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Flashcards in Pulmonary Deck (53)
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1

What to assess for in regards to pulmonary history?

  • Baseline pulmonary function
    • Exercise tolerance, dyspnea, orthopnea, smoking, sleep apnea
  • Chronic lung disease
    • Severity, meds, recent hospitalizations, frequency of exacerbations, & effective treatment
  • Acute lung disease
    • Recent URIs, abx, current symptoms
  • Previous anesthesia experiences
    • Procedures, pulmonary complications, anesthesia technique utilized
      • Pts w/ chronic lung dx often have difficulty achieving extubation criteria. a) do you remember if you had a tube inserted into your throat to help you breathe? b) did you have to be placed in ICU after your surgery, 3) did you receive a shot into your back, your hip, or in the surgical area to numb the area and decrease pain?  All of these questions provide greater insight into a patient’s medical history.
  • Medical clearance
    • Evaluation of current status & therapies
    • Availability of lab & diagnostic studies
    • “clearance” is not the preferred term.  Some pts require optimization prior to sx.Input from a pulmonologist and/or cardiologist might be needed for pts w/ severe respiratory illnesses.

2

What are are some quesitons to ask in regards to obstructive pulmonary disease?

problem with getting air out....

  • Asthma
    • An acute reversible airway obstruction that is accompanied by chronic airway inflammation & hyperreactivity
    • Ask about SOB, chest tightness, cough, recent exacerbations, therapy (esp steroids), hospitalizations, intuation
  • Chronic Obstructive Pulmonary Disease (chronic bronchitis and emphyema)
    • Airflow obstruction – difficulty getting air out
    • Ask about smoking hx, dyspnea, cough, wheezing, sputum production, tachypnea, home o2

3

Assessment considerations in restricttive pulmonary disease?

  • Pulmonary fibrosis, sarcoidosis, obesity
    • Reduction in total lung capacity – reduction in all lung capacities
    • Proportional decrease in all lung volumes
    • Ask about SOB, exercise tolerance, home o2 use

4

Examples of restrictive disease?

  • Neg press pulm edema
  • Kyphoscoliosis
  • Pregnancy
  • Sarcoidosis
  • Pneumothorax
  • Pleural effusion
  • Ascites
  • Neurological disorders (musc dystrophy)

5

Examples of obstructive diseases?

Asthma

Chronic bronchitis

Emphysema

6

What to assess for on initial survey of respriation and thorax?

Initial survey of respiration & thorax- quickly assess for resp distress

  • Inspect color for cyanosis or pallor
  • Listen for audible sounds of breathing
  • Inspect the neck (accessory muscles)
  • Tracheal position
  • Observe respirations
  • Look directly at the thorax if poss
  • Observe the shape of the chest – is it barrel shaped?
    • The lateral diameter of the chest in the normal adult is greater than the AP diameter.
    • The ratio of its AP diameter to the lateral diameter is ~0.7 to 0.9 and increases w/ age
  • Observe for chest deformities –  usually present in peds, adolescents, & young adults. Sx avail for excavatum. Both are correctable . even when no corrective action is taken, severe functional limitations rarely experienced
    • Pectus carinatum "pigeon chest"
    • pectus excavatum" funnel chest"

7

What is pectus carinatum?

  • Pectus carinatum “pigeon chest”
    • Protrusion of sternum.
    • Present during adolescent growth spurts ie puberty
    • Less common than  excavatum

8

What is pectus exacavatum?

  • Causes a caved in, depressed chest, sometimes the ribs can flare out
    • Associated comorbidities & functional limitations rarely exist
  •  Unbalanced costochondral hypertrophy - exact cause unknown
  • ~1 of every 150-1000 births w/ 3:1 male predominance
  • Occurs ~ 5-6x more often than pectus carinatum
  • Often displays during puberty. Might worsen til ~ 18 yo, although can be present @ birth
  • Up to 43% have a family hx of the deformity
  • May be associated scoliosis & connective tissue disorders ie Marfans, Ehlers-Danlos, & Noonan’s syndrome
    • Focus on s/s that are assoc w/ these associated dx, can help deter if need addt’l preop testing.
      • Ie cardiac manifestations – MV prolapse, AV dilation, & BBB
    • Observe for bruising & skin friability which is a sign of ED
    • Look for high arched palates --> point to associated syndrome which may need more testing
  • In addition to cosmetic considerations, severe PEX may result in cardiac compression & cardiopulmonary impairment
  • Symptoms might include:
    • Dyspnea
    • Loss of endurance
    • Chest pain
    • Progressive fatigue
    • Palpitations, tachycardia
    • Syncope

