Pulmonary function
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Pulmonary Function. Anatomy. In utero lung development Begins-21-28 day gestation Complete at 16 weeks Approx. 15-26 divisions. Anatomy. True alveoli @ 28 weeks Continue past birth, with 20 mil @ birth 300 mil @ 10 yrs (peak) Lung volume- 80% air 10% blood

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Pulmonary Function

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Pulmonary function

Pulmonary Function


Anatomy

Anatomy

  • In utero lung development

  • Begins-21-28 day gestation

  • Complete at 16 weeks

  • Approx. 15-26 divisions


Anatomy1

Anatomy

  • True alveoli @ 28 weeks

  • Continue past birth, with 20 mil @ birth

  • 300 mil @ 10 yrs (peak)

  • Lung volume-

  • 80% air

  • 10% blood

  • 10% solid tissue


Anatomy2

Anatomy

  • Alveolar-Capillary membrane

  • 5 Layers-

  • alveolar epithelium

  • basement membrane

  • ground substance

  • basal membrane

  • capillary epithelium


Anatomy3

Anatomy

  • Bronchi

  • 23 branches from trachea to alveoli

  • larger airways lined with ciliated columnar

  • epithelium

  • flatten in the alveoli

  • mucociliated esculator


Anatomy4

Anatomy

  • Alveoli-

  • Type I

  • cover 90 %

  • make up 50 %

  • gas exchange

  • Type II

  • cover 10%

  • make up 50 %

  • lipoprotein- surfactant- decrease surface

  • tension


Anatomy5

Anatomy

  • Bony Thorax

  • 12 ribs

  • 1-5 attach to sternum

  • 6-10 fuse to costal cartilage arch

  • 11-12 free floating

  • Lobe sections

  • R- 3 lobes, major & minor fissure 10 segs

  • L- 2 lobes, major fissure 8 segs


Anatomy6

Anatomy

  • Lymphatics

  • generally drain to ipsilateral hilum

  • from intralobar nodes

  • mediastinal nodes drain cephadal

  • exception- LLL may > R mediastinal

  • Nerves

  • none in parenchyma

  • rich in parietal pleura (painful chest tube)


Anatomy7

Anatomy

  • Blood supply

  • 2 fold

  • pulmonary artery

  • bronchial arteries off aorta


Pulmonary function tests

Pulmonary Function Tests

  • Pre Operative Evaluation

  • Measures

  • lung volumes

  • elasticity

  • recoil

  • complaince


Pulmonary function tests1

Pulmonary Function Tests

  • Blood Gases

  • pO2

  • pCO2 >43-45 severe functional loss

  • i.e. > 50 %

  • Volume measurements

  • FEV1 normal > .8L ^ risks if less

  • FEV1/FVC ratio

  • obstructive- ratio low

  • restrictive- ratio normal (both reduced)


Pulmonary function tests2

Pulmonary Function Tests

  • Exercise Testing

  • DL CO- measures CO from alveoli to

  • hemoglobin (affinity >200 times)

  • <50% high risk of failure

  • VO2-(max O2 consumption)

  • <15 ml/min/kg high risk

  • Vent/Perfusion scan functional segments

  • Clinical- stair climb 1,wedge 2,lobe 3,lung


Surgical incisions

Surgical Incisions

  • Types

  • Post. Lat

  • Axillary

  • Ant. Lat

  • Median sternotomy

  • Thoracoabdominal

  • Clamshell

  • VATS

  • Up to one quarter functional loss


Preoperative risks

Preoperative Risks

  • Increased

  • age

  • smoking

  • COPD

  • asthma

  • obesity

  • diabetes

  • poor nutritional state


Preoperative treatment

Preoperative Treatment

  • Smoking cessation- >2 wks, ideal > 4-6 wks

  • Bronchodialators

  • Antibiotics- Bronchitis

  • Steriods- short term

  • Incentive Spirometry training

  • DVT prophylaxis

  • Sub-q heparin or equal

  • Compression device

  • Consider- epidural, nerve blocks, PCA’s


Lung cancer

Lung Cancer

  • General

  • 173,000 new yearly

  • 14% all cancer

  • 28% all cancer deaths (most freq)

