Ch.23 Anesthesia for patients with respiratory disease

1
Ch.23 Anesthesia for patients with respiratory
disease

• ??? 1?
• ???

2
Introduction

• ?? ? ?? ???? pulmonary disease? ??? ??? ? ??.
• Pulmonary risk factors
• m/c 6 risk factors
• Cx Atelectasis, pneumonia, pulmonary embolism,
  respiratory failure ???? ?? ??.
• ???? ????? ?? ???? 2?? predictors? op site?
  dyspnea ?????.

3
Introduction

• Smoking? MMEF(maximal midexpiratory flow) rate?
  ?????? ?????.
• PFT? ????? ??? pulmonary compromise? ??? ? ?? ??
  ?? ????.
• ??? ???? ?? pulmonary disease? closing capacity?
  ????.
• Obesity FRC ??, WOB ??, DVT ??? ??
• Diaphragm ??? ???
• diaphragmatic dysfx.? restrictive
  ventilatory defect? ????, FRC? ?????,
• microatelectasis, loss of lung volume?
  ????.

4
Obstructive pulmonary disease

• Asthma, emphysema, chronic bronchitis, cystic
  fibrosis, bronchiectasis, bronchiolitis ? ????.
• ?? ??? ??? airway resistance??.
• MMEF(FEF25-75)lt70 ?? ?? ???? abnormality
• ????? ??? gt2.0L/s ,??? gt1.6L/s
• FEV1, FEV1/FVC ? ? 70 ??? ????.
• Airway resistance ? air trapping
• V/Q imbalance? ?????.
• residual volume, TLC ?? ????.
• Obstruction? ?????, ??? expiratory wheezing?
  ????, ??? insp.and exp. Wheezing? ?? ???.

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Obstructive pulmonary diseaseAsthma

• Preoperative consideration
• 5-7???
• 3?? ?? Airway inflammation, hyperreactivity,
  reversibility
• Airborne substance, pollens, animal danders,
  dusts, pollutants?? ?? ???? ,
• ?? ????? aspirin, NSAID, sulfiting agents,
  tartrazine?? ?? ?? ??.
• Exercise, emotional excitement, viral infetions
  ?? bronchospasm? ????.
• Extrinsic (allergic) asthma? intrinsic asthma?
  ???? ?? ???? ??? ??? ?? ???, chronic bronchitis?
  ?? overlap ??.

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Obstructive pulmonary diseaseAsthma

• Pathophysiology
• ?????? ????? ?? bronchial mast cell?? chemical
  mediators? ???? bronchospasm? ????.
• Classic allergic asthma??? mast cell ??? IgE? Ag?
  ?? degranulation ???
• ?? histamine? ???? bronchoconstriction ??
• ?????? bronchial tone? ????? ?? ??? ?? , diurnal
  variation? ??.
• ?? 6?? peak airway resistance? ???.
• Bronchi? ?? Vagal afferents? histamine, cold air,
  inhaled irritants, instrumentation(trachea
  intubation)? sensitive??, reflex vagal
  activation? ?? bronchoconstriction? ????.

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Obstructive pulmonary diseaseAsthma

• Asthma attack?, Bronchoconstriction, mucosal
  edema, secretion? ?? ?? lower airway? gas flow?
  ??? ?????.
• Phagocytose? allergen ? ???? ?? allergen? mast
  cell? ??? ??? degranulation? ??? ??
• Attack? ???? ?? ??? ???? ????.
• Prolonged or severe attack? WOB ?????, hypoxemia,
  tachypnea, hypocapnia ? ???, PaCO2? ????? ??? ???
  ? ?? ??? ??? ? ??? ?? ????.
• Pulsus paradoxus? ECG??? ??? ? ??.

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Obstructive pulmonary diseaseAsthma

• Treatment
• B-adrenergic agonist, methylxanthines,
  glucocorticoids, anticholinergics, leukotriene
  blockers, mast cell stabilizing agents
• Prevention cromolyn sodium, nedocromil
• Sympathomimetics? ?? ???
• b2 agonist? bronchodilation terburaline ,
  albuterol by metered dose inhaler or aerosol
• Theophylline ? narrow therapeutic
  range(10-20ug/mL)? ???? ??.
• Glucocorticoid ????? ???, beclomethasone,
  triamcinolone, fluticasone, budesonide? ??.

