Exam 4 - Restrictive Flashcards
What is the hallmark of restrictive lung disease?
the inability to increase lung volume in proportion to an increase in alveolar pressure
RLD affects lung expansion and compliance!
2
What factors can cause RLD?
- connective tissue disease
- environmental
- pulm fibrosis
- increase fluid in alveoli or interstitial space
- diseases that limit excursion of diaphgram/ chest
2
RLD leads to reduced surface area for gas diffusion, causing what 2 complications?
V/Q mismatch and hypoxia
2
As lung elasticity worsens, what symptoms manifest in the patients?
hypoxia, inability to clear secretions and hypoventilation
2
In RLD, what changes do you see in FEV/FVC testing and diffusing capacity tests?
What changes in lung volumes?
- reduced FEV1, low FVC= normal or increased ratio!
- reduced diffusing capacity for for CO
- all lung volumes are decreased, especially TLC
2
What is the principal feature of RLD?
decreased TLC!
4
TLC is used to classify Restrictive Lung disease. What is the predicted value of:
mild disease
moderate
severe
mild 65-80%
moderate 50-65%
severe: <50%!
4
Causes of RLD chart
What causes pulmonary edema?
intravascular fluid leakage into the interstitium and alveolar space!
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Acute pulmonary edema can be caused by what 2 changes in the capillary?
increased capillary pressure or increased capillary permeability
Both of these lead to “capillary stress failure”
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What does pulm edema look like on CXR?
What pattern is seen w/ increased cap pressure?
bilateral, symmetric perihelar opacities!
Butterfly pattern seen w/ increased capillary pressure vs permeability
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Pulm edema caused by increased capillary permeability is characterized by what 2 factors in edema fluid?
a high concentration of protein and secretory products in edema fluid
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In increased permeability pulm edema, what happens to the alveoli?
You get diffuse alveolar damage associated with ARDS
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What are the clinical manifestations of cardiogenic pulmonary edema
cardiogenic pulm edema is seen in decompensated HF
dyspnea
tachypnea
elevated cardiac pressures
SNS activation
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Cardiopulmonary edema should be suspected if pt has what changes in cardiac pressures?
a decreased systolic or diastolic pressure!
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Risk for cardiogenic pulm edema is increased w/ conditions that increase preload.
What 2 valve dysfunctions cause this?
aortic and mitral valve regurg!
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Risk for cardiogenic pulm edema is also increased w/ conditions that increase afterload or SVR?
What 3 diseases do this?
LV outflow tract obstruction
mitral stenosis
reno vascular HTN
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Negative pressure pulm edema results after the relief of upper airway obstruction.
What are common causes?
aka post obstructive pulm edema
laryngospasm, epiglotttis, tumors, obesity, hiccups, OSA
8
When is the onset of pulm edema after the relief of obstruction?
What are the s/s ?
up to 2 hours post obstruction!
s/s: tachypnea, cough, SpO2 below 95%
may be confused w aspiration or PE!
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Describe the changes in pressures that occur that cause increased transcapillary pressure gradient leading up to pulm edema
The development of negative intrapleural pressure decrease the interstitial hydrostatic pressure, this increases VR and LV afterload
-this leads to SNS activation, HTN and central displacement of blood
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What is the treatment of negative pressure pulm edema?
How long does it take to resolve
supplemental O2 and maintence of patent airway!
Mechanival ventilation may be needed
Might resolve in 12-24 hr
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What is an intrapulmonary shunt?
Right-to-left pulmonary shunting: perfusion of nonventilated alveoli
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Neurogenic Pulmonary Edema:
- Develops in a ______ fraction of acute brain injury pts.
- occurs ________ - ________ after CNS injury and may manifest during the periop period.
- A massive outpouring of _____ impulses from the injured CNS causesgeneralized ____________ and blood volume shifting into the _________ circulation.
- the increased pulmonary capillary pressure c/b translocation of blood volume leads to the transfer of fluid into the _________ _________.
