Exam 4 - Obstructive Respiratory Diseases Flashcards
What are the 5 most common viral pathogens responsible for URIs?
rhinovirus, coronavirus, influenza virus, parainfluenza virus, and respiratory syncytial virus (RSV)
s3
Noninfectious nasopharyngitis can be ____ or ____ in origin.
allergic or vasomotor
s3
Why is the diagnosis of URIs mainly based on just clinical s/sx? (as opposed to labs/tests)
Viral cultures & lab tests lack sensitivity, and are time and cost consuming
* impractical in a busy clinical setting
s3
what accounts for ̴95% of all URIs?
Infectious (viral or bacterial) nasopharyngitis
s3
Who is at a much higher risk of perioperative respiratory adverse events (PRAEs) s/a transient hypoxemia, laryngospasm, breath holding, and coughing?
Children with URI’s
s4
Should we postpone surgery for a pt who has had a chronic URI and is stable?
No, a pt who has had a URI for days-weeks and is stable or improving can be safely managed without postponing surgery
s4
for how long may airway hyperreactivity persist?
6 weeks
So if surgery is delayed bec of an URI, pts should not be rescheduled within 6 weeks
s4
What is used to determine risk of proceeding with surgery for a pt w/ URI?
COLDS scoring system
s4
What 5 things does the COLDS scoring system take into account?
current sx’s
onset of symptoms (higher risk <2 weeks ago)
presence of lung disease
airway device (higher risk with ETT)
surgery (higher risk with major airway surgery)
s4
Anesthetic management of pts w/URI’s should include (3 things):
adequate hydration, reducing secretions, and limiting manipulation of the sensitive airway
s5
What type of local anesthetic can reduce upper airway sensitivity?
Nebulized or topical local anesthetic on the vocal cords
s5
Use of what airway may help reduce the risk of laryngospasm?
Use of a LMA rather than an ETT
s5
Considerations for induction and maintenance for pts with acute URI are similar to those with _____.
asthma
s5
if there are no contraindications, what may result in smoother emergence?
deep extubation
s5
Adverse respiratory events in pts w URI include (6 things):
bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis
s6
Whats common in pts with Acute URI that can be treated easily w supplemental O2?
Intraoperative and postoperative hypoxemia
s6
What are some differentials between Acute URI vs Influenza?
Acute URI: earache, runny nose, nasal congestion, sore throat, hoarseness
All other sx are seen in both URI and flu!
Asthma is considered chronic inflammation of the mucosa of the ____ airways.
lower airways
s7
In asthma, activation of the inflammatory cascade leads to infiltration of airway mucosa with:
This results in airway edema, especially in the ______.
- infiltration of the airway mucosa with eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes
- bronchi
s7
What are the 3 main inflammatory mediators in asthma?
histamine, prostaglandin D2, and leukotrienes
s7
What are 5 asthma provoking stimulators?
- allergens
- pharmacologic agents: ASA, BB, some NSAIDs, sulfaring agents
- infections
- exercise
- emotional stress
s7
What are some sx of asthma (6)?
expiratory wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia
s8
What is status asthmaticus?
life-threatening bronchospasm that persists despite treatment
s8
What 4 factors should attention be focused on when obtaining hx from an asthma pt?
previous intubation, ICU admission, 2+ hospitalizations for asthma in the past year, and the presence of coexisting diseases
s8
When is asthma diagnosed? (like what pt reports and what does PFT show)
when a pt reports symptoms of wheezing, chest tightness, or SOB and demonstrates airflow obstruction on PFT that is at least partially reversible with bronchodilators
s9
What does classification of asthma severity depend on?
symptoms, PFTs, and medication usage
s9
Indications for preop pulmonary evaluation typically include:
1) ____ on room air or the need for home ____ without a known cause
2) a bicarbonate ____ mEq/L or Pco2 ____ mmHg in w/o diagnosed pulmonary dz
3) a history of respiratory ____ due to an existing problem
4) severe ____ __ ____ attributed to respiratory disease
5) planned ____
6) difficulty assessing pulmonary ____ by clinical signs
7) the need to distinguish causes of respiratory ____
8) the need to determine the response to ____
9) suspected pulmonary ____
Indications for preop pulmonary evaluation typically include:
1) hypoxemia on room air or the need for home 02 without a known cause
2) a bicarbonate >33 mEq/L or Pco2 >50 mmHg in w/o diagnosed pulmonary dz
3) a history of respiratory failure due to an existing problem
4) severe shortness of breath attributed to respiratory disease
5) planned pneumonectomy
6) difficulty assessing pulmonary function by clinical signs
7) the need to distinguish causes of respiratory compromise
8) the need to determine the response to bronchodilators
9) suspected pulmonary HTN
S38
________________deficiency is an inherited disorder associated with premature development of COPD
This deficiency indicates genetic disease and need for lifelong ____________therapy
**α1-antitrypsin **deficiency is an inherited disorder associated with premature development of COPD
low α1-antitrypsin indicates genetic disease and need for lifelong **replacement **therapy
31
What is maximum voluntary ventilation?
