Pulmonary

Question 1

If a patient has ongoing pulmonary disease, then they should really be cleared by

Answer 1

their pulmonologist or medical doctor prior to surgery

Question 2

A person usually (underestimates/overestimates) how much they smoke per day?

Answer 2

Underestimates

Question 3

During auscultation, patients should take ____ breaths first, and then ___ breaths

Answer 3

quiet, then deep

Question 4

Describe bronchial breath sounds

Answer 4

Normal breath sounds of the tracheobronchial tree (large airways).

Heard best at: Trachea, sternoclaviular joint, and the right posterior interscapular space

Sounds like: High pitch and rapid/loud air movement

Question 5

With bronchial breath sounds there is a ____ between inspiration and expiration

Answer 5

Pause

Question 6

Describe vesicular breath sounds

Answer 6

Normal sounds you should hear over lung tissue
Softer and lower pitched than bronchial
No pause between inspiration and expiration.
Expiration is shorter (meaning we will hear more during inspiration)

Question 7

When are bronchial breath sounds abnormal

Answer 7

Whenever they are heard somewhere they shouldn’t be (in the periphery)

Question 8

What is lung consolidation?

Answer 8

Lung tissue that has been filled with liquid

Question 9

What type of breath sounds should you hear in consolidation?

Answer 9

Low pitched-bronchial (more bronchial because the tissue that should be making vesicular sounds are not opening)

Question 10

What is cavitary disease?

Answer 10

Disease where normal lung tissue is replaced by a cavity

Question 11

What type of breath sounds should you hear in cavitary disease?

Answer 11

High pitched bronchial, because the lung tissue that should be making vesicular sounds is replaced by a cavity (essentially a large-airway).

Question 12

When are crackles insignificant?

Answer 12

If they clear with deep breathing

Question 13

What is wheezing?

Answer 13

Musical noise as air passes through constricted bronchioles. Usually heard on expiration (when the airways constrict), but can be heard on inspiration as well.

Question 14

What is stridor?

Answer 14

High pitched sound on inhalation due to narrowing of the larynx. Think about how hard you would be truing to breathe in if your larynx was constricted!

Question 15

Can PFTs be used alone to make a diagnosis?

Answer 15

No, they must be taken into consideration with other factors

Question 16

What are PFTs used for?

Answer 16

Diagnosis
Evaluate disease progression and treatment
Assessing risk of pulm compliations

Question 17

Who are good candidates for PFTs?

Answer 17

COPD
Smokers with persistent cough
Wheezing or dyspnea on exertion
Morbid obesity (once they have pulm HTN or OHS)
Thoracic surgery patients (lung surgery)
Open upper abdominal procedures
Those > 70

Remember that PFTs are NOT routinely recommended. Just for those you questions how well they will do from a pulm standpoint post-op

Question 18

Tests that assess abnormalities of gas exchange

Answer 18

ABG
Pulse-ox
Capnography

Question 19

Spirometry

Answer 19

Tells you:
1) Volume (Normal is 80-120% of predicted value)

2) Flow (normal is 80-100% of predicted value)

Question 20

Predicted values for spirometry are based on

Answer 20

Age
Height/weight
Gender
Race

Question 21

Asthma is a disease of

Answer 21

inflammation

Question 22

What happens to lung volumes in restrictive disease?

Answer 22

A proportional decrease in ALL lung volumes

Question 23

What is the most commonly measured parameter in spirometry

Answer 23

Vital capacity

Question 24

What is normal VC?

Answer 24

60-70mL/kg

Normal is >80% of predicted value

Question 25

What is FVC?

Answer 25

Forced vital capacity (max inspiration followed by a FORCED expiration--meaning the patient has to cooperate with the test). It graphs volume vs. time (meaning that it measures FLOW). ``` Test measures resistance to flow: 80-120% is normal 70-79% = mild 50-69% = moderate <50% = severe ```

Question 26

In COPD, FVC will be

Answer 26

Reduced (even if their VC is normal) | This is because the small airways close early and cause gas trapping

Question 27

What is FEV1?

Answer 27

The amount of air you can forcefully expire in 1 second.

