ASSESSMENT OF THE RESPIRATORY SYSTEM

Anesthesia considerations

Martha Richter, MSN, CRNA

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

Patient History
Irritation of airway Signs of infectious process History of TB; when; treated? History of Pneumocystis Carinii? Presence of cough; dry? Sputum characteristics Social issues Ever have a CXR?

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

Differentiate breath sounds

NORMAL Vescicular sounds over peripheral lungs Long inspir/short exhal. Air moving thru hollow tube. HEARD Over trachea and larynx (C6-7, suprasternal notch) Over peripheral lung field (vesicular) Anterior 1st-2nd ICS Posterior around T4(louder than vesicular

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.

ABNORMAL BREATH SOUNDS

Bronchial breath sounds-tracheal-like sounds heard over the lung field; harsh, blowing. Break between exhalation and inhalation Prolonged expiratory phase Obstruction vs partial obstruction to flow Infectious acute vs chronic

Consolidation Contributors
Compression of lung tissue leading to diminished breath sounds Internal
Pneumonia Obstruction of airway (s) Emphysema Foreign Body

Consolidation Contributors
External factors
Air/fluid in pleural space Pleural thickening Increased chest wall thickening Splinting

Laminar vs Turbulent Flow

Laminar
Orderly movement Occurs in smaller airways where linear velocity is low b/o huge number of parallel pathways Poiseuilles law

Turbulent
Resistent greatly increased Occurs when Reynolds number >2000 Can be auscultated when caused by sudden bronchoconstriction

Why does it matter?

Impact on anesthesia care plan What modifications will we need to build into our plan? Will we need to consider modifications of the usual? What is our goal in caring for a patient who is compromised?

Asthmatic sounds
Prolonged expiration with wheezing (sibilant rhonchi) Break between inspiration/expiration because of bronchoconstrictive process

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?

RALES
Inspiratory Air thru secretions Discreet, short duration Variable pitch, intensity

RALES
FINE
Alveolar fluid End-expiratory Occur with CHF, pneumonia

COARSE
Exudate in large&small bronchi Early-mid insp/exhal Loud gurgling Severe Pulmonary edema, terminal phase of illness Sonorous rhonchus Clears with cough/suction

MEDIUM
Fld/mucous in bronchioles Mid-late inspiration Like carbonated fizz Clears with cough

Atelectatic Rales
Imperfect lung expansion; ..incomplete expansion of lung/portion of lung
Porth,p533

Diminished breath sounds Late in respiration Fine inspiratory, disappear with deep breath More common in elderly, immobile

RHONCHI
Sibilant (wheezing) or snoring (lower pitch) Expiratory more common Due to partial obstruction in smaller bronchi and bronchioles May clear with cough

STRIDOR
Indicates upper airway obstruction
Inspiratory crowing Acute Epiglottitis Tracheal narrowing
Croup Laryngospasm Any others?

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 fluid is removed

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?

CHRONIC BRONCHITIS
May see:
Inc respiratory rate Use of accessories Intercostal retraction

Will see:
Decreased BS intensity Rales-all levels Wheezes Rales/wheezes MAY clear after cough

Will see:
Prolonged expiration Increased chest AP diameter Decreased motion of diaphragm

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

ATELECTASIS
Decreased breath sounds Occasional rales Dull/flat percussion Increased respirations, heart rate Incidence increases after surgery:anesthesia, pain, narcotics, immobility

LARGE MASS (TUMOR)

Internal vs external to lung Dullness over tumor May have fine rales, dimished breath sounds, vocal changes Occasional friction pleural rub NEED TO KNOW: What part of the airway is affected and to what degree?

PNEUMOTHORAX
Increased respiratory rate May have tracheal deviation toward the affected side May see cyanosis Splinting on the affected side

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 plan of care? How is this insight different from the way youve approached patients with these issues prior to this time?

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

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

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 deep breath Often fine rales at bases with occasional wheezes

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 fine rales and progresses to rhonchi, occasional wheezing

ASTHMA
EXTRINSIC
Allergic
Environmental Elevated IgE Antigens

INTRINSIC
Cardiac
Due to pulmonary congestion w/CHF Paroxysmal nocturnal dyspnea Chronic dry non productive cough gets worse when supine

Bronchial
Allergens, infections,cold air, exercise, drugs&chemicals, anxiety, nasal polyps

ASTHMA CONSIDERATIONS
What does the patient require to control their 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?

PULMONARY INTERSTITIAL FIBROSIS

Restrictive Tachypneic pattern (Inc rate, dec VT) Impaired diffusion=SaO2 decs with exercise states High pitched fine-medium rales Intercostal retractions

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?

PREOPERATIVE SCREENING
PFTs CXR ABG Cardiac evaluation CBC Pulmonologist evaluation

GETTING READY FOR THE PULMONARY IMPAIRED

Consider Chest PT Consider Glucocorticoids Consider Bronchodilators Advise patient to abstain from smoking 4-6 hours pre-op (1/2 life of CO) Consider H2 blockers Antibiotics in the face of pulm infection Check the FEV1 Consider diuretics if appropriate

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.

INDUCTION OF ANESTHESIA
Pre-O2 is prime! Denitrogenation Combination of agents must assure adequate depth of anesthesia prior to intubation! Agents: Thiopental, narcotics, volatile agents, lidocaine, ketamine, benzos, propofol

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 mixed venous gases Standard monitors

WHAT ABOUT INHALATIONALS?

Halothane & Sevoflurane
Potent bronchodilators in adults&children

Desflurane
Airway irritant at >1MAC Requires slow introduction to avoid coughing issues Quickest off = fastest emergence of inhalationalsNathanson, M. et
al,Anesthesia&Analgesia 1995:81:1186-1190

Enflurane & Isoflurane

Bronchodilators May be irritants

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

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

MAINTAINING ANESTHESIA
Volatile anesthetic tailored to patient Controlled ventilation-watch your pressures! Warm & humidify the air Muscle relaxation tailored to patient Will your endpoint address extubation? Keep this in mind with your choices.

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

THE PATIENTS WHEEZING!

Albuterol administered via ETTaerosolized 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 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 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 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

PULMONARY CONSIDERATIONS
Thank you!