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Anesthesia & Coexisting Disease > Ex2 Respiratory Dx > Flashcards

Ex2 Respiratory Dx Flashcards

1
Q

75% of inspiration consists of

A

active contraction of diaphragm

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2
Q

25% of inspiration consists of

A

external intercostal muscles

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3
Q

expiration occurs as a result of

A

passive recoil of ribcage

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4
Q

forced expiration uses

A

internal intercostals/abdominal muscles

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5
Q

95% of URIs are

A

infective nasopharyngitis

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6
Q

safe to give anesthesia after URI after ____

A

4 weeks post-URI

**6w+ for reactive airways

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7
Q

Elective surgery 2 weeks after URI - proceed, postpone, cancel?

A

Cancel - reschedule in 2 weeks

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8
Q

Effect of GA on URI

A

decreases tracheal mucociliary flow/pulm bactericidal activity
PPV may force infxn deeper
immune response altered d/t surgery

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9
Q

intrinsic lung dx

-characteristics

A
  • cause either:
    1. inflammation/scarring of lung tx
    2. fill air spaces w/ exudate/debris
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10
Q

intrinsic lung dx - examples

A

asthma, COPD

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11
Q

extrinsic lung dx

-characteristics

A

chest wall, pleura, resp muscles = disordered

–> cause lung restriction + ventilatory dysfunction

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12
Q

Asthma is more common in

A

Females > males

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13
Q

asthma is characterized by

A
  • chronic inflammation
  • reversible expiratory airflow obstruction
  • bronchial hyperreactivity
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14
Q

asthma alternative explanation

A

abnormal autonomic regulation of neural fxn imbalance between bronchoconstrictor/dilator neural imput

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15
Q

FEV1

A

Volume of air that can be forcefully exhaled in 1 second

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16
Q

FVC

A

max amount of air that can be expelled after deep inhalation

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17
Q

normal M/F FVC

A 
M = 4.8L
F = 3.7L
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18
Q

FEV1/FVC

A

75-80%

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19
Q

direct measures of severity of asthma

A

FEV1

MMEF

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20
Q

MMEF

A

Forced expiratory flow at 25-75% of vital capacity (FEF 24-75%)
-measurement of flow thru midpoint of forced expiration

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21
Q

MVV

A

max voluntary ventilation

-measured over 15 seconds

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22
Q

Normal MVV

A

F: 80-120 L/min
M: 140-180 L/min

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23
Q

flow volume loop - asthma

A

downward scooping of exp.l limb (ice cream cone with scoop missing)
-Increased total lung capacity

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24
Q

Asthma: how severe?

FEV1 65-80%

A

mild asymptomatic

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25
Q

Asthma: how severe?

FEV1 50-64%

A

moderate

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26
Q

Asthma: how severe?

FEV1 35-49%

A

marked

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27
Q

Asthma: how severe?

FEV1 < 35%

A

severe

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28
Q

Asthma ABG

A

hypocarbia

respiratory alkalosis

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29
Q

CXR/ECG findings: asthma

A

CXR: hyperinflation
ECG: RH strain, irritability

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30
Q

When is PaO2 abnormal in asthma?

A

Marked + severe

< 60

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31
Q

FEV1 < 80%

A

obstructive airway disease

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32
Q

asthma tx

A
  1. controllers

2. relievers

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33
Q

Asthma controllers

A

-modify airway environment so that acute narrowing occurs less
-take longer to work
*corticosteroids (beclamethasone, fluticasone, budesonide)
*Cromolyn
*Leukotriene modifiers (Singulair/montelukast), salmeterol
Methylxantines (theophylline)

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34
Q

Asthma Relievers

A

rescue agents

  • beta agonists (albuterol, metaproterenol)
  • anticholinergics (ipratropium, atropine, glycopyrrolate)
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35
Q

Asthmatic may become hypercarbic if

A

impending fatigue + respiratory failure

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36
Q

status asthmaticus tx

A
  • continuous inhaled B-agonist
  • IV corticosteroids
  • Magnesium, leukotriene inhibitors, terbutaline, epi
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37
Q

Epi dosage - status asthmaticus

A

SubQ 0.4mL of 1:1000

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38
Q

Terbutaline dosage - status asthmaticus

A

SubQ 0.25 mg
q15-30m
max dose 0.5mg in 4h

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39
Q

indicative of risk factors peri-op in asthma patients

A

Decreased FEV1
or FVC < 70%
+
FEV1/FVC < 65%

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40
Q

Major elective surgery should be postponed if

A

+ wheezing

Peak expiratory flow < 80% or less than personal best

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41
Q

VA choice for asthma

A

Sevoflurane

42
Q

How to prevent auto-PEEP in asthma

A

I:E from 1:2 to 1:3 or 1:4

43
Q

Best anesthetic for asthma

A

regional
*if GA: LMA > ETT
LMA risk: less control over expiratory phase

44
Q

DOC for asthma induction/GA

A
  1. propofol

2. ketamine

45
Q

After induction with IV agent, what other Rx (asthma)?