9

What should be considered when evaluating pectus exacavatum

Psychological issues can be SIGNIFICANT, esp in adolescents & young adults

  • Don't focus too much attention at the defect. Don't stare and ask direct questions about it, espeically if a teen or young adult; especially if surgery is unrelated to the defect!
  • body image very important at this age
  • However, don't overlook the disorder. If pediatric, ask questions to patient and parent. Do you have pediatrician that you see regularly? Do you play sports? are you able to run around with your friends? have you ever passed out or had chest pain?
  • Sx - Nuss procedure & cosmetic procedures commonly used to correct.
  • Evaluation:
    • Individually tailored to pt’s symptoms & responses to aforementioned questions
    • Noncontrast CT--> extent of deformity
    • EKG --> arrhythmias
    • ECHO -->cardiac compression, MVP
    • PFTs
    • Exercise stress testing

10

What to assess for on palpation during pulmonary exam?

  • Areas of tenderness
  • Crepitus
  • Tactile/ vocal fremitus – palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the pt is speaking. Vibrations should be symmetrical
    • Tactile frem- place palms or ulnar surfaces of hands on chest while pt says 99 repeteadly. Alterations in vocal fremitus could suggest PNA, pleural effusion, COPD, etc

11

What to assess for during percussion portion of pulmonary asessment?

  • Helps you to establish whether the underlying tissues are air filled, fluid filled, or consolidated & ID the pathology to them
  • Healthy lungs are resonant
  • Fluid filled cavities and solid tissues percuss dullness & can indicate PNA, tumor, or pleural effusion

12

How do you auscultate the lungs?

  • Breathing normally, mouth open
  • 1) apply Diaphragm of stethoscope – directly to pts skin bc over clothes or gowns can alter breath sounds
  • 2) listen to ant & post chests
  • 3) listen above the clavicles bc the lung apices extend above them
    • Apices, middle & lower lung fields, posterior, lateral, & anterior
  • 4) Alternate & compare sides- ie if listen to R clavicle, 2nd pt of ausc should be above the L clav & continue stair step technique for all fields
  • Quiet respirations first, then deep breaths

13

What are normal breath sounds heard during auscultation?

  • Vesicular – heard over most lung fields
    • Quality – lower pitch & softer
    • Duration – inspiratory sounds last longer than expiratory sounds
  • Bronchovesicular- heart best @ 1st & 2nd ICS anteriorly & between scapulae
    • Quality- intermediate pitch & sound
    • Duration – expiratory & inspiratory sounds almost equal
  • Bronchial- heard best over the manubrium (larger prox airways)
    • Quality – higher, loud, hollow pitch
    • Duration – expiatory sounds last longer than inspiratory sounds

14

What are vesicular breath sounds?

  • heard over most lung fields
  • Quality – lower pitch & softer
  • Duration – inspiratory sounds last longer than expiratory sounds

15

What are bronchovesicular breath sounds?

  • heart best @ 1st & 2nd ICS anteriorly & between scapulae
    • Quality- intermediate pitch & sound
    • Duration – expiratory & inspiratory sounds almost equal

16

What are bronchial breath sounds?

  • heard best over the manubrium (larger prox airways)
    • Quality – higher, loud, hollow pitch
    • Duration – expiatory sounds last longer than inspiratory sounds

17

What are adventitious breath sounds?

Abnormal breath sounds

  • If bronchial breath sounds are auscultated anywhere other than expected (manubrium is expected)
    • Suspect replacement of air-filled lung tissue by consolidation - ex PNA

Adventitious sounds – umbrella term for abnormal breath sounds

  • Wheeze (high pitched), rhonchi (low pitched)
    • Musical, usually on expiration but may be heard on inspiration
  • Stridor
    • High pitched, usually on inspiration
  • Crackles/ rales – less distinct
    • Tearing Velcro open
    • Crackles of HF are best heard in the posterior lung fields
    • Pulm edema- crackles
    • Clearing of crackles, wheezes, or rhonchi after coughing or position change --> inspissated (mucoid) secretions --> present in bronchitis, atelectasis
  • Beware of the silent chest (no air mvmt) --> clinical emergency

18

What is a wheeze? rhonchi?

Wheeze= high pitched

rhonchi= low pitch

  • musical, usually on expiraiton but may be heard on inspiration

19

What is stridor?

high pitched, usually on inspiration

20

What are crackles/rales?

