RESTRICTIVE LUNG DISEASE

1
RESTRICTIVE LUNG DISEASE

• AN OVERVIEW
• Martha Richter, MSN, CRNA

2
RESTRICTIVE LUNG DISEASE

• OBJECTIVES
• The student will
• Describe basic principles for this diagnostic
  group
• Compare 2 differences with this group and those
  with obstructive disease
• List 2 desired outcomes of Anesthetic care

3
RESTRICTIVE LUNG DISEASE

• An interstitial disease with inflammatory and
  fibrotic changes in interstitium/interalveolar
  septum
• Characterized by dec lung compliance, normal
  airway resistance, decreased diffusion capacity,
  dec LV, varying degrees of hypoxemia

4
RESTRICTIVE LUNG DISEASE

• THEORY
• There is a common pathogenesis
• Injury to alveolar epithelium-inflam process
  involves alveoliinterstitium-accum of inflam and
  immune cells continues lung tissue
  damage-normal tissue is replaced with fibrous scar

5
RESTRICTIVE LUNG DISEASE

• INTRINSIC
• Pulmonary edema-fluid accumulates in interstitium
  alveoli by hydrostatic, cardiogenic or
  non-cardiogenic mechs.
• Pulmonary Interstitial Disease-inflam/fibrosis of
  interstit., alveoli or vasc. Beds. (may lead to
  PH Cor pulmonale) Sarcoid, radiation fibrosis,
  chronic hypersensitivity pneumonia

6
RESTRICTIVE LUNG DISEASE

• Acute intrinsic
• pulmonary edema(movement of intravasc fld into
  lung interstit alveoli secondary to inc pulm
  vasc press)
• Chronic intrinsic
• Pulmonary fibrosis caused by radiation injury,
  cytotoxic and noncytotoxic drug reaction, O2
  toxicity, autoimmune disease, Sarcoidosis

7
RESTRICTIVE LUNG DISEASE

• Chronic extrinsic
• Disorders that inhibit normal lung excursion.
  Includes flail chest, pneumothorax, pleural
  effusion, ascites, obesity, pregnancy,
  neuromuscular disease

8
RESTRICTIVE LUNG DISEASE

• EXTRINSIC
• Pleural disease-fibrosis/effusion
• Chest wall deformity-kyphoscoliosis,pectus
  excavatum, trauma or burns
• Diaphragmatic compression-obesity, ascites,
  pregnancy, retraction during surgery
• Surgical removal lung tissue

9
RESTRICTIVE LUNG DISEASE

• Other causes include
• Diminished generation of expiratory force
• CNS diseases, peripheral nerve diseases
  neuromuscular diseases,
• Muscles of respiration have diminished muscle
  tension-dec expir flow rates-atelectasis
• ANY CONDITION THAT INTERFERES WITH NORMAL LUNG
  EXPANSION DURING INSPIRATION.

10
PFTS RESTRICTIVE LUNG DISEASE

• Flow volume loopappears to be miniature normal
  loop b/o dec LV
• MeF25-75normal
• TLC dec
• FEV1 dec
• FRC dec
• FEV1/FVC normal

11
RESTRICTIVE LUNG DISEASE

• Diagnosis treatment
• Hx of exposure CXRs used to follow progression.
  BX lavage via bronchoscope to confirm dx. Lung
  scans to quantify alveolitis.

12
RESTRICTIVE LUNG DISEASE

• Goals of treatment
• Identify remove injurious agent
• Suppress inflammatory response
• Prevent progression
• O2 in late stages

13
ANESTHETIC CONSIDERATIONS

• Because this class of patients notoriously have a
  dec FRC, they will desaturate quickly this will
  be seen prior to intub (period of apnea) and
  after extub if O2 isnt maintained.
• PEEP will help increase FRC
• PIPs will be inc b/o stiff lungs
• Low Vt with inc RR will dec possibility of
  barotrauma, but inc risk of atelectasis
• Best goal is to have pt ambulating as quickly as
  possible

