Flashcards in Lung Diseases And Anesthetic Concerns Deck (32):
What is COPD caused by?
- occupational or environmental exposure
- recurrent infections
- genetic factors
What are the 3 most common symptoms with COPD?
What do you need to obtain as part of your pre-op hx for COPD patients?
-Smoking history: always ask 2 questions
- do you smoke? PPD and duration
- have you ever smoked/when did you quit?
* dyspnea: presence, severity, exercise tolerance, home O2 requirement, baseline SpO2 on room air *****
- productive cough—> how often? Fever?
- wheezing—> how often, reversible?
- admissions to hospital: incubated? Length of stay? Prolonged ventilation? Infection
- can the climb a flight of stairs
What are some pre-op studies to obtain for a patient with COPD?
- SpO2 on room air
- ABG: elevated CO2 and HCO3 (30s)- you know pt is a big CO2 retainer
- CXR: hyperinflation, bless or bullseye, flattened diaphragm, infiltrates, effusions CA, atelactasis, PTX
- CBC: WBC, elevated Hct
- PFTs: degree of obstruction and bronchodilator response
- electrolytes: elevated bicarbonate to compensate for resp acidosis
What are high risk PFT results?
- FEV1 <2L
- FEV1/FVC < 0.5
- VC < 15cc/Kg in adult or <10cc/Kg in peds
- VC<40-50% than predicted
- normal is 80%
If FEV1 is in the 40-50% range what should you warn your patient?
They may remain of the vent for a few days after surgery
What are they most common symptoms present in chronic bronchitis?
* SPUTUM PRODUCTION
* RECURRENT INFECTION
- airway obstruction
- mucus gland hyperplasia, mucus plugging, inflammation, edema, peribronchiolar fibrosis, bronchoconstriction
*BLUE BLOATERS *
What causes chronic bronchitis?
- occupational exposure (radon, coal, asbestosis)
What are characteristics of blue bloaters (chronic bronchitis or asthmatic bronchitis)?
- chronic productive cough
- CYANOTIC (blue)
- obese, OSA, pickwickian syndrome (obesity, decreased pulm function, polycythemia)
- short, fat neck
- frequent wheeze
- relatively young
What happens with emphysema?
- variable cough
- enlarged airspaces from destruction of elastic and collagen network or alveolar walls (without fibrosis)
- loss of pulmonary elastic recoil
- loss of airway support leads to narrowing and collapse during exhalation—> AIR TRAPPING
Why are people with emphysema referred to as pink puffers?
Healing through pursed lips, puffing from dyspnea
Enough O2 (pink) but difficulty with exhalation
What causes emphysema?
- coal miners
****alpha 1 antitrypsin deficiency—> autodigestion of pulmonary tissues by proteases ****
What are common characteristics of pink puffers (emphysema)?
- minimal cough
- pink color
- dyspnea, hyperinflation and distant breath sounds
- pursed lips= auto Peep, air trapping
What is seen with asthmatic bronchitis?
- chronic productive cough
- episodic bronchospasm
- airway obstruction
Only partially reversible- some degree of obstruction will always remain
- can be a progression of asthma
What is true about smoking?
- Doubles the risk of CAD
- 6Xs the risk of post- op complications
- COHb (carboxy hemoglobin can be elevated up to 15%
- 25 pack-year increases physiologic age by 8 years
* NICOTINE STIMULATES SYMPATHETIC GANGLIA—> catecholamines released from adrenal medulla —> increasing HR, BP, and SVR
* persists for 30 minutes after last cigarette
Smoking is an irritant to the airway. What does this cause as a result?
- mucus production
- decreased ciliary activity
- decreased pulmonary macrophage activity
- increased inflammatory response
- proteolytic enzyme release
- reduced surfactant integrity
Before induction of a smoker, what should you make sure you do?
Pre-oxygentate well (ET O2 80-90)
Avoid instrumentation of airway until deep level of anesthesia
What affects does smoking cessation have on the body at different times?
* advise pt to stop smoking at least 12 hours prior to surgery *
- 12-24 h: reduces COHb and nicotine levels to that of non-smokers
- after 2 days: airway reactivity is near the level of a non-smoker
- >8 weeks: will reduce post-op complications
- >2 years: will reduce risk of MI to that of nonsmoking population
What do you need to do with the ventilator in a pt with COPD intraoperatively?
- vent adjustments:
- 1:3 —> require longer exhalation times
- closely monitor peal insp. Pressures—> avoid rupturing Blebs
CO2 retainers: keep ETCO2 near pts baseline to avoid alkalosis
- large gradient between ETCO2 and PaO2–> compare Et value to ABG to know what norms are
What else should be done with a COPD pt intraoperatively?
- N2O may expand bullae
- airway stimulation with light anesthesia- des, iso
- ALINE to monitor ABGs, since ETCO2 less accurate
- laryngospasm d/t secretions—> suction frequently
- mucocilliary clearance worsened after inhalation agents
- bronchospasm: Avoid *histamine releasing drugs*
- morphine, neostigmine, Pentothal
- treat with nebulized albuterol, especially before extubation
Regional anesthesia with COPD is a good choice for which types of surgery?
A neuraxial block above _____ will diminish ability to cough and begin motor and sensory loss of external intercostals.
T10 (right at the umbulicus)
_____ is at the nipple line.
An interscalene block will frequently block the ipsilateral __________ nerve, which can cause_______________________.
Phrenic nerve (C3,4,5)
Loss of 1/2 of the diaphragm, along with loss of intercostal muscle movement—> severe anxiety in COPD person
(Also may see hoarseness and droopy eye ipsalaterally)
T/F Continuous regional can be used in post-op period for pain control and improved pulmonary mechanics.
* remember, regional may turn into general at any time *
What is the classic triad of symptoms in Asthma?
What triggers an attack?
- occupational or environmental exposures
- ETT stimulation—> right after intubation may have SEVERE BRONCHOSPASM!! (Epi is drug of choice here)
What is asthma?
** smooth muscle hypertrophy, bronchospasm, mucosal edema, mucus plugging **
-more than just Airway hyperreactivity
- bronchial wall inflammation.
- variable degrees of reversible airflow obstruction
What should be done for a person with Asthma pre-op?
- assess severity—> hx of intubation
- 3 admits/year
- > 3 ER visits/year
- last ER visit < 1 month ago
- hx of ICU admits
- recent steroid use
- recent URI
- how often they use their inhaler
- Check PEFP to assess current status
—> severe is <40%
- moderate is 40-60% predicted
If decreased wheezing is noticed in a pt with asthma is this a good or a bad thing?
Bad—> may indicate worsening of disease and decreased air exchange
*coughing and no wheezing may be crashing and very little air exchange
How do you treat asthma?
Nebulized albuterol. *
Deepen level of anesthesia—> all inhaled agents cause bronchodilation
Epinephrine: IV or racemic
Terbutaline-preferred in pregnant pts