- Pulmonary _______ & hypervolemia can also injure blood vessels in the lungs.
- small
- minutes - hours
- SNS
- vasoconstriction
- pulmonary circulation
- interstitium
- alveoli
- HTN
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What condition can be seen in pts using e-cigarettes and vaping?
EVALI (E-Cigarette Vaping Associated Lung Injury)
S17
EVALI is associated with what 5 other conditions?
- pneumonia
- diffuse alveolar damage
- acute fibrinous pneumonitis
- bronchiolitis
- interstitial lung disease (ILD)
S17
What 5 additives are associated with EVALI?
- THC
- Vit E acetate
- Nicotine
- CBD
- other oils
S17
What are the sx of EVALI?
- dyspnea
- cough
- N/V/D
- abd pain
- chest pain
Pt may be febrile, tachycardia, tachypnea, and hypoxic
S17
Radiologic findings of EVALI are similar to what condition?
ARDS
S17
What are the treatments of EVALI
- ABX
- Steroids
- Supportive care
S17
What do survivors of severe COVID can have persistently?
inflammatory interstitial lung disease
S18
What are the sx of COVID 19 Induced restrictive lung disease?
dyspnea to ventilator dependance and pulmonary fibrosis
S18
What PFT result is the most commonly reported finding COVID 19 Induced restrictive lung disease?
drop in diffusion capacity
S18
Who are are at the highest risk for long term pulmonary complications with COVID 19 Induced restrictive lung disease?
Pts who need mechanical ventilation
S18
What negative pulmonary changes do survivors of COVID-19 have?
- decreased exercise capacity
- hypoxia
- opacities on CT
S18
What is the PaO2 of ARF despite02 supplementation and in the absence of a right-to-left intracardiac shunt?
< 60 mmHg
S19
What happens to PaC02 d/o the relationship of alveolar ventilation to C02 production?
increased
unchanged
decreased
S19
What is the PaCO2 in the absence of respiratory-compensated metabolic alkalosis of ARF diagnosis?
PaCO2 > 50 mmHg
How is ARF characterized?
- abrupt increased PaC02
- decreasedpH
S19
What is increased and what is normal in Chronic Respiratory failure?
PaCO2 increased
pH is normal
normal pH reflects renal compensation for respiratory acidosis
S19
What are the 3 tx goals for ARF?
1) a patent airway
2) hypoxemia correction
3) removal of excess C02
S19
What kind of devices can O2 be provided?
And when are they only helpful?
- NC
- venturi mask
- nonrebreather
- T-piece
only helpful in mild to moderate V/Q mismatching
S20
What is initiated when methods fail to maintain Pa02 >60 mmHg?
continuous positive airway pressure (CPAP)
S20
What is the benefit of CPAP?
What is the risk if CPAP?
**benefit: increase lung volumes **
(opening collapsed alveoli and decreasing right-to-left intrapulmonary shunting)
**risk: aspiration **
(via face mask esp pts with N/V)
S20
What is the SpO2 % when PaO2 is > 60 mmHg?
Sp02 is **>90% **
S20
What kind of ventilation is fixed TV w/inflation pressure as dependent variable
Volume-cycled ventilation
S21
What can the pressure relief valve do?
- prevents further gas flow → preventing high airway pressures
- triggers an alarm to alert the provider of a change in pulmonary compliance
S21
What are worsening pulmonary edema, pneumothorax, kinked ETT, or a mucous plug reflecting on the ventilator?
Significant increases in PAP
S21
What is maintained on the vent despite small changes in PAP?
consistent Tidal volume
S21
What is a disadvantage of volume-cycled ventilation regarding leaks in the delivery system?
inability to compensate for leak
S21
High- Altitude Pulmonary Edema (HAPE):
- HAPE may occur at heights ranging from _____ - ______m and is influenced by the rate of ________ to that altitude.
- Onset is often _______ but typically occurs within 48-72 hours at high altitude.
- less severe symptoms of “_______ __________” may preceed pulmonary edema.
