Exam 4- Obstructive Respiratory Disease - organize Flashcards
What are the 5 most common viral pathogens responsible for URIs?
rhinovirus, coronavirus, influenza virus, parainfluenza virus, and respiratory syncytial virus (RSV)
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Noninfectious nasopharyngitis can be ____ or ____ in origin.
allergic or vasomotor
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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
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what accounts for ̴95% of all URIs?
Infectious (viral or bacterial) nasopharyngitis
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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
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
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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
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What is used to determine risk of proceeding with surgery for a pt w/ URI?
COLDS scoring system
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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)
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Anesthetic management of pts w/URI’s should include (3 things):
adequate hydration, reducing secretions, and limiting manipulation of the sensitive airway
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What type of local anesthetic can reduce upper airway sensitivity?
Nebulized or topical local anesthetic on the vocal cords
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Use of what airway may help reduce the risk of laryngospasm?
Use of a LMA rather than an ETT
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Considerations for induction and maintenance for pts with acute URI are similar to those with _____.
asthma
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if there are no contraindications, what may result in smoother emergence?
deep extubation
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Adverse respiratory events in pts w URI include (6 things):
bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis
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Whats common in pts with Acute URI that can be treated easily w supplemental O2?
Intraoperative and postoperative hypoxemia
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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!
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Asthma is considered chronic inflammation of the mucosa of the ____ airways.
lower airways
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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
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What are the 3 main inflammatory mediators in asthma?
histamine, prostaglandin D2, and leukotrienes
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What are 5 asthma provoking stimulators?
- allergens
- pharmacologic agents: ASA, BB, some NSAIDs, sulfaring agents
- infections
- exercise
- emotional stress
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What are some sx of asthma (6)?
expiratory wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia
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What is status asthmaticus?
life-threatening bronchospasm that persists despite treatment
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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
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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
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What does classification of asthma severity depend on?
symptoms, PFTs, and medication usage
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What is maximum voluntary ventilation?
max air that can be inhaled and exhaled within 1 min
males: 140-180 L; females 80-120 L
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FEV1, FEF (forced expiratory flow) and midexpiratory phase flow are direct measurements of the severity of what?
expiratory obstruction
These are used to assess the severity of an asthma attack
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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
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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!
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In a pt w/ bronchospasm, FEV1 is _____ than 80%.
Peak flow and maximum flow rate (FEF 25%-75%) are also ____
lower than 80%
decreased
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Flow volume loops
obstructuve: O
restrictive w/ limitation on inspiration and expiration: R(E)
and paraenchymal restrictive (RP)
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What causes an tachypnea and hyperventilation during an asthma attack?
neural reflexes of lungs, not hypoxemia
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What are common ABG findings in symptomatic asthma?
hypocarbia and respiratory alkalosis!
*however a mild asthma attack = normal PaO2 and normal PaCO2 *
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As expiratory obstruction worsens, V/Q mismatching may result in a PaO2 of ____?
The PaCO2 will increase when FEV1 is what percentage?
<60 mmHg
25% of predicted
fatique of breathing skeletal muscles contributes to hypercapnea
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Due to mucous plugging and pulm HTN, pt w/ severe asthma demonstrate what 2 symptoms?
hyperinflation and hiliar vascular congestion
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During an asthma attack, what might the EKG show?
RV strain or ventricular irritability
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What is the 1st line of treatment for patient with mild asthma?
What other medication can be added to help improve the symptoms of asthma, reduce exacerbations and decrease risk of hospitalization?
- short-acting inhaled β2 agonist
- daily inhaled corticosteroids
*This is only recommended in those w/ < 2 exacerbations/month *
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True or false: if asthma symptoms remain uncontrolled, daily inhaled β2 agonist
True
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What medication can be use to decrease the use of long -term medications for asthma ?
base of a study
SQ immunotherapy
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What other therapies that can be use as treatment for asthmas?
- inhaled muscarinic antagonists
- leukotriene modifiers
- mast cell stabilizers
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What medication is reserved for severe asthma that is uncontrolled with inhalational medications?
Systemic corticosteroids
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What is the name of the only nonpharmacologic treatment for refractory asthma?
Bronchial thermoplasty (BT)
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How is Bronchial thermoplasty (BT) utilize to treat refractory asthma?
uses a bronchoscopy to deliver radiofrequency ablation of airway smooth muscles to all lung fields except the right middle lobe
*procedure is performed in three sessions and uses intense heat, which carries a risk of airway fire
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Loss of airway smooth muscle mass can reduce what ?
bronchoconstriction
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What is useful in monitoring the reponse to treatment?
Serial PFTs
FEV1 improves to about 50% of normal, pts usually have minimal or no symptoms
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What is the emergency treatment for acute severe asthma?
- consists of high-dose
- short-acting β2 agonists
- systemic corticosteroids
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What is the difference in asthma vs acute severe asthma ?
