Pulmonary FunctionPulmonary Function

AnatomyAnatomy

In utero lung developmentIn utero lung development Begins-21-28 day gestationBegins-21-28 day gestation Complete at 16 weeksComplete at 16 weeks Approx. 15-26 divisionsApprox. 15-26 divisions

AnatomyAnatomy

True alveoli @ 28 weeksTrue alveoli @ 28 weeks Continue past birth, with 20 mil @ birthContinue past birth, with 20 mil @ birth 300 mil @ 10 yrs (peak)300 mil @ 10 yrs (peak) Lung volume-Lung volume- 80% air80% air 10% blood10% blood 10% solid tissue10% solid tissue

AnatomyAnatomy

Alveolar-Capillary membraneAlveolar-Capillary membrane 5 Layers-5 Layers- alveolar epitheliumalveolar epithelium basement membranebasement membrane ground substanceground substance basal membranebasal membrane capillary epitheliumcapillary epithelium

AnatomyAnatomy

BronchiBronchi 23 branches from trachea to alveoli23 branches from trachea to alveoli larger airways lined with ciliated columnarlarger airways lined with ciliated columnar epitheliumepithelium flatten in the alveoliflatten in the alveoli mucociliated esculatormucociliated esculator

AnatomyAnatomy

Alveoli-Alveoli- Type IType I cover 90 %cover 90 % make up 50 %make up 50 % gas exchangegas exchange Type IIType II cover 10%cover 10% make up 50 %make up 50 % lipoprotein- surfactant- decrease surfacelipoprotein- surfactant- decrease surface tensiontension

AnatomyAnatomy

Bony ThoraxBony Thorax 12 ribs12 ribs 1-5 attach to sternum1-5 attach to sternum 6-10 fuse to costal cartilage arch6-10 fuse to costal cartilage arch 11-12 free floating11-12 free floating Lobe sectionsLobe sections R- 3 lobes, major & minor fissure 10 segsR- 3 lobes, major & minor fissure 10 segs L- 2 lobes, major fissure 8 segsL- 2 lobes, major fissure 8 segs

AnatomyAnatomy

LymphaticsLymphatics generally drain to ipsilateral hilumgenerally drain to ipsilateral hilum from intralobar nodesfrom intralobar nodes mediastinal nodes drain cephadalmediastinal nodes drain cephadal exception- LLL may > R mediastinalexception- LLL may > R mediastinal NervesNerves none in parenchymanone in parenchyma rich in parietal pleura (painful chest tube)rich in parietal pleura (painful chest tube)

AnatomyAnatomy

Blood supplyBlood supply 2 fold2 fold pulmonary arterypulmonary artery bronchial arteries off aortabronchial arteries off aorta

Pulmonary Function TestsPulmonary Function Tests

Pre Operative EvaluationPre Operative Evaluation MeasuresMeasures lung volumeslung volumes elasticityelasticity recoilrecoil complaincecomplaince

Pulmonary Function TestsPulmonary Function Tests

Blood GasesBlood Gases pO2pO2 pCO2 >43-45 severe functional losspCO2 >43-45 severe functional loss i.e. > 50 %i.e. > 50 % Volume measurementsVolume measurements FEV1 normal > .8L ^ risks if lessFEV1 normal > .8L ^ risks if less FEV1/FVC ratioFEV1/FVC ratio obstructive- ratio low obstructive- ratio low restrictive- ratio normal (both reduced)restrictive- ratio normal (both reduced)

Pulmonary Function TestsPulmonary Function Tests

Exercise TestingExercise Testing DL CO- measures CO from alveoli toDL CO- measures CO from alveoli to hemoglobin (affinity >200 times)hemoglobin (affinity >200 times) <50% high risk of failure<50% high risk of failure VO2-(max O2 consumption)VO2-(max O2 consumption) <15 ml/min/kg high risk<15 ml/min/kg high risk Vent/Perfusion scan functional segmentsVent/Perfusion scan functional segments Clinical- stair climb 1,wedge 2,lobe 3,lungClinical- stair climb 1,wedge 2,lobe 3,lung

Surgical IncisionsSurgical Incisions

TypesTypes Post. LatPost. Lat AxillaryAxillary Ant. LatAnt. Lat Median sternotomyMedian sternotomy ThoracoabdominalThoracoabdominal ClamshellClamshell VATSVATS Up to one quarter functional lossUp to one quarter functional loss

Preoperative RisksPreoperative Risks

IncreasedIncreased ageage smokingsmoking COPDCOPD asthmaasthma obesityobesity diabetesdiabetes poor nutritional statepoor nutritional state

Preoperative TreatmentPreoperative Treatment

Smoking cessation- >2 wks, ideal > 4-6 wksSmoking cessation- >2 wks, ideal > 4-6 wks BronchodialatorsBronchodialators Antibiotics- BronchitisAntibiotics- Bronchitis Steriods- short termSteriods- short term Incentive Spirometry trainingIncentive Spirometry training DVT prophylaxisDVT prophylaxis Sub-q heparin or equalSub-q heparin or equal Compression deviceCompression device Consider- epidural, nerve blocks, PCA’sConsider- epidural, nerve blocks, PCA’s

Lung CancerLung Cancer

GeneralGeneral 173,000 new yearly173,000 new yearly 14% all cancer14% all cancer 28% all cancer deaths (most freq)28% all cancer deaths (most freq) decrease mortality in men 1991-1996decrease mortality in men 1991-1996 increase in women since 1987 > breast CAincrease in women since 1987 > breast CA lag in smoking cessation lag in smoking cessation

Lung CancerLung Cancer

SurvivalSurvival Overall 5 year 14%Overall 5 year 14% Regional disease 20 %Regional disease 20 % Distant disease 2 %Distant disease 2 % Only 15% localized at time of dxOnly 15% localized at time of dx