14
PULMONARY EDEMA

• Starling equation
• Primary determinents that balance fluid across
  the semipermeable capillary membrane 1.pulm
  interstit fld press (hydrostaticPif and osmotic
  if)
• Hydrostatic press in pulm caps (Pc)
• Osmotic press of plasma ( p)

15
STARLING EQUATION

• Qk(Pc-Pif)-( p- if)
• Qtotal amt fluid crosses membrane
• Kfld filtration coefficient which describes
  permeability of membrane
• Peforce favoring fld movement out of membrane
  this is in direct opposition to Pif.
• Pif forces fld inward - P forces flds out
• p keeps fld in capillary if pulls fld
  into interstitium

16
STARLING FORCES

• The balance of forces favors fluid filtration
  into the interstitial space, where lymph remove
  filtered fld -gtreturn to systemic circ
• Pulmonary edema occurs when any variables are
  altered.
• Most important components inc pressure and inc
  permeability

17
PULMONARY EDEMA

• Cardiogenic inc. pressure, hydrostatic
• Most common. Occurs when Pc inc.
• Initiated by LV dysfunc/failure
• PCP 20-25fld transudate rate overwhelms the
  lymphatic ability to drainalveolar flooding.
• Normal PCP 10-16
• CAD, HTN, cardiomyopathy, MR, MS

18
PULMONARY EDEMA

• Non-cardiogenic
• Insult that disrupts barrier function of
  blood-tissue interface, increases permeability.
• PCWP lt12
• Assoc with fld and protein leak
• Pulmonary emb., ARDS, aspiration syndrome,
  inhaled toxic fumes gases, near drowning,
  anaphylaxis, pancreatitis, DIC, trauma, altitude,
  fibrosing mediastinitis, head trauma

19
PULMONARY EDEMA-POST AIRWAY OBSTRUCTION

• Forced inhalation against closed glottis
• Most common causelaryngospasm after extubation
• Inc (-) intrathor press, transpleural and alv
  press -gtenlarges pulm vasc vol insterstit fld
  vol -gtoverwhelms lymphatics -gtinterstit fld moves
  into alveoli-gthypoxia-gtmassive sympathetic
  discharge-gtsystem vasoconstrict-gtinc bld to pulm
  vasculature-gthypoxia inc-gtdec myocard activity,
  LVF

20
PULMONARY EDEMA-POST AIRWAY OBSTRUCTION

• Not everybody develops pulm edema!
• Predisposing young males, long periods of
  obstruction, high amts perioperative flds,
  pre-exist cardiac/pulm conditions

21
PULMONARY EDEMA-POST AIRWAY OBSTRUCTION

• Treatment
• Prompt recognition
• Secure the airway
• O2 support
• diuretics

22
PULMONARY EDEMA-POST AIRWAY OBSTRUCTION

• Onset is usually immediate, but can occur up to
  several hours later
• Observe 60-90 min

23
PULMONARY EDEMA-POST OBSTRUCTED AIRWAY

• Differentiate cardiogenic/noncardiogenic
• HP
• Tachypneia not relieved with O2
• Retraction
• Htn/diaphoresis/tachycardia
• Pink frothy sputum
• Basilar crackles
• CVP inc with cardio
• Enl cardiac silhouette with cardio
• S3-S4 gallop with cardio
• CXR-pl effusions, white out areas
• ABG-hypoxemia hypocarbia (hypervent) progressing
  to hypercarbia (tired patient) pH related to
  PaCO2

24
PULMONARY EDEMA-POST AIRWAY OBSTRUCTION

• Anesthesia management
• Medical emergency-treat the underlying cause,
  support organs, optimize O2 delivery
• May require high FIO2, ETT, PPV, PEEP/CPAP
• Pharm support
• Inotropes, vasodilators, steroids, diuretics

25
RADIATION THERAPY INDUCED RESTRICTIVE LUNG DISEASE

• After Rx for lung, breast, esophogeal, lymph
  node, mediastinal tumors
• Severity re directly to volume lung irradiated,
  rate of delivery, total dose, quality of
  radiation, concomitant chemo, prior courses
  radiation to same area, current use
  corticosteroids
• Cause of pneumonitis is unknown