max air that can be inhaled and exhaled within 1 min
males: 140-180 L/min; females 80-120 L/min
10
____________should be measured in pts with uncontrolled disease despite adequate bronchodilator treatment
** Eosinophils** should be measured in pts with uncontrolled disease despite adequate bronchodilator treatment
31
What respiratory test is sufficient to assess COPD lung disease?
spirometry with FEV1
S38
____________ eosinophil levels indicate the need for inhaled ____________.
____________ eosinophil levels are associated with poor response and increased risk of ___________.
high eosinophil indicate the need for inhaled glucocorticoids
low levels are associated with poor response and increased risk of pneumonia
31
FEV1, FEF (forced expiratory flow) and midexpiratory phase flow are direct measurements of the severity of what?
expiratory obstruction
These are used to asess the severity of an asthma attack
11
ABGs often remain normal until COPD is severe
Pa02 doesn’t usually decrease until the FEV1 is ____________% of predicted, and PaC02 may not increase until the FEV1 is even _________.
ABGs often remain normal until COPD is severe
Pa02 doesn’t usually decrease until the FEV1 is **<50% **of predicted, and PaC02 may not increase until the FEV1 is even lower
31
T/F
COPD treatment is designed to alleviate symptoms and slow progression
TRUE
COPD treatment is designed to alleviate symptoms and slow progression
32
How are flow-volume loops obtained with COPD?
- assessed under dynamic conditions by measuring airflow related to lung volume
-
Expiratory flow ratescan be plotted against lung volumes to produce flow-volume curves
-Start at TLC and force expire to RV -
Inspiration flow rates are added to these curves
-Max inspire from RV to TLC
-flow is most rapid at midpoint = curve
is U shaped
I summarized the slide
S39
The 1st step in treating COPD is reducing exposure to ____________and ________________pollutants
The 1st step in treating COPD is reducing exposure to smoking and environmental pollutants
32
During an asthma attack, what type of results are seen in FEV1?
Flow volume loop? Lung volumes?
Diffusing capacity for CO?
FEV1 <35%
Flow volume loops show a downward scooping of expiratory part
FRC increases, but TLC remains normal
Diffusing capacity for CO not changed
11
Smoking cessation can decrease COPD disease progression and lower mortality by up to:
a. 20%
b. 8%
c. 18%
d. 32%
C. 18%
- Chronic bronchitis and lung degeneration may also diminish or disappear*
32
The first medical treatment for COPD begins with inhalers, specifically long-acting:
a. muscarinic antagonist
b. muscarinic agonist
A. Muscarinic antagonists
32
In pt w/ expiratory obstruction, what suggests the diagnosis of asthma?
relief of obstruction after bronchodilator
abnormalities in PFT seen for days even w/ absence of symtpoms!
11
If dyspnea persists with COPD, the second treatment that can be added is a long-acting:
a. β2 agonist
b. β2 antagonist
A. β2 agonist
32
What are expected to show in the flow volume loop of a COPD pt?
- decreased expiratory flow rate at any given lung volume
- expiratory curve is concave
- RV is increased because of air trapping
S39
The third treatment for COPD, inhaled ________________, is most effective with associated ____________, rhinitis, elevated eosinophils, and history of _______________
The third treatment, inhaled glucocorticoids, is most effective with associated asthma, rhinitis, elevated eosinophils, and history of **exacerbations **
32
Correctly using inhaled tx’s can improve sx, improve FEV1, and reduce exacerbations
Other tx’s include ____________& ____________ vaccines, and ____________ (when RHF or CHF has developed)
Correctly using inhaled tx’s can improve sx, improve FEV1, and reduce exacerbations
Other tx’s include flu & pneumonia vaccines, and diuretics (when RHF or CHF has developed)
33
What are patient related risk factors for development of postoperative pulmonary complications?
- Age > 60 yr
- ASA > 2
- CHF
- Pre-existing pulmonary disease
- Cigarette smoking
S40 table
During exacerbations, antibiotics, corticosteroids, and ____________ may be necessary
Pulmonary rehab programs are beneficial as they can increase ____________ capacity
During exacerbations, antibiotics, corticosteroids, and theophylline may be necessary
Pulmonary rehab programs are beneficial as they can increase exercise capacity
33
T/F
COPD Exacerbations may be due to URI’s and antibiotics are always warranted
FALSE
Exacerbations may be due to URI’s or may be *noninfective *
* so antibiotics are not always warranted
33
In a pt w/ bronchospasm, FEV1 is _____ than 80%.