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Obstructive pulmonary diseaseAsthma - anesthetic
considerations

• Anesthetic considerations
• Preoperative management
• ?? ??? ??? acute attack?? ?? ?? ?? ??? ?? ????
  ??.
• Dyspnea, wheezing ,medication?? ??? , ??? ??
  attack? ??? ?? Clinical history ? ????.
• Chest PA? air trapping? ??? ??.
• PFTs(FEV1,FEV/FVC)? clinical impression? ????.
• ?? PFT ??? ??? ????.
• attack? ? ??? ?? ???? ? ?, aerosol b2-agonist ?
  IV steroid ?? reversible ??? ??? ????, ABGA? ???
  ??.

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Obstructive pulmonary diseaseAsthma - anesthetic
considerations

• Premedication
• BDZ?? ???? preop sedation ??? ????.
• ??? secretion? ??? anticholinergic agent? ???
  ???.
• H2blocker (such as cimetidine, ranitidine,
  famotidine)? ????? bronchodilatioin? ?????, ???
  ?? H1 recepter? activating ?? bronchoconstriction?
  ???? ? ???? ??? ?? ??.
• Bronchodilator? ?? ?? ??? ?? ??? ??.
• Long term glucocorticoid? ?? ?? ???? adrenal
  suppression ?? ?? ??? ??? Hydrocortisone
  (50-100mg)??, ?? ? 8???? 100mg? ??.

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Obstructive pulmonary diseaseAsthma - anesthetic
considerations

• Intraoperative management
• ??? ?? ??? ??? instrumentation (trachea
  intubation) ? ???.
• ?? ?? ??? Emotional stress , pain, stimulation?
  ?? bronchospasm? ??? ? ??.
• Histamine release ? ??? ?? ??? ??.
• Curare, atracurium, mivacurium, morphine,
  meperidine, thiopental
• Succinylcholine? ?? ??? histamine release ????
  ??? ?????? ???? ????.

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Obstructive pulmonary diseaseAsthma - anesthetic
considerations

• ??? ??? Smooth induction? emergence ???
  stiumulation? ??? ? ?? ?? ????.
• Propofol ? etomidate? ????.
• Halothane, sevoflurane ? ????? bronchodilation
  ??? smooth induction ? ? ?? ?
• Desflurane, isoflurane? ??? mild irritant effect?
  ??.
• Reflex bronchospasm intubation ?? 2-3 MAC??
  volatile inhalation ??? ??? thiopental(12mg/kg)
  ?? IV lidocaine (12mg/kg) ?????? ??? ? ??.

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Obstructive pulmonary diseaseAsthma - anesthetic
considerations

• Tidal volume? 10ml/kg ??? ??, expiratory time?
  ???? ? ?? gas flow? ???? ???? , air trapping?
  ???.
• Intraoperative bronchospasm
• Wheezing? ???, Peak pressure ? ????, expiratory
  tidal volume? ????? capnograph?? rising waveform?
  ????.
• ?? volatile gas? ????
• B agonist by aerosol, IV hydrocortisone(1.5-2mg/kg
  )
• ?? ?? ?? tracheal tube ??, bronchial intubation?
  
• Deep extubation, lidocaine (1.5-2mg/kg) bolus?
  ??? ?

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Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Preoperative considerations
• Cigarette smoking? ???? ??.
• ???? ??? asymptomatic??? mildly symptomatic
  ????? PFT? expiratory airflow obstruction? ????.
• ??? obstruction? bronchodilator? ?? ????? ??
• Chronic bronchitis ? emphysema? ????.

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Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Chronic bronchitis
• ?? ??? 2?? 3? ??? productive cough ??? ??
• ??? bronchial mucous glands ? mucosal edema ? ??
  airflow obstruction? ???
• Recurrent pulmonary infection ? ??? bronchospasm
  ? ???? ??.
• RV? ????? TLC? ????.

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Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Emphysema
• Terminal bronchiole ??? airway? irreversible
  enlargement ? destruction of alveolar septa ??
  ??.
• CT? ??? ? ?? ?? cigarette smoking? ???? ??.
• Elastic recoil? ???? expiration? premature
  collapse? ????.
• ? RV, FRC, TLC, RV/TLC ratio ?? ??
• Alveolar septa ? pulmonary capillary? ??? DLCO
  capacity? ????, pulmonary HTN ? ????.
• Large cystic areas ? bullae? ?? Dead space? ????
  ??.
• PaO2 ? ?? ????? ???? PaCO2? ????.

