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Respiratory problems in the OB PACU

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Respiratory problems in the OB PACU Tom Archer, MD, MBA Director, OB Anesthesia UCSD Hillcrest August 16, 2012 Pulmonary edema Increased capillary permeability (lung ... – PowerPoint PPT presentation

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Title: Respiratory problems in the OB PACU


1
Respiratory problems in the OB PACU
  • Tom Archer, MD, MBA
  • Director, OB Anesthesia
  • UCSD Hillcrest
  • August 16, 2012

2
Vast subject for one hour
  • Keep it practical and clinical.
  • Keep it focused on OB and PACU.
  • Enough anatomy and pathophysiology to give
    background and depth.

3
What we like from nurses and OBs
  • Get us involved early!
  • We should never be upset with your getting us
    involved early in patient care!
  • Morbid obesity
  • Asthma
  • Anesthesia fears, Hx of problems
  • Any significant medical problem

4
Use simple observation
  • Talk with and examine the patient.
  • Dont think too much about fancy tests.

5
Signs and symptoms
  • What is the patient experiencing? Talk to her! Is
    she cyanotic? Put her on O2!
  • What is her voice like?
  • Does sitting up make it better (diaphragm
    descends, lung expands)?
  • Can the patient move her arms and legs?

6
Signs and symptoms
  • How much air is the patient moving? Put your hand
    to her mouth.
  • What do you hear when you ask her to take a
    rapid, deep breath?
  • Has she had breathing problems in the past
    (asthma)?
  • What does she usually use (rescue inhaler)?

7
Signs and symptoms
  • What is the SpO2? Is the sensor applied properly?
    Same side as BP cuff?
  • What do you hear on auscultation?
  • Listen in all lung fields. Anything? Rales,
    wheezes, stridor?

8
Signs and symptoms
  • Rales too much fluid in the alveoli.
  • Wheezes (expiratory sound) narrowed
    intra-thoracic (bronchial) tubes
  • Stridor (inspiratory sound) narrowed
    extra-thoracic trachea or larynx.

9
Signs and symptoms
  • What are the neck veins like?
  • CXR essential for any serious problem
  • ABG nice if you can get it, but dont waste
    time and effort if you cant. Think arterial line
    for serial ABGs.

10
What is the patient experiencing? Talk to her!
  • Dont forget to talk with the patient!
  • When did the problem start?
  • Has this ever happened before?
  • Does she have chest pain?

11
Put her on O2! Is she cyanotic?
  • Cyanosis means there is de-oxygenated blood,
    blood is not matched with O2.
  • Blood that passes through the lung without
    getting exposed to oxygen.
  • Shunt or low V/Q

12
www.argentour.com/tangoi.html
The dance of pulmonary physiology Blood and
oxygen coming together.
13
Sometimes the match between blood and oxygen
isnt perfect!
http//www.bookmakersltd.com/art/edwards_art/3Prin
cessFrog.jpg
14
Failures of gas exchange
Shunt
Low V/Q
Alveolar dead space
Diffusion barrier
alveolus
capillary
High V/Q
15
ABGs
  • In respiratory distress, we expect both PO2 and
    PCO2 to be decreased.
  • If PO2 is decreased and PCO2 is increased, this
    is a true emergency!
  • Normally, hyperventilated parts of lung will
    compensate for hypoventilated parts of lung for
    CO2, but not for O2

16
Respiratory changes of pregnancy Mother-to-be is
consuming more O2, producing more CO2 and is
breathing harder!
17
Mom 4 ml O2 / kg / min
Feto-placental unit 12 ml O2 / kg / min
Mother is consuming and delivering oxygen for
two!
www.studentlife.villanova.edu
18
At term, mother has respiratory alkalosis with
metabolic compensation (less HCO3- buffer).
ABGs Non-pregnant At term
PaCO2 40 30
PaO2 100 103
pH 7.40 7.44
HCO3- 24 18
Chestnut
19
Functional residual capacity (FRC) gas left in
the lung after we breathe out.
20
Functional residual capacity (FRC) is our air
tank for apnea.
www.picture-newsletter.com/scuba-diving/scuba...
from Google images
21
Pregnant Mom has a smaller air tank.
Non-pregnant woman
www.pyramydair.com/blog/images/scuba-web.jpg
22
Pregnant patient has less margin of safety for
apnea.
  • If pregnant patient stops breathing she will
    desaturate faster than non-pregnant patient.
  • Apnea from hypotension, seizure, anesthesia
    induction, high spinal, magnesium overdose, etc.)

23
Ramping up the obese patient to facilitate
intubation. Sitting up will also help any
respiratory problem in the PACU.
www.airpal.com/ramp.htm
24
Specific respiratory problems
25
Asthma-- has she had breathing problems in the
past?
26
Wheezing
  • Expiratory sound.
  • Worse with low lung volumes.
  • Smooth muscle contraction airway edema
    secretions
  • Sit patient up / beta agonist rescue inhaler /
    steroid?

