drains pleural space

Question 53

when are PleurX drain's indicated?

Answer 53

recurrent pleural effusions, done in place of repeated thoracentesis procedures

Question 54

where are PleurX drains' commonly seen?

Answer 54

palliative or hospice situations -- can be manageed at home