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Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Treatment
• ?? ?? ??? ? ??? ??
• Reversibility? ?? ???? long term bronchodilator?
  ??
• -inhaled b2 adrenergic agonists,
  glucocorticoids, ipratropium? ?? ??
• ??? ?? ??? sputum ??? ? ? ??.-antibiotics? ??
• Hypoxemia?? ???? supplemental oxygen ?? ??
• PaO2? 55mmHg ???? pulmonary hypertension? ?? ??
  low-flow oxygen therapy (12L/min)
• Oxygen therapy? PaCO2? ??? ???? ? ??? PaO2?
  60mmHg???? ?? ? respiratory failure? ?? ? ??.
• Cor pulmonale? pulmonary edema? ??? diuretics ??

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Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Anesthetic considerations
• Preoperative management
• ?? dyspnea, sputum, wheezing? ??? ??? ???? ?
• FEV1lt25 (lt1L) ?? ??? ????? dyspnea? ????,
  chronic bronchits?? ?? CO2 retention, pulmonary
  HTN? ???? ??.
• PFTs, CXR, ABGA? ???? ?
• Bullous change? ?? ?? ??? ?? ??? ??,
• ?? ???? cardiac disease? ??? ???? ?? ??
  cardiovascular evaluation? ?? ?

19
Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Anesthetic considerations
• Preoperative management
• Asthma?? ?????, preoperative preparation??? ??
  ??? ????? ?? ????, ???? ???? hypoxemia ??
  ,relieving bronchospasm, reducing secretions,
  mobilizing, treating infection ? ??
• ??? 68? ?? ??? ? ? ????? ?? ? ??. 24?? ?? ??????
  methemoglobin? ??? ???? Hb? ?? ?? ??? ?? ???.
• Chest physiotherapy? antibiotics? secretion? ???
  ? ??? ??.
• Bronchodilator(bronchospasm), glucocorticoid(sever
  e disease),oxygenation(pulmonary HTN), periop
  digitalization(cor pulmonale, Rt ventricular
  failure)

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Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Intraoperative management
• General ?? Regional anesthesia? ??
• ???, high spinal or epidural anesthesia? lung
  volume? ???? ? ??, ?????? ?????, dyspnea?
  secretion retention? ????.
• Preoxygenation? ???? Anesthetic agents ???
  asthmatic patient? ??
• Moderate and severe disease? ?? ??? ?? expiratory
  obstruction? ?? ? ??.
• Ventilation TV? ?? ?? slow rating ???. ? air
  trapping? ?? ? ??.
• Humidified gas? ???? ??, NO? ??? ??. bullae?
  pul. HTN ?? ???? pneumothorax , pulmonary
  artery pressure ????

21
Obstructive pulmonary diseaseChronic obstuctive
pulmonary disease

• Intraoperative management
• ???? ???? ? ?? ?? ?? ? ABGA ???
• Ventilation? arterial pH ? ???? ????? ??
• PaCO2? ?????? ?? ? CO2 retention ? ????
  alkalosis? ????.
• pulmonary HTN?? CVP monitorin ??.
• Pulmonary bullae? ?? ???? positive pressure? ??
  ??? ?? ? ??.
• Tension PTx? ???, ????, peak Paw? ??,TV??? ????
  ??.
• ???? ??? 2nd intercostal space? midclavicular
  line ? intercather ? ???? ??.
• ?? ?? Early extubation

22
Restrictive pulmonary disease

• ??
• - Lung compliance? ??
• - Lung vol.? ??
• - WOB ??
• FEV1?FVC? ????, FEV1/FVC? ??
• Acute and chronic intrinsic pulmonary disorders?
  extrinsic disorder (pleura, chest wall,
  diaphragm, or neuromuscular function)? ????.

23
Restrictive pulmonary diseaseAcute intrinsic
pulmonary disorders

• ARDS, infectious pneumonia, aspiration
  pneumonitis
• Preop. Consideration
• Extravascular lung water? ??? lung compliance ??
• ARDS?? Fluid overload, permeability??? ??