26
RADIATION INDUCED RESTRICTIVE DISEASE

• Cardinal symptom cough
• Interstit edema may resolve/progress to fibrosis
• Leads to cor pulmonale, resp failure b/o fibrosis
  of large lung volume

27
RADIATION INDUCED RESTRICTIVE LUNG DISEASE

• Lung compliance decs-gtinc work of breathing-gtdec
  lung vol (rapid resp rate with sm Vt) -gt dec
  diffusing capacity

28
RADIATION INDUCED RESTRICTIVE LUNG DISEASE

• PFTS
• Dec VC
• Dec IC
• Dec TLC
• Dec RV
• Dec FEV1

29
RADIATION INDUCED RESTRICTIVE LUNG DISEASE

• Potential complications of rad Rx
• Pneumonitis
• Rib fractures
• Pleural effusion
• Spontaneous pneumothorax
• Infection
• Acute/chronic pericarditis

30
RADIATION INDUCED RESTRICTIVE LUNG DISEASE

• Indirect consequences of tumors
• TE fistula
• Bronchial obstruction

31
RADIATION INDUCED RESTRICTIVE LUNG DISEASE

• RX
• antibiotics
• anticoagulants
• steroids
• Supportive
• O2 with close monitoring-prev O2 toxicity
• cough suppression

32
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• May be
• Idiopathic
• Neuropathic (polio, CP, syringomyelia)
• Myopathic (MD, amyotonia)
• traumatic

33
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• SCOLIOSIS lateral spinal curve
• KYPHOSIS affects posterior curves
• KYPHOSCOLIOSIS lateral bend and rotation of
  vertebral column
• Respiratory dysfunction related to degree
  (severity) of curves

34
RESTRICTIVE DISEASE AND SCOLIOSIS/KYPHOSIS

• IDIOPATHIC
• Most common 80
• Infantile (rare)
• Adolescent (common)
• Cervical scoliosisdifficult airway

35
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• Kyphosis affects pulm function if curve is severe
• Scoliosis affects pulm function in all forms.
• Resp failure predicted by VC and magnitude of
  angle

36
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• SCOLIOSIS
• Dec PF with curves gt60 deg
• Pulm sx develop with curves gt70 deg
• Signif gas exchange with curves gt100 deg
• Mechanical ventilation is inefficient

37
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• SCOLIOSIS
• Early
• Dec VC, TLC, FRC, RV, chest wall compliance
• Late
• V/Q mismatch with hypoxia, inc PAP, inc PaCO2,
  abn response to CO2, inc work breathing, cor
  pulmonale, resp failure

38
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• KYPHOSCOLIOSIS
• Creates skeletal chest wall deform
• Dec LV pulm vasc bed
• Vent failure b/o lung size (30-65 normal)
• As pt ages-gtchest compliance dec-gtinc work of
  breathing-gtdec vent-gtmuscle weakness

39
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• Assoc conditions
• MVP common
• MR
• Inc PVR (response to hypoxemia,chest wall
  compression)
• PH -gtRVH

40
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• Medical management
• Observe, no Rx
• Nonoperative Rx braces, electrical stimulation
• Surgical Rx AP fusions, instrumentation

41
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• Anesthetic management
• Preop-thorough review incl eval severity of
  degree of curve
• CBC,PT,PTT,lytes, BUN,Cr
• PFT,ECG,CXR
• ABG if PFT abn

42
RESTRICTIVE LUNG DISEASE AND SCOLIOSIS/KYPHOSIS

• Intraop considerations-standard
• No N20 (inc PVR)
• Ventilator to maintain SaO2 and normocarbia
• Positioning considerations
• Heat humidify gases
• Remember sensitivity to narcs!

43
RESTRICTIVE LUNG DISEASES

• The principals of management follow similar
  considerations
• Assess the degree of compromise
• Know where to get information
• Make an informed plan
• Thank you.