- 2500-5000
- ascent
- gradual
- mountain sickness
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What are the 2 primary modes of volume-cycled ventilation?
- AC (assisted/controlledventilation)
- SIMV (synchronized intermittent mandatory ventilation)
S21
The net effect of an intrapulmonary shunt is a decrease in _____.
Why does this occur?
decrease in Pa02,
Occurs from dilution of oxygenated blood with hypo-oxygenated blood containing coming from unventilated alveoli
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Re-Expansion Pulmonary Edema:
- The rapid expansion of a __________ lung may lead to REPE.
- The risk of REPE after relief of pneumothorax or pleural effusion is related to:
1. Amount of air/liquid that was in the ________ space (>1 L increases the risk)
2. The ________ of collapse (>24 hours increases the risk
3. ________ of re-expansion
- Collapsed
- pleural
- duration
- speed
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A physiologic shunt typically comprises what percentage of COP?
2-5%
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Re-expansion Pulmonary Edema:
- The high ________ content of pulmonary edema fluid suggests that enhanced capillary membrane __________ is a factor in its development.
- Treatment is ___________ care.
- protein
- permeability
- Supportive
11
What is a physiologic shunt?
right-to-left pulmonary shunting but this one is from:
passage of pulmonary arterial blood directly to the left side of the circulation through the bronchial and thebesian veins
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Drug Induced Pulmonary Edema:
- can occur after the administration of certain drugs, especially opioids ( _______ ) and _________.
- the high _________ concentration in the pulmonary edema fluid suggests it is a high-___________ pulmonary edema.
- heroine
- cocaine
- protein
- permeability
12
- What does the shunt fraction tell us in pts breathing <100% O2?
- What does the shunt fraction tell us in pts breathing 100% O2?
- shunt fraction tell us the contribution of V/Q mismatching as well as right-to-left intrapulmonary shunting
- shunt fraction eliminates the contribution of V/Q mismatching and only tells us right-to-left intrapulmonary shunting
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Drug-Induced Pulmonary Edema:
- ________ causes pulmonary vasoconstriction, acute myocardial ischemia, and myocardial infarction.
- _________does not reverse opioid-induced pulmonary edema.
- Treatment of drug-induced pulmonary edema is __________.
- may include __________ and mechanical ventilation.
- Cocaine
- Naloxone
- Supportive
- Intubation
12
What must be considered when determining whether the pt can tolerate extubation?
pt is alert and cooperative and can tolerate a trial of SV without tachypnea, tachycardia, or respiratory distress
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Drug-Induced Pulonary Edema:
- ________ __________ __________ (___) is another condition with similarsx.
- Ifpulmonary edema does not respond to _________, DAH islikely.
- Diffuse Alveolar Hemorrhage (DAH)
- diuretics
12
what are the 7 guidelines for discontinuing mechanical ventilation?
- Vital capacity of >15 mL/kg
- Alveolar-arterial oxygen difference of <350 cmH2O while breathing 100% 02
- Pa02 of >60 mm Hg with an Fi02 of <0.5
- Negative inspiratory pressure of more than −20 cmH2O
- Normal pHa
- RR <20
- VD:VT of < 0.6
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What 3 options are considered when a pt is ready for a trial of vent withdrawal?
- SIMV, which allows progressively fewer mandatory breaths until pt breathing on their own
- Intermittent trials of total removal of mechanical support and breathing through a T-piece
- Use of decreasing levels of pressure support ventilation
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High-Altitude Pulmonary Edema (HAPE)
- Cause of this high-permeability pulmonary edema is presumed to be ________ pulmonary vasoconstriction, which _______ pulmonary vascular pressure.
- Treatment includes 02 administration and quick _______ from the high altitude.
- Inhalation of _______ ________may improve oxygenation
- hypoxic
- increases
- descent
- nitric oxide
13
What tell us the pt won’t be able to tolerate extubation?
Breathing at rapid rates with low tidal volumes
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Anesthesia Implications for Pulmonary Edema:
__________ surgery should be delayed in pts with pulmonary edema, and every effort must be made to optimize cardiorespiratory function before surgery.