  • decrease mortality in men 1991-1996

  • increase in women since 1987 > breast CA

  • lag in smoking cessation


Lung cancer1

Lung Cancer

  • Survival

  • Overall 5 year 14%

  • Regional disease 20 %

  • Distant disease 2 %

  • Only 15% localized at time of dx

  • Stage I & II– generally surgery

  • Stage IIIA and up—generally XRT, chemo


Lung cancer2

Lung Cancer

  • Etiology

  • cigarettes

  • alcohol

  • environmental

  • asbestos, radon,nickel, radiation,

  • arsenic, chromium, air pollution,

  • second-hand smoke


Lung cancer3

Lung Cancer

  • Pathology

  • R>L secondary to 55% lung on R

  • Stages

  • proliferation

  • atypical nuclei

  • stratification

  • squamous metaplasia

  • CA in situ

  • invasive CA


Lung cancer4

Lung Cancer

  • Types

  • Adeno CA 45%

  • peripheral, early mets, mucous cells

  • Bronchoalveolar CA <5%

  • subtype of adeno, best prognosis

  • Squamous Cell CA 30%

  • centrally located, later mets, local invade


Lung cancer5

Lung Cancer

  • Types (cont)

  • Large Cell CA 10%

  • peripheral, early mets

  • Small Cell CA 20%

  • central, aggressive, early mets bone,

  • brain, chemo (!), oat cell


Lung cancer6

Lung Cancer

  • Metastasis

  • typically, lobar>hilar>mediastinal (ipsilat)

  • exception, LLL>contralateral mediastinum

  • hematologous spread

  • liver, adrenals, bone, brain, kidneys, lung


Lung cancer7

Lung Cancer

  • Detection

  • local symptoms

  • cough, pnemonia, hemoptysis, rib pain,

  • nerve involvement

  • distant symptoms

  • weight loss, bone pain, neurologic,

  • paraneoplastic,


Lung cancer8

Lung Cancer

  • Staging

  • TNM

  • adopted 1986

  • revised 1997


Lung cancer9

Lung Cancer

  • Special Circumstances

  • Superior Sulcus CA

  • Solitary pulmonary nodule

  • overall 33% CA

  • risk roughly age of patient

  • Molecular Markers

  • poor survival-DNA aneuploidy;

  • oncogenes KRAS, Her 2, p53 mutation


Respiratory failure

Respiratory Failure

  • Clinical Assessment

  • Distress

  • >24 breaths/min

  • accessory mm usage

  • color

  • O2 content difficult to tell

  • Pulse Ox

  • sat 90% approx pO2 of 60


Respiratory failure1

Respiratory Failure

  • Ventilatory Settings

  • Tidal Volume 12-15 ml/kg

  • PEEP +5 (starting)

  • Rate 10-12

  • Mode IMV

  • O2 % depends


Respiratory failure2

Respiratory Failure

  • Ventilator Weaning

  • pO2 > 70

  • stable BP

  • Cause corrected

  • NIF > 30

  • RR < 24

  • pH > 7.35

  • pCO < 50


Respiratory failure3

Respiratory Failure

  • Ventilators

  • + pressure vents 1950’s Scandinavia

  • polio

  • Excellent support

  • Negatives

  • decrease venous return

  • ^ dead space

  • ^ work of breathing

  • ^ venous admixture


Respiratory failure4

Respiratory Failure

  • Ventilators

  • favor flow to nongravity dependent

  • portions of lung, ^ shunt

  • O2 deficits not correctable with PPV

  • alone

  • Fighting the vent

  • hypercarbia, acidemia, CNS problems,

  • low O2, pain, anxiety


Respiratory failure5

Respiratory Failure

  • Ventilator Modes

  • PPV deliver TV without ^ MAP

  • large TV- dec deadspace,atelectasis

  • Control Mode Ventilation

  • frequency and depth independent of

  • patient’s response

  • Assist Control Mode

  • initiates breath whenever preset limit

  • is hit by patient


Respiratory failure6

Respiratory Failure

  • Ventilator Modes (cont)

  • Intermittent Mandatory Ventilation (IMV)

  • PPV independent of patient

  • no impedence to spontanous breath

  • + gas flow

  • SIMV

  • synchronized to patient

  • assist control w/ spontanous ventilation

  • ^ work of breathing, demand flow


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