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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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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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