Question 28

FEV1/FVC values

Answer 28

``` 70-80% = normal 60-75% = mild obstruction 50-59% = moderate obstruction <50% = severe obstruction ```

Question 29

What is FEF25-75%?

Answer 29

Forced expiratory flow during the middle portion of FVC. May reflect effort independent expiration and small airway status. Sensitive in early stages of obstructive disease

Question 30

What is more reliable in early disease, FEF25-75% or FEV1/FVC?

Answer 30

FEF25-75% - Remember that this is the effort independent portion and is sensitive to the status of small airways, especially early in disease

Question 31

Interpretation of FEF25-75% values

Answer 31

>60% of predicted value = normal 40-60% = mild 20-40% = moderate <10% = severe obstruction

Question 32

What is maximum voluntary ventilation (MVV)?

Answer 32

The largest volume of air a person is able to inhale and exhale in one minute (although test is only performed over 10, 12, or 15 seconds)

Question 33

MVV is ____ in obstructive disease

Answer 33

decreased

Question 34

MVV is ____ in restrictive disease

Answer 34

Normal (although someone with restrictive disease d/t to paralysis will have a decreased MVV)

Question 35

What information does FRC tell you?

Answer 35

Tells you about compliance and how well someone can tolerate apnea. Someone with a low FRC will have a harder time maintaining their sats during apnea.

Question 36

How is FRC measured?

Answer 36

Nitrogen wash-out Basically, someone breathes 100% O2 until the nitrogen analyzer attached to the spirometer detects a nitrogen concentration < 7%. Then all the nitrogen the person breathed out is added together to calculate FRC.

Question 37

Appearance of the flow/volume loop in obstructive disease

Answer 37

Scooped out expiration d/t air trapping

Question 38

FV Loop in restrictive disease

Answer 38

Basically a normal loop, but skinnier d/t reduced volumes (volume is on the x axis)

Question 39

Flattened upstroke in a FV loop indicates

Answer 39

Some sort of upper airway obstruction such as tracheal stenosis. In the anesthetized patient, this could be a mucus plus, kinked ET tube, etc.

Question 40

PA, Pa, and Pv pressures and Lung Zones

Answer 40

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

Question 41

Does Zone 1 type V:Q normally occur in the awake and spontaneously breathing patient?

Answer 41

NO! Normally, we should have enough BP to force blood into the apices. However, this type of V:Q may occur if BP drops or alveolar pressure increases (like in PPV!)

Question 42

Does Zone 3 type V:Q normally occur in the awake and spontaneously breathing patient?

Answer 42

NO! Normally a nice deep breath should provide enough PA to overcome the arterial and venous pressures.

Question 43

Zone 3 is an example of a

Answer 43

Shunt. Because there is a lot of blood flow, but little ventilation.

Question 44

In the awake and spontaneously breathing patient, where is ventilation the smallest?

Answer 44

At the highest portion of the lung

Question 45

In the awake and spontaneously breathing patient, where is ventilation the best?

Answer 45

In the more dependent parts of the lung. Here, the alveoli are compressed d/t gravity and the lung tissue has good compliance.

Question 46

Pulmonary risks of PPV

Answer 46

Atelectasis (if not enough TV) Increased blood flow to the dependent lung Increased ventilation in the independent lung (^^ above two cause worsened V:Q mismatch) Dead space (apparatus) Potential for barotrauma

Question 47

How to counteract the pulm risks of PPV

Answer 47

Set PAW pressures to 15cm above what their normal PAW is Deliver an adequate TV (to prevent atelectasis) Maintain BP to perfuse the lung well PEEP (prevent atelectasis) FiO2

Question 48

CV risks of PPV

Answer 48

Decreased preload and BP (decreased preload will decrease CO, which decreases BP) Can cause right to left shunt if the person has an atrial-septal defect Counteract these effects with positioning, fluids, alpha and beta stimulants, and inotropes

Question 49

Who may cancel a case if the patient has been smoking?

Answer 49

Plastics or ortho, because it will interfere with wound healing.

Question 50

How to maximize pulm function before surgery?

Answer 50

Smoking cessation Mobilize secretions and treat infections Treat bronchospasm Improve motivation ad stamina

Question 51

Effects of smoking cessation

Answer 51

12-24 hours = carboxyhemoglobin levels return to normal, and patient is able to oxygenate better 2-3 weeks = mucociliary function returns and the patient has an increase in secretions and airway irritability 4 weeks = secretions reduce 8 weeks = rate of post-op pulmonary complications decrease** ideal amount of time to stop smoking before surgery

Question 52

How can we help mobilize secretions?

Answer 52

Hydrate!! Vibration/percussion Aerosol therapy Mucolytic agents?? (may increase secretions and cause irritable airways)

Question 53

Meds used to treat/prevent bronchospasm

Answer 53

B2 agonists Anticholinergics (atrovent) Methylxanthines Corticosteroids (will probably need a booster dose of this before surgery)

Question 54

Point to note with FRC and restrictive disease

Answer 54

FRC will be reduced, so less safe apnea time. Be careful with your pre-op sedation. Also, this decrease in FRC accelerates uptake of inhaled agents

Question 55

Restrictive disease and regional anesthesia

Answer 55

Be careful of block > T10. This will cause loss of accessory muscles that they need to breath!!

Question 56

Restrictive disease and PPV

Answer 56

Expect increased PAW pressures Decrease TV to 4-8 mL/kg Increase RR to 14-18 (to normalize MV) Give PEEP (but remember this will decrease preload)

Question 57

Affect of anesthesia on FRC

Answer 57

Normally, there is a 10-15% decrease in supine position Additional 5-10% with GA Plateau of FRC occurs after 10 minutes, regardless of ventilation Can take up to 3-7 days for FRC to recover after upper abdominal surgery

Question 58

VC may have up to a ___% reduction after an upper abdominal procedure, and take up to __ days to return to normal

Answer 58

40% 14 days And this is for a healthy patient! Will be even worse for someone with pulmonary disease

Question 59

How can we reduce airway reactivity?

Answer 59

Aggressive bronchodilator therapy High alveolar concentrations of inhaled anesthetics (remember that IAs are bronchodilators!!) IV opioids/lidocaine prior to AW manipulation Single-dose corticosteroids

Question 60

Vent management for obstructive disease

Answer 60

Large TV (remember their lung volumes are increased!) Slow resp rate Longer exp-time Keep PIP below 40cmH20 Intrinsic PEEP may occur due to air trapping

Question 61

In obstructive disease, MVV is

Answer 61

reduced

Question 62

In restrictive disease, MVV is

Answer 62

normal | although it depends on cause, obviously someone with muscle disease will have reduced MVV

Question 63

What does FRC tell you about?

Answer 63

Safe apnea time and pulmonary compliance

Question 64

Effect of obstructive disease on FEF25-75%

Answer 64

Reduced | Remember that this test tells you about the small airways, and small airways close early in obstructive disease

Question 65

When may zone 1 occur?

Answer 65

PPV or drop in BP

Question 66

In PPV, you get increased ventilation to the ______ lung

Answer 66

Independent

Question 67

Vent settings for restrictive disease

Answer 67

Lower TV (4-8mL/kg) Increased RR (14-18bpm) Give PEEP Expect high peak airway pressures

Question 68

In obstructive disease, we should avoid PIP above

Answer 68

40 | Remember that their airways have thinned, and we want to avoid high pressures.