Elective
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Chemical Pneumonitis (Aspiration Pneumonitis):
- If aspiration noted, the ________ should be suctioned and the pt turned to the ______.
- _________ position will not stop reflux, but can prevent aspiration once gastric contents are in the _________.
- oropharynx
- side
- Trendelenburg
- pharynx
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The Pa02 should remain ___ mmHg with Fi02 ____.
PaO2 Greater than 60 mmHg w/ FiO2 <0.5
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Anesthesia Implications for Pulmonary Edema:
- Large ______ _______ may need to be drained.
- Persistent _________ may require mechanical ventilation and positive end-expiratory pressure (PEEP).
- ___________ monitoring useful in the assessment and treatment of pulmonary edema.
- Pleural Effusions
- Hypoxemia
- Hemodynamic
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The PaC02 should remain ____ and the pHa ____.
PaCO2 less than 50 mmHg and pHa >7.30
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Anesthesia Implications for Pulmonary Edema:
- Current evidence shows benefit from ventilation using low ___ & a RR of 14-18 while keeping end-inspiratory plateau pressures < ____ cm H2O.
- careful titration of ______ along with inspiratory _______ is recommended to optimize lung compliance.
- TV
- 30
- PEEP
- Pause
14
What is commonly needed after extubation d/t V/Q mismatching?
Supplemental O2
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Anesthesia Implications for Pulmonary Edema:
- Pts with Restrictive Lung Disease typically have _______, _________ breathing.
- ___________ should not be used as the sole criteria for delaying ____________ if gas exchange and other assessments are satisfactory.
- rapid
- shallow
- Tachypnea
- extubation
14
O2 weaning is accomplished by:
gradually decreasing the FiO2
guided by measurements of PaO2 and/or monitoring of Sp02
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Chemical Pneumonitis (Aspiration Pneumonitis):
- Pts w/ _________ airway reflexes are at risk for aspiration.
- __________ the HOB during intubation & extubation decrease aspiration risk
- decreased
- Elevating
15
Along with being awake and alert, what else should the patient have for possible vent weaning?
active laryngeal reflexes and the ability to generate an effective cough and clear secretions
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Chemical Pneumonitis (Aspiration Pneumonitis)
- Chemical pneumonitis sx: _______ onset dyspnea, tachycardia, and __________.
- When _________ fluid is aspirated, it distributes throughout the lungs and destroys ________ -producing cells and pulmonary capillary endothelium.
- As a result, there is ________ and leakage of intravascular fluid into the lungs, producing capillary-__________ pulmonary edema.
- abrupt
- desaturation
- gastric
- surfactant
- atelectasis
- permeable
15
WHat is assoc with the highest risk of ARDS?
Sepsis
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Chemical Pneumonitis (Aspiration Pneumonitis)
- This acute lung injury might present with tachypnea, bronchospasm, _______ pulmonary HTN, and ________ hypoxemia.
- CXR may not demonstrate evidence of ________ pneumonitis for ___ - ____ hrs.
- if the ptaspirated in _______ position, radiographic evidence of aspiration is most likely in the superior segment of the ______.
- acute
- arterial
- aspiration
- 6-12
- supine
- RLL
15
What is ARDS caused by and how does it manifest?
caused by inflammatory injury to the lungs
and manifests as acute hypoxemic respiratory failure
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What are the 3 hallmarks of ARDS?
- Rapid-onset respiratory failure
- arterial hypoxemia
- CXR findings similar to cardiogenic pulmonary edema
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Chemical Pneumonitis (Aspiration Pneumonitis):
- Measurement of gastric fluid ____ is useful, since it reflects the pH of the aspirated fluid.
- The aspirated gastric fluid is rapidly redistributed to _________ lung regions, so ________ is not useful.
- pH
- peripheral
- lavage
16
In ARDS, what causes the increased alveolar-capillary membrane permeability and alveolar edema?
Proinflammatory cytokines
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