A

Ventilation with VA (Sevo)
+ Lido IV
+ opioids (Remifentanil)

46
Q

Remifentanil infusion

A

0.05 - 0.1 mcg/kg/min

47
Q

COPD is characterized by

A
  • progressive airflow limitation NOT fully reversible

- expiratory flow obstruction

48
Q

COPD - primary ventilatory drive

A

Chronic hypercarbia blunts drive; dependent on Oxygen

49
Q

Risk factors - COPD

A 
#1- smoking
resp infxn, occupational exposure, genetic factors (antitrypsin-1 deficiency)
50
Q

S/S COPD

A

hallmark - chronic productive cough + progressive exercise limitation

51
Q

PFT - COPD

A

Decreased:
FEV1, FEF25-75%, ERV
Increased: FRC, RV (air trapping)

52
Q

Treatment of COPD

A

Smoking cessation***
short term: increased sputum production
long term: O2 therapy

53
Q

O2 therapy - COPD

A

Supplementation if:
PaO2 < 55mmHg
Hct > 55%
or evidence of cor pulmonale

54
Q

Goal in O2 therapy for COPD

A

PaO2 60-80 mmHg

55
Q

Rx therapy - COPD

A

B2 agonists, corticosteroids, diuretics

56
Q

Predictive of post op pulmonary complications

A

smoking, diffuse wheezing, productive cough
> 60 y/o, COPD
emergency surgery
surgery specific: thoracic, head/neck, neuro, vasc/aortic aneurysm surgery
anes. duration > 2.5h
GA
Albumin < 3.5 g/dL

57
Q

PFTs useful for ____ (COPD)

A

thoracic surgery

58
Q

Preoperatively - COPD pt to reduce risk can do____

A

clear bacterial infxn
smoking cessation
tx bronchospasm

59
Q

Regional preferred for COPD patients if ____

A

do not require above T6 (ventilatory dysfunction)

60
Q

Ventilation of COPD

A

Low RR, TV 6-8mL/kg, slow inspiratory flow rate

*Air trapping: decreased recoil leads to retained air that should be exhaled

61
Q

detection of air trapping

A
  1. capnography upslope
  2. exp flow rate does not reach 0
  3. PEEP develops/increases
  4. BP falls as PEEP increases
62
Q

bronchiectasis

A

localized, irreversible dilation of a bronchus

-d/t infxn

63
Q

s/s bronchiectasis

A

productive cough, large amounts of sputum, clubbing of fingers

64
Q

CF - clinical manifestations

A

cough, purulent sputum production, exertional dyspnea

65
Q

diagnosis: CF

A

Sweat test: Sweat Cl > 80 mEq/L

66
Q

Tracheal Stenosis - symptomatic when?

A

trachea < 5 cm

67
Q

Restrictive Lung Disease: PFTs show

A

Decreased lung volume, compliance, with preservation of expiratory flow rates
Decreased FRC, FEV1
Normal/increased FEV1/FVC

68
Q

Acute intrinsic restrictive lung disease

A 
pulmonary edema
atelectasis
ARDs 
Aspiration
Neurogenic problems
69
Q

Chronic intrinsic restrictive lung disease

A

Interstitial lung disease - fibrosis

-sarcoidosis, hypersensitivity pneumonitis, eosinophilic granuloma, lymphangioleiomyomatosis

70
Q

Chronic extrinsic restrictive lung disease

A

chest wall, pleura, mediastinum
-scoliosis, pneumothorax, mediastinal mass
muscular dystrophy, guillain-barre, myasthenia gravis
spinal cord transection (at or below C5)

71
Q

Pt presents to elective surgery with pulm edema - proceed?

A

Postpone + treat symptoms

  • all acute restrictive disease
  • i.e. drain large pleural effusion, persistent hypoxemia
72
Q

intra-op management of pulmonary edema

A

Lower TV
Higher RR
goal: end insp plateau pressure < 30
Consider sending to ICU on vent

73
Q

Interstitial Lung disease

A

Chronic intrinsic lung disease

-pulm fibrosis: loss of pulm vasculature, + pHTN, cor pulmonale, dyspnea, tachypnea

74
Q

Preoperative management: chronic intrinsic restrictive lung disease

A

Infection: treat
Secretions: clear
smoking cessation

75
Q

indicative of severe pulmonary dysfxn (chronic restrictive dx)

A

Vital capacity < 15 mL/kg

76
Q

Intraop considerations - chronic restrictive lung dx

A 
*use ACPC 
Hypoxemia + normocarbia
apneic periods not tolerated
GA, supine position, controlled ventilation=decreased FRC
**VA uptake = faster*
lower PIP (prevent barