assessment of the respiratory system.ppt

8/14/2019 ASSESSMENT OF THE RESPIRATORY SYSTEM.ppt

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ASSESSMENT OF THE

RESPIRATORY SYSTEM

Anesthesia considerations

Martha Richter, MSN, CRNA


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Objectives

The student will be able to:

List 4 important assessment points

Discuss laminar vs turbulent flow of air Identify 3 appropriate actions when

intraoperative airway obstruction occurs

Discuss safe emergence practices Recognize 3 different types of atelectasis


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Patient History

Irritation of airway

Signs of infectious process

History of TB; when; treated?

History of Pneumocystis Carinii?

Presence of cough; dry? Sputumcharacteristics

Social issues

Ever have a CXR?


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HOW DOES THE AIRWAY LOOK?

Along with Mallampati score, consider

Cervical extension

Size&compliance of mandibular space

Interincisor distance Length & thickness of neck

Presence of overriding maxillary teeth

Ability to voluntarily prognoth

Configuration of palate

Presence of beard, large breasts, relevent cancers,

abscesses, hemorrhage, tracheal disruption


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Differentiate breath sounds

NORMAL

Vescicular soundsover peripheral lungs

Long inspir/shortexhal.

Air moving thru hollowtube.

HEARD

Over trachea andlarynx (C6-7,

suprasternal notch) Over peripheral lung

field (vesicular)

Anterior 1st-2ndICS

PosterioraroundT4(louder thanvesicular


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Normal breath sounds

The result of a mixture of vesicular and

tracheal sounds where the large bronchi

and alveoli are both in range of your

stethoscope.


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ABNORMAL BREATH SOUNDS

Bronchial breathsounds-tracheal-likesounds heard overthe lung field; harsh,blowing.

Break betweenexhalation andinhalation

Prolonged expiratoryphase

Obstruction vs partialobstruction to flow

Infectious acute vs

chronic


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Consolidation Contributors

Compression of lung tissue leading to

diminished breath sounds

Internal

Pneumonia

Obstruction of airway (s)

Emphysema

Foreign Body


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Consolidation Contributors

External factors

Air/fluid in pleural space

Pleural thickening

Increased chest wall thickening

Splinting


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Laminar vs Turbulent Flow

Laminar

Orderly movement

Occurs in smaller

airways where linearvelocity is low b/o

huge number of

parallel pathways

Poiseuilles law

Turbulent

Resistent greatly

increased

Occurs whenReynolds number

>2000

Can be auscultated

when caused bysudden

bronchoconstriction


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Asthmatic sounds

Prolonged expiration with wheezing

(sibilant rhonchi)

Break between inspiration/expiration

because of bronchoconstrictive process


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Asthmatic Clues

Voice

not loud (whisper pectoriloquy)

not clear, speaking may be difficult to

understand (bronchophony)

May have difficulty completing sentences

because of reactive airway issues

Coupled with Emphysema?


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RALES

Inspiratory

Air thru secretions

Discreet, short duration Variable pitch, intensity


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RALES

FINE Alveolar fluid

End-expiratory

Occur with CHF,pneumonia

MEDIUM Fld/mucous in

bronchioles

Mid-late inspiration

Like carbonated fizz

Clears with cough

COARSE Exudate in

large&small bronchi

Early-mid insp/exhal

Loud gurgling

Severe Pulmonaryedema, terminal phaseof illness

Sonorous rhonchus Clears with

cough/suction


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Atelectatic Rales

Imperfect lung expansion; ..incomplete

expansion of lung/portion of lungPorth,p533

Diminished breath sounds

Late in respiration

Fine inspiratory, disappear with deep breath

More common in elderly, immobile


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RHONCHI

Sibilant (wheezing) or snoring (lower pitch)

Expiratory more common

Due to partial obstruction in smallerbronchi and bronchioles

May clear with cough


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STRIDOR

Indicates upper airway obstruction

Inspiratory crowing

Acute Epiglottitis

Tracheal narrowing

Croup

Laryngospasm

Any others?