- bronchospasm doesn’t resolve despite usual treatment
- considered life threatening
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How often can INH β2 agonistsbe adminstered?
every 15-20 minfor several doses without adverse hemodynamic effects
although pts may experience unpleasant sensations resulting from adrenergic overstimulation
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Why is IV corticosteroides adminstered early for treatment of acute severe asthma?
What are the 2 corticosteroids most commomly used
onset takes several hours
Hydrocortione and methlprednisone
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Why is supplemential O2 given to a patient that is experiencing acute severe asthma attack?
to help maintain 02 saturation >90%
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What other drugs can be administered to patietnts that are experiencing acute severe asthma?
- magnesium
- oral leukotriene inhibitors experiencing
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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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What are the risk factors that would contribute to bronchospasms during surgery?
- type of surgery (higher with upper abdominal and oncologic surgery)
- how recent the last attack occurred
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How does General Anesthesia effects a patient with asthma?
- depression of cough reflex
- impairment of mucociliary function
- reduction of palatopharyngeal muscle tone
- depression of diaphragmatic function
- increased fluid in the airway wall
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What other factors can affect an asthmatic receiving anesthesia
airway stimulation by intubation,
PNS activation, and/or release of neurotransmitters
*such as substance P and neurokinins also play a role percentage *
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What are some pre-op assessment that need to be done for a patient that that has Asthma ?
- assessment of disease severity
- current treatment, and the
- need for additional therapy before surgery
- history of symptom control
- frequency of exacerbations
- Physicalappearance and use of accessory muscles
- Auscultation of the chest to detect wheezing or crepitations is important
- Eosinophil counts
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During a pre-op Assessment for a patient that as asthma, what type of test and mediation should be taken in consideration?
- Preop PFTs (esp FEV1) before and after bronchodilator may be indicated
( A reduction in FEV1 or forced vital capacity (FVC) to <70% of predicted, and/orFEV1:FVC ratio <65% of predicted, is a risk for periop respiratory complications) - Preop chest physiotherapy, antibiotics, and a bronchodilators can often improve reversible components of asthma
- ABGs (if there is any question about the adequacy of ventilation or oxygenation)
- Anti-inflammatories and bronchodilators should be continued until induction
- If the pt is has been on systemic corticosteroids within the past 6 months, a stress-dose hydrocortisone or methylprednisolone is indicated
- Pts should be free of wheezing and have a PEFR of >80% of predicted or their personal best value before surgery
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- symptoms = emphysema characterized by lung _____ damage ,, chronic ____ ,, productive _______ ,, small airway dz
- _____ leading cause of death
COPD
- parenchymal ,, bronchitis ,, cough
- 3rd
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COPD risks (long list)
o smoking, occupational exposure, asbestos, gold mining, biomass fuel, air pollution, genetic factors, age, female gender, poor lung development during gestation, low birth weight, recurrent childhood respiratory infections, low socioeconomic class, and asthma
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COPD leads to ?? (5)
- deterioration in recoil/elasticity
- decrease bronchiolar wall structure
- increased velocity through narrowed bronchi
- active bronchospasm + obstruction from secretions
- destruction of lung parenchyma + enlarge air sacs
*emphysema
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COPD Symptoms ::
* vary with ___________
* __________ at rest ,, chronic __________ and __________ production
* exacerbations»_space;> _________ and prolonged ___________ times
* breath sounds are ____________ and __________ wheezes
* as progresses :: exacerbations are more _________ and triggered by _____________ resp infx
- severity
- dyspnea ,, cough ,, sputum
- tachypnea ,, expiratory
- decreased ,, expiratory
- frequent ,, bacterial
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COPD Diagnosis:
- Definitive diagnosis is made with ______________
- PFTS = decrease in ______ and ________
- increase in _______ volume d/t gas trapping which causes a _______ airway diameter
- spirometry
- FEV1/FVC ratio + FEF25-75
- residual
- enlarged
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Common findings of COPD include
* FEV1:FVC <_____%
* increased _____ and _____
* reduced ______
- <70%
- FRC + TLC
- DLCO
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COPD Diagnosis:
- CXR findings = may be ______ even with severe COPD
- ________ suggests emphysema
- ______ confirms emphysema
- minimal
- hyperlucency
- bullae
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COPD Diagnosis:
Most Sensitive to diagnose COPD
CT
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COPD Diagnosis:
- Multi Organ Loss of Tissue (MOLT) is a ____ of COPD
- high rates of _____ cancer
- Sx = ______ enlargement , ______ destruction , loss of _______, muscle, fat tissues
- phenotype
- lung
- airspace , alveolar , bone
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COPD Diagnosis:
Bronchitic Phenotype = _________ narrowing and _______ thickening
* accompanied by _______ syndrome and ______ disease
- bronchiolar + wall
- metabolic + cardiac
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____________ 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
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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
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________________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
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____________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
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All of the COPD treatments in a chart!
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All of the COPD exacerbation treatments in a chart!
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