27
Wheezing is not a complete diagnosis
  • Smooth muscle spasm (bronchospasm) can cause
    wheezing.
  • Airway edema can cause wheezing (fluid overload,
    CHF)

28
All That Wheezes Is Not Asthma Diagnosing the
Mimics www.mdchoice.com/emed/main.asp?template0
pag...
29
He3 MR showing ventilation defects in a normal
subject and in increasingly severe asthmatics.
Author Samee, S Altes T Powers P de Lange
EE Knight-Scott J Rakes G Title Imaging the
lungs in asthmatic patients by using
hyperpolarized helium-3 magnetic resonance
assessment of response to methacholine and
exercise challenge Journal Title Journal of
Allergy Clinical Immunology Volume 111   Issue
6   Date 2003   Pages 1205-11
30
(No Transcript)
31
Pulmonary edema
www.learningradiology.com/.../cow267lg.jpg
32
Pulmonary edema is not a complete diagnosis!
  • Too much water in the lung.
  • Hydrostatic pressure heart failure or simple
    fluid overload.
  • Alveolar capillary damage and fluid leak
    aspiration, sepsis (both lead to ARDS).

33
Pulmonary edema
  • Hydrostatic too much pressure in the alveolar
    capillaries (normal lung too much fluid
    pressure).
  • Too much IV fluid (pre-eclampsia)
  • Congestive heart failure (peripartum
    cardiomyopathy? LV failure with pre-eclampsia?)
  • Renal failure

www.learningradiology.com/.../cow267lg.jpg
34
Pulmonary edema
  • Increased capillary permeability (lung damage).
  • Pre-eclampsia
  • Aspiration (usually with GA)
  • Sepsis (chorioamnionitis)
  • Anaphylaxis (antibiotics)
  • Pulmonary embolus
  • Amniotic fluid embolus (very rare)

www.learningradiology.com/.../cow267lg.jpg
35
Atelectasis
  • An area of lung is compressed.
  • External compression (obesity, pregnancy, supine
    posture)
  • Gas absorption (mucus plug) or after right
    mainstem bronchus intubation.
  • Treatment is upright posture, deep breathing and
    removal of mucus plugs.

36
Atelectasis in obesity dependent regions
37
Atelectasis left upper lobe
www.med.yale.edu/.../graphics/rad1.gif
38
Right mainstem bronchus intubation
39
Has her voice changed? Does she have stridor?
  • Voice change larynx change
  • Edema from ETT trauma
  • Edema from pre-eclampsia
  • Allergic reaction (hereditary angioedema).

40
The AIRWAY can be closed off by swelling of
tongue or larynx.
41
Normal larynx
http//www.dochazenfield.com/images/Larynx_side-by
-side_Rotated_Labeled.gif
42
Laryngeal edema voice change or stridor
43
http//www.healthsystem.virginia.edu/Internet/Anes
thesiology-Elective/images/anesth0018.jpg
44
Stridor
  • Inspiratory crow. Listen with stethoscope over
    the neck as part of your exam.
  • Stridor suggests obstruction in the trachea,
    vocal cords or throat.

45
Neuromuscular paralysis can the patient move her
arms and legs?
  • Did she recently get a dose of epidural local
    anesthetic (for post-op pain relief)?
  • Does she have a high spinal or epidural?
  • Did she get a GA? Does she have residual
    neuromuscular blockade?

46
Can the patient move her arms and legs?
  • Magnesium will exacerbate neuromuscular disease
    or neuromuscular blocking agents.
  • Does she have unrecognized neuromuscular disease?
  • Myasthenia gravis?

47
Pulmonary embolus
48
Pulmonary embolus
  • Can have normal chest x-ray.
  • Can have pain, or not.
  • Spiral CT is fancy test of choice.
  • V/Q scan is not nearly as good a test.

49
Pulmonary embolus
  • May be associated with hypotension.
  • May be associated with distended neck veins.

50
Pneumothorax
  • After GA and intubation
  • Feel for subcutaneous emphysema (air). Rice
    crispies at base of neck.
  • Tension pneumothorax would have distended neck
    veins and hypotension.

51
Tension pneumothorax
52
Distended neck veins
www.meddean.luc.edu/.../phyabn/image15.jpg
53
General measures
  • Put her on oxygen by mask, at least 6 L/min (but
    increasing rate beyond 6 makes little
    difference).
  • Sit her up in bed (but watch for hypotension if
    neuraxial block is in place).
  • Make sure SOB is not due to hypotension.

54
How much air is the patient moving? Put your hand
to her mouth.
  • With chest wall numbness patient does not feel
    herself breathing, but can be breathing very
    well.
  • If tidal volume really is decreased, this is a
    true emergency!

55
Respiratory emergency
  • Respiratory rate gt 24-30
  • Cyanosis or low sats
  • Rising CO2 (arterial)
  • Patient tiring out. Change in consciousness.
  • Seizure (think hypoxia and / or aspiration)

56
Respiratory emergency
  • Think anesthesiologist, oxygen, intubation,
    crash cart, Ambu bag, suction, getting to head of
    bed, call for ventilator, CXR.
  • But get patient well oxygenated before
    intubation, if possible, because of delay in
    intubation and rapid desaturation.

57
Summary
  • Respiratory problems are infrequent in OB young,
    healthy patients.
  • Take a good history.
  • Make simple, systematic observations.
  • Is the patient in bad trouble?

58
Summary
  • Please get us anesthesiologists involved early.
  • Thank you!

59
The End
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