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The Pleural Issues

FRICTION RUB

Irritation w/o fluid

Freq heard end expir

Heard antero-lat Grating,

noncontinuous

Heard in pulmonary

embolus, pleurisy,pneumonia

PLEURAL

EFFUSION

Inc resp rate

Tracheal deviation Dec. fremitus

(tactile&vocal)

Dec. breath sounds

Friction rub after fluidis removed


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WHY DO WE CONSIDER THIS?

What happens when there is an external

compression on the lung(s)?

What are the options with tracheal

deviation? How will this affect our

induction?

Will these patients require special

considerations in their care?


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CHRONIC BRONCHITIS

May see:

Inc respiratory rate

Use of accessories

Intercostal retraction Will see:

Prolonged expiration

Increased chest AP

diameter

Decreased motion of

diaphragm

Will see:

Decreased BS

intensity

Rales-all levels Wheezes

Rales/wheezes MAY

clear after cough


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ATELECTASIS

Incomplete expansion of lung/portion

4 categories:

Obstructive (airless lung)-tumor, foreign body,mucous

plug, stricture Passive (compressive/recoil)-low inspir. Volumes,

pleural effusion, pneumothorax,pleural masses

Adhesive (decreased surfactant)-hyaline memrane

disease, pulmonary embolus Cicatrization (fibrosis:local/general=volume

loss)Kahn,C.,2004


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ATELECTASIS

Decreased breath sounds

Occasional rales Dull/flat percussion

Increased respirations, heart rate

Incidence increases aftersurgery:anesthesia, pain, narcotics,

immobility


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LARGE MASS (TUMOR)

Internal vs external to lung

Dullness over tumor

May have fine rales, dimished breathsounds, vocal changes

Occasional friction pleural rub

NEED TO KNOW: What part of the airwayis affected and to what degree?


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PNEUMOTHORAX

Increased respiratory rate

May have tracheal deviation toward the

affected side

May see cyanosis

Splinting on the affected side


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START THINKING

Is there anything in the knowledge that

you are gaining from your evaluation of the

patients respiratory system that you need

to incorporate into your logic for your planof care? How is this insight different from

the way youve approached patients with

these issues prior to this time?


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PNEUMONIA

Bronchial breathing, sounds E&A may be

changed with extensive consolidation

Occasional rales/rhonchi-clear with

cough/suction

Occasiona pleural friction rub

Inc. resp rate, ocasional cyanosis,

increased fremitus, dullness on percussion


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SUBCUTANEOUS EMPHYSEMA

Crackling sounds that is similar to rales,

but is felt under the skin.

Due to air accumulated under the skin.

How does this differ from


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EMPHYSEMA

Chronic airway

obstructive disease

Inc. resp. rate, use of

accessories,intercostal retractions,

increased AP

diameter of chest,

dec. chest expansion,hyperresonance to

percussion

Usually require

elevation of HOB

Little/no inc breath

sounds with deepbreath

Often fine rales at

bases with occasional

wheezes


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PULMONARY EDEMA

Cardiac vs. non-cardiac

Degree of control

Inc. resp rate, ?cyanosis, use of

accessories, apprehensive. Dull percussion b/o interstitial edema,

bronchovesicular sounds that may be

obscured by rales later; starts with finerales and progresses to rhonchi,occasional wheezing


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ASTHMA

EXTRINSIC

Allergic

Environmental

Elevated IgE

Antigens

Bronchial

Allergens,

infections,cold air,

exercise,drugs&chemicals,

anxiety, nasal polyps

INTRINSIC

Cardiac

Due to pulmonary

congestion w/CHF

Paroxysmal nocturnal

dyspnea

Chronic dry non

productive cough gets

worse when supine


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ASTHMA CONSIDERATIONS

What does the patient require to controltheir symptoms? Are they compliant?

What is their nutritional status?

Any ongoing infectious process? What are you going to do that will

influence their disease process, and how

will you ameliorate any problems? What is the planned surgery? Elective or

Emergent?


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PULMONARY INTERSTITIAL

FIBROSIS

Restrictive

Tachypneic pattern (Inc rate, dec VT)

Impaired diffusion=SaO2 decs withexercise states

High pitched fine-medium rales

Intercostal retractions


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PULMONARY RISK FACTORS

Pre-existing pulmonary disease

Scheduled surgery (e.g. thoracic,

abdominal)

Still smoking? Other exposures?

Obesity? Morbid?

Age >60 years How long will the procedure take? >3

hours?


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PREOPERATIVE SCREENING

PFTs

CXR

ABG Cardiac evaluation

CBC

Pulmonologist evaluation


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GETTING READY FOR THE

PULMONARY IMPAIRED

Consider Chest PT

Consider Glucocorticoids

Consider Bronchodilators

Advise patient to abstain from smoking 4-6hours pre-op (1/2 life of CO)

Consider H2 blockers

Antibiotics in the face of pulm infection

Check the FEV1

Consider diuretics if appropriate


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SAFE SEDATION

Choose a non-respiratory depressant with

an emotional component.

Benzos are good, titrated slowly

Ketamine may be used in select

circumstances. Remember the copious

secretions!

Better to avoid narcotics and

anticholinergies in this population.


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INDUCTION OF ANESTHESIA

Pre-O2 is prime!

Denitrogenation

Combination of agents must assureadequate depth of anesthesia prior to

intubation!

Agents: Thiopental, narcotics, volatile

agents, lidocaine, ketamine, benzos,

propofol


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WHAT MONITORS TO CHOOSE?

In the face of severe lung disease and

major surgery:

Consider arterial line

Consider central line

Consider urinary catheter

Consider PA catheter with Cor pulmonale or

any situation where you want to sample mixedvenous gases

Standard monitors


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WHAT ABOUT INTUBATION?

Blunt their responses!

Thiopental 1-2 mg/kg

Propofol .5-2.5mg/kg (remember hypotension)

Lidocaine 1-2 mg/kg

2-3 MAC inhalationals

Muscle relaxant tailored to patient


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WHAT ABOUT THE

VENTILATOR?

Large volumes with slower rates

I:E ration 1:3

Humidify gases Maintain normal CO2

Remember the oxyhemoglobin dissociation

curve

Remember the effects of clinical alkalosis


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MAINTAINING ANESTHESIA

Volatile anesthetic tailored to patient

Controlled ventilation-watch your pressures!

Warm & humidify the airMuscle relaxation tailored to patient

Will your endpoint address extubation?

Keep this in mind with your choices.


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WHEEZING PATIENT

DIFFERENTIAL (INTRAOP)

Examine ETT for obstruction: kinked?

Secretions? Overinflated balloon?

Did the ETT mainstem?

Consider Pulmonary edema

Consider pneumothorax

Consider reactive airway b/o ETT


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THE PATIENTS WHEEZING!

Albuterol administered via ETT-

aerosolized

Terbutaline 0.25 mg subcu

Aminophylline IV

6mg/kg bolus; infuse 0.5-0.9 mg/kg/hr

REMEMBER THE EFFECTS OF

MYOCARDIAL SENSITIZATION WHEN

USING HALOTHANE!

WHAT DO I SEE WITH


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WHAT DO I SEE WITH

OBSTRUCTION?

Look at your PIP

What does the ETCO2 waveform look

like?

Have things changed abruptly or slowly?

How are your breath sounds?

Call for assistance if available

EMERGENCE CONSIDERATIONS


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EMERGENCE CONSIDERATIONS

IN PULMONARY PATIENTS

Good oxygenation

Blunt airway reflexes

Lidocaine 1.5mg/kg.

Awake extubation after evaluation of

recovery from muscle relaxants, gases

FEV1 >50%

REVIEW ANESTHESIA


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REVIEW: ANESTHESIA

IMPLICATIONS

Warm & humidify gases

Use of Inhalationals

N2O implication with bullous patients

Use of Ketamine Possibility of bronchospasm on emergence

Use of LMA vs ETT

Vent vs spontaneous in PACU

Analgesia

Stress reduction


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PULMONARY

CONSIDERATIONSThank you!

assessment of the respiratory system.ppt

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