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Pulmonary Function

This detailed overview explores pulmonary anatomy, lung development from gestation to childhood, and the complexities of pulmonary function tests. It covers essential components like alveoli, bronchi, blood supply, and key metrics in lung volumes and gases. Additionally, it addresses preoperative assessments, risks associated with lung cancer, and cancer types. The staging and detection methods for lung cancer are also examined, along with specifics on respiratory failure and ventilatory settings. This resource is crucial for understanding lung health in clinical practice.

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Pulmonary Function

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  1. Pulmonary Function

  2. Anatomy • In utero lung development • Begins-21-28 day gestation • Complete at 16 weeks • Approx. 15-26 divisions

  3. 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

  4. Anatomy • Alveolar-Capillary membrane • 5 Layers- • alveolar epithelium • basement membrane • ground substance • basal membrane • capillary epithelium

  5. Anatomy • Bronchi • 23 branches from trachea to alveoli • larger airways lined with ciliated columnar • epithelium • flatten in the alveoli • mucociliated esculator

  6. Anatomy • Alveoli- • Type I • cover 90 % • make up 50 % • gas exchange • Type II • cover 10% • make up 50 % • lipoprotein- surfactant- decrease surface • tension

  7. 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

  8. 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)

  9. Anatomy • Blood supply • 2 fold • pulmonary artery • bronchial arteries off aorta

  10. Pulmonary Function Tests • Pre Operative Evaluation • Measures • lung volumes • elasticity • recoil • complaince

  11. 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)

  12. 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

  13. Surgical Incisions • Types • Post. Lat • Axillary • Ant. Lat • Median sternotomy • Thoracoabdominal • Clamshell • VATS • Up to one quarter functional loss

  14. Preoperative Risks • Increased • age • smoking • COPD • asthma • obesity • diabetes • poor nutritional state

  15. 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

  16. 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

  17. 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

  18. Lung Cancer • Etiology • cigarettes • alcohol • environmental • asbestos, radon,nickel, radiation, • arsenic, chromium, air pollution, • second-hand smoke

  19. Lung Cancer • Pathology • R>L secondary to 55% lung on R • Stages • proliferation • atypical nuclei • stratification • squamous metaplasia • CA in situ • invasive CA

  20. 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

  21. Lung Cancer • Types (cont) • Large Cell CA 10% • peripheral, early mets • Small Cell CA 20% • central, aggressive, early mets bone, • brain, chemo (!), oat cell

  22. Lung Cancer • Metastasis • typically, lobar>hilar>mediastinal (ipsilat) • exception, LLL>contralateral mediastinum • hematologous spread • liver, adrenals, bone, brain, kidneys, lung

  23. Lung Cancer • Detection • local symptoms • cough, pnemonia, hemoptysis, rib pain, • nerve involvement • distant symptoms • weight loss, bone pain, neurologic, • paraneoplastic,

  24. Lung Cancer • Staging • TNM • adopted 1986 • revised 1997

  25. 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

  26. 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

  27. Respiratory Failure • Ventilatory Settings • Tidal Volume 12-15 ml/kg • PEEP +5 (starting) • Rate 10-12 • Mode IMV • O2 % depends

  28. Respiratory Failure • Ventilator Weaning • pO2 > 70 • stable BP • Cause corrected • NIF > 30 • RR < 24 • pH > 7.35 • pCO < 50

  29. Respiratory Failure • Ventilators • + pressure vents 1950’s Scandinavia • polio • Excellent support • Negatives • decrease venous return • ^ dead space • ^ work of breathing • ^ venous admixture

  30. 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

  31. 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

  32. 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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