Stage I & II– generally surgeryStage I & II– generally surgery Stage IIIA and up—generally XRT, chemoStage IIIA and up—generally XRT, chemo

Lung CancerLung Cancer

EtiologyEtiology cigarettescigarettes alcoholalcohol environmentalenvironmental asbestos, radon,nickel, radiation,asbestos, radon,nickel, radiation, arsenic, chromium, air pollution,arsenic, chromium, air pollution, second-hand smokesecond-hand smoke

Lung CancerLung Cancer

PathologyPathology R>L secondary to 55% lung on RR>L secondary to 55% lung on R StagesStages proliferationproliferation atypical nucleiatypical nuclei stratificationstratification squamous metaplasiasquamous metaplasia CA in situCA in situ invasive CAinvasive CA

Lung CancerLung Cancer

TypesTypes Adeno CA 45%Adeno CA 45% peripheral, early mets, mucous cellsperipheral, early mets, mucous cells Bronchoalveolar CA <5%Bronchoalveolar CA <5% subtype of adeno, best prognosissubtype of adeno, best prognosis Squamous Cell CA 30%Squamous Cell CA 30% centrally located, later mets, local invadecentrally located, later mets, local invade

Lung CancerLung Cancer

Types (cont)Types (cont) Large Cell CA 10%Large Cell CA 10% peripheral, early metsperipheral, early mets Small Cell CA 20%Small Cell CA 20% central, aggressive, early mets bone, central, aggressive, early mets bone, brain, chemo (!), oat cellbrain, chemo (!), oat cell

Lung CancerLung Cancer

MetastasisMetastasis typically, lobar>hilar>mediastinal (ipsilat)typically, lobar>hilar>mediastinal (ipsilat) exception, LLL>contralateral mediastinumexception, LLL>contralateral mediastinum hematologous spreadhematologous spread liver, adrenals, bone, brain, kidneys, lungliver, adrenals, bone, brain, kidneys, lung

Lung CancerLung Cancer

DetectionDetection local symptomslocal symptoms cough, pnemonia, hemoptysis, rib pain,cough, pnemonia, hemoptysis, rib pain, nerve involvementnerve involvement distant symptomsdistant symptoms weight loss, bone pain, neurologic,weight loss, bone pain, neurologic, paraneoplastic,paraneoplastic,

Lung CancerLung Cancer

StagingStaging TNMTNM adopted 1986adopted 1986 revised 1997revised 1997

Lung CancerLung Cancer

Special CircumstancesSpecial Circumstances Superior Sulcus CASuperior Sulcus CA Solitary pulmonary noduleSolitary pulmonary nodule overall 33% CAoverall 33% CA risk roughly age of patientrisk roughly age of patient Molecular MarkersMolecular Markers poor survival-DNA aneuploidy; poor survival-DNA aneuploidy; oncogenes KRAS, Her 2, p53 mutationoncogenes KRAS, Her 2, p53 mutation

Respiratory FailureRespiratory Failure

Clinical AssessmentClinical Assessment DistressDistress >24 breaths/min>24 breaths/min accessory mm usageaccessory mm usage colorcolor O2 content difficult to tellO2 content difficult to tell Pulse OxPulse Ox sat 90% approx pO2 of 60sat 90% approx pO2 of 60

Respiratory FailureRespiratory Failure

Ventilatory SettingsVentilatory Settings Tidal Volume 12-15 ml/kgTidal Volume 12-15 ml/kg PEEP +5 (starting)PEEP +5 (starting) Rate 10-12Rate 10-12 Mode IMVMode IMV O2 % dependsO2 % depends

Respiratory FailureRespiratory Failure

Ventilator WeaningVentilator Weaning pO2 > 70pO2 > 70 stable BPstable BP Cause correctedCause corrected NIF > 30NIF > 30 RR < 24RR < 24 pH > 7.35pH > 7.35 pCO < 50pCO < 50

Respiratory FailureRespiratory Failure

VentilatorsVentilators + pressure vents 1950’s Scandinavia+ pressure vents 1950’s Scandinavia poliopolio Excellent supportExcellent support NegativesNegatives decrease venous returndecrease venous return ^ dead space^ dead space ^ work of breathing^ work of breathing ^ venous admixture^ venous admixture

Respiratory FailureRespiratory Failure

VentilatorsVentilators favor flow to nongravity dependentfavor flow to nongravity dependent portions of lung, ^ shuntportions of lung, ^ shunt O2 deficits not correctable with PPV O2 deficits not correctable with PPV alonealone Fighting the ventFighting the vent hypercarbia, acidemia, CNS problems,hypercarbia, acidemia, CNS problems, low O2, pain, anxietylow O2, pain, anxiety

Respiratory FailureRespiratory Failure

Ventilator ModesVentilator Modes PPV deliver TV without ^ MAPPPV deliver TV without ^ MAP large TV- dec deadspace,atelectasislarge TV- dec deadspace,atelectasis Control Mode VentilationControl Mode Ventilation frequency and depth independent offrequency and depth independent of patient’s responsepatient’s response Assist Control ModeAssist Control Mode initiates breath whenever preset limitinitiates breath whenever preset limit is hit by patientis hit by patient

Respiratory FailureRespiratory Failure

Ventilator Modes (cont)Ventilator Modes (cont) Intermittent Mandatory Ventilation (IMV)Intermittent Mandatory Ventilation (IMV) PPV independent of patientPPV independent of patient no impedence to spontanous breathno impedence to spontanous breath + gas flow+ gas flow SIMVSIMV synchronized to patientsynchronized to patient assist control w/ spontanous ventilationassist control w/ spontanous ventilation ^ work of breathing, demand flow^ work of breathing, demand flow