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Restrictive pulmonary diseaseAcute intrinsic
pulmonary disorders

• Anesthetic considerations
• Preop management
• Oxygenation, ventilation ???
• Fluid overload? diuretics
• HF? inotropics
• Large pleural effusion? drainage
• Persistent hypoxemia? PEEP

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Restrictive pulmonary diseaseAcute intrinsic
pulmonary disorders

• Intraop management
• High oxygen with PEEP? Paw ? 30???
• TV? 48ml/kg , ventilatory rate ? 1418?/min
• Aggressive hemodynamic monitoring

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Restrictive pulmonary diseaseChronic intrinsic
pulmonary disorders

• Interstitial lung disease?? ? ?
• ?? insidious onset, chronic inflammation,
  progressive pulmonary fibrosis
• ?? ??? ???, drug toxicity, radiation
  pneumonitis, idiopathic , autoimmune,
  sarcoidosis, chronic pulmonary aspiration, oxygen
  toxicity, severe ARDS

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Restrictive pulmonary diseaseChronic intrinsic
pulmonary disorders

• Preop. Considerations
• ????? dyspnea on exertion, ??? nonproductive
  cough ??
• P/E fine crackles
• CXR ground-glass, honeycomb
• ?? ??? ??? ??, further exposure? ????.
• Glucocorticoid, oxygen

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Restrictive pulmonary diseaseChronic intrinsic
pulmonary disorders

• Anesthetic considerations
• Preop management
• ????? ?? ??? ??? ??? ????? ??
• PFTs, ABGA, VC(15mL/kg??? severe dysfunction?
  ???.)
• Intraop management
• Control ventilation ?? Drug selection ?? ??
• ? FRC? ???? ?? ??? induction? rapid hypoxemia ??
  ??.
• ?? ???? ??(SpO2gt8892???)
• Smaller TV with a faster rate

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Pulmonary embolismPreop considerations

1. Blood clots, fat, tumor cells, air, amniotic
   fluid, or foreign material ? venous system?? ????
   ??.
2. ????? ?? blood clots? m/c ??? ??.

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Pulmonary embolismPreop considerations

• Pathophysiology
• Embolic occlusion ? dead space, pulmonary shunt,
  hypoxemia? ????
• Affected area? surfactant? ???? ?? 12? ??
  atelectasis? ??, ?? ? vessels? ???, pulmonary
  infarction? ??? ? ??.
• ???? ??? ??? 50? ??? pulmonary HTN? ??? ,??
  cardiac or pulmonary disease? ??? ??? ??? ?? ???
  pulmonary HTN? ?? ? ??.
• Thrombus? ?? 12? ? ???? ????.

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Pulmonary embolismPreop considerations

• Diagnosis
• Sudden tachypnea, dyspnea, chest pain,
  hemoptysis(? infarction??)
• Wheezing, ABGA? hypoxemia with respiratory
  alkalosis
• CXR wedge shaped density with an infart
• Cardiac sign tachycardia, S2? wide fixed
  splitting, hypotension with elevated CVP(?Rv
  failure???)
• ECG tachycardia, new right axis deviation, RBBB,
  tall T wave
• Pulmonary angiography(most accurate),perfusion
  ventilation scans

32
Pulmonary embolismPreop considerations

• Treatment
• Best treatment prevention
• Heparin 5000U subcu. every 12hr(high risk)
• Warfarin, aspirin, or dextran therapy
• Early ambulation, elastic stockings, pneumatic
  compression
• Thrombolytic therapy ? Cix
• Massive pulmonary embolism or circulatory
  collapse, ?? ??, active bleeding
• ? ???? IVC umbrella filter??

33
Pulmonary embolismAnesthetic considerations

• Intraop management
• Vena cava filters? sedation??? ??
• ?? anesthetic agents? ???? hypotension? ? ??
• Anestheia? ??? ??? ???, regional anesthesia? ?? ?
  DVT? ???? ???? ??? bleeding time? ??? ???? C/I.
• Pulmonary embolectomy
• Positive pressure ventilation, all anesthetic
  agents ? ?? poor tolerated ?
• opiod, etomidate, ketamine ? small dose? ???? ??
  , CPB? ???

34
Pulmonary embolismAnesthetic considerations

• Intraop pulmonary embolism
• Significant pul. Embolism? ??? ????? high
  suspicion? ????
• Air embolism? ???? ?? ???? ??? ??, ???? ?? ? fat
  embolism? ?? ???? ??.
• Thromboembolism? ??? ??? ? ? ?? ?? ?? clot?
  surgical manipulation, position change? ?? ????
  ?? ? ??.
• ????? hypotension, hypoxemia, bronchospasm ?? ?
  ??.
• TEE ???? air? Rt. Atrium?? ???? ?? central venous
  cannulation? ?? ??? aspiration ?? ??.
• ?? ?? emboli? ??? supportive??, IV fluid,
  inotropes,? ????.