Anesthesia considerations
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?
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
Turbulent
Resistent greatly increased Occurs when Reynolds number >2000 Can be auscultated when caused by sudden bronchoconstriction
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
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?
PLEURAL EFFUSION
Inc resp rate Tracheal deviation Dec. fremitus (tactile&vocal) Dec. breath sounds Friction rub after fluid is removed
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
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?
PREOPERATIVE SCREENING
PFTs CXR ABG Cardiac evaluation CBC Pulmonologist evaluation
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
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
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.
Awake extubation after evaluation of recovery from muscle relaxants, gases FEV1 >50%
PULMONARY CONSIDERATIONS
Thank you!