Peak flow and maximum flow rate (FEF 25%-75%) are also ____
lower than 80%
decreased
12
To decrease the risk of death, long-term home 02 is recommended when the Pa02 is <_______mmHg, the HCT >______%, or if evidence of ___________.
To decrease the risk of death, long-term home 02 is recommended when the Pa02 is <55mmHg, the HCT >55%, or if evidence of cor-pulmonale
34
What are procedure related risk factors for development of postoperative pulmonary complications?
Surgeries
* emergency sx
* abdominal or thoracic sx
* head & neck sx
* neurosurgery
* vascular/aortic aneurysm sx
Anesthesia
* prolonged anesthesia (>2.5h)
* General anesthesia
S40 table
The goal of supplemental 02 is to achieve a Pa02 >________mmHg, which can usually be accomplished w/ NC @ ____L/min
The goal of supplemental 02 is to achieve a Pa02 >**60 **mmHg, which can usually be accomplished w/ NC @ 2 L/min
34
The 02 flow rate can be titrated as needed according to ____ or _______.
The 02 flow rate can be titrated as needed according to ABG or Sp02
34
What test predictor show risk factors for development of postoperative pulmonary complications?
Albumin level < 3.5 g/dL
S40 table
T/F - Supplemental 02 is ________ effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing _______________
Supplemental 02 is more effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing erythrocytosis
34
Pts should be advised to do deep breathing exercises or ________________ ________________, which may improve respiratory function postoperatively
Pts should be advised to do deep breathing exercises or incentive spirometry, which may improve respiratory function postoperatively
34
What pre-op strategies to do to reduce post-op complications?
- smoking cessation for at least 6 weeks
- treat evidence of Expiratory airflow obstruction
- treat respiratory infection with ABX
- Pt education regarding lung volume expansion maneuvers
S41 table
All of the COPD treatments in a chart!
35
All of the COPD exacerbation treatments in a chart!
35
Flow volume loops
obstructuve: O
restrictive w/ limitation on inspiration and expiration: R(E)
and paraenchymal restrictive (RP)
13
In pts w/severe refractory COPD andoverdistended lung tissue, lung ____________ ____________ surgery may be required
Surgical removal allows more areas of normal lung to ________ and improve function
It is commonly performed via a ________________ sternotomy or a (VATS).
What does VATS stand for?
In pts w/severe refractory COPD andoverdistended lung tissue, lung **volume reduction **surgery may be required
Surgical removal of these overdistended areas allows more areas of normal lung to expand and improve lung function
Lung volume reduction surgery is most commonly performed via a median sternotomy or a video-assisted thoracoscopic surgery (VATS)
36
What intraop strategies to do to reduce post-op complications?
- use minimally invasive sx techniques (if possible)
- consider Regional Anesthesia
- avoid sx procedure > 3 hours
S41 table
Mechanisms for improvement in lung function include:
1) increased _______ ___________, which increases expiratory airflow
2) decreased ____________, which improves diaphragmatic and chest wall mechanics
3) decreased ____________/____________ mismatch, improving alveolar gas exchange
Mechanisms for improvement in lung function include:
1) increased elastic recoil, which increases expiratory airflow
2) decreased hyperinflation, which improves diaphragmatic and chest wall mechanics
3) decreased ventilation/perfusion mismatch, improving alveolar gas exchange
36
Anesthesia mgmt for lung-volume reduction surgery includes: a __________-______________ ETT, avoidance of _________ _________, and minimizing excessive airway pressure
________ is an unreliable guide for fluid management in this situation due to surgical alterations that will affect ________________ pressures
Anesthesia mgmt for lung-volume reduction surgery includes: a double-lumen ETT, avoidance of nitrous oxide, and minimizing excessive airway pressure
CVP is an unreliable guide for fluid management in this situation due to surgical alterations that will affect **intrathoracic **pressures
37
What post-op strategies to do to reduce post-op complications?
- institute lung volume expansion maneuvers
- maximize analgesia
S41 table
Treatment of Acute Severe Asthma
Fill in the blanks:
* Supplemental oxygen to maintain SaO2 > ____%
- ____ agonists by metered- dose inhaler every ____ - ____ or by ____ nebulizet administration
- intervenous ____ ( hydrocotisone or ____)
- IV fluids to maintain ____
- ____ broad -spectrum antibiotics
- Anticholinergiv (____) by inhalation
- IV ____ sulfate
- ____ intubation and mechanical ventilation (when PaCO2 is > ____ mmhg)
- Sedation and _____
- Mechanical ventialation parameters:
- Gernal ansthesia with a ____ ____ to produce _____
- _______ _______ _______ _______ (ECMO) as a last resort
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