  • Tearing Velcro open
  • Crackles of HF are best heard in the posterior lung fields
  • Pulm edema- crackles
  • Clearing of crackles, wheezes, or rhonchi after coughing or position change à inspissated (mucoid) secretions à present in bronchitis, atelectasis

21

What additional testing may be required in obstructive or restrictive disease?

  • O2 saturation w/ pulse oximetry
  • Chest radiograph
  • Arterial blood gases
  • Pulmonary function testing
  • Chest computed tomography
  • Lab testing – CBC, CMP
  • EKG

22

What is purpose of PFT? Indications?

  • Purpose
    • Standardized
    • Objective
    • Req pt cooperation
  • Indication
    • Assist in diagnosis
    • Evaluate treatment
    • Disease progression
    • Risk assessment – ie postop risk

23

Who are appropriate candidates for PFT?

Appropriate candidates for testing

  • Patients with evidence of COPD
  • Smokers with persistent cough
  • Wheezing or dyspnea on exertion
  • Morbid obesity
  • Thoracic surgery patients
  • Open upper abdominal procedures
  • Patients > 70 years of age

Routine PFTs are NOT recommended

24

Who is at risk for postop pulmonary complications?

Categorized as:

  • patient related
    • age >60
    • ASA 3-4
    • CHF
    • COPD
    • Cigarette smoking
  • procedure related
    • aortic >thoracic> upper abdominal- neuro-peripheral vascular> emergency
    • duration of anesthesia >2.5 hours
    • general anesthesia
  • diagnostic testing related
    • only albumin <3.5 is at increase risk for increased pulmonary risks.

25

What do pulmonary function tests measure?

  1. Dynamic lung vol—how quickly air can be moved in and out of the lungs over a given time
  2. Static lung vol—how much air the lungs can hold at a specific time
  3. Diffusing capacity–how well the lungs can transfer gas across the alveolar-capillary membrane

26

What are static lung volumes?

  • How much air the lungs can hold at a given time
  • These vols include insp reserve vol, exp reserve vol, TV, & residual vol.
  • Spirometry cant mesaure RV bc RV cant be exhaled. and therefore can't measure TLC
  • FRC isn’t capable of being measured by spirometry bc RV is a component of FRC.
  • RV + expiratory reserve vol = FRC.
  • Look in the book to see correlation b/w various vols & capacities. Nagelhout 5th edition p 598 

27

What is FRC? How do we measure it?

  • Functional Residual Capacity- Volume of gas in the lungs after passive exhalation
    • Residual volume is the volume of gas in the lungs after forced max expiration
  • FRC can assist in quantifying the degree of pulmonary restriction
  • Measured
    • Indirectly
      • By Nitrogen wash-out
      • Nitrogen analyzer attached to spirometer & nitrogen end pt estab.
      • End point= alveolar nitrogen concentration falls below 7%, usually takes about 7-10 minutes

28

What is spirometry and lung volumes measured? What are predicted values based on?

  • Dynamic lung volumes can easily be eval w/ spirometry Spirometry = measure of air moving in & out of lungs during various resp maneuvers. Deters how much air can be inhaled & exhaled & how fast.
  • The pt is asked to sit up straight, inhale maximally, estab a good seal around mouthpiece, & exhale as hard as possible & count for at least 6 sec. this is repeated 3 x & the best of the 3 trials is recorded.
  • Spirometry can record the measures listed here.
  • Spirometry is based on forced vital capacity (FVC). The FVC is divided into time intervals
    • FEV1
    • FEV1/FVC ratio
    • FEV 25-75%
  • Predicted values based on
    • Age
    • Height, weight
    • gender

29

What is forced vital capacity?

  • Max inspiration (taking deepest breath possible) & total amt of air expired as quickly as poss with forced expiration
    • Majority of FVC can be exhaled in <3s in normal people, but more prolonged in obsx dx.
  • Function of vol/time
  • Measures resistance to flow
  • Effort and cooperation dependent
  • Interpretation % predicted
    • 80-120%              normal
    • 70-79%                 mild
    • 50-69%                 moderate
    • <50%                     severe

30

What is FEV1?

  • Forced Expiratory Volume in 1 sec: FEV1
    • vol of air forcefully expired from full inspiration in the first second
    • Normal is 75-80% of FVC
    • Effort and cooperation dependent
    • Interpretation of FEV1/FVC
      • >80%            normal
      • 60-79%         mild
      • 50-59%         moderate
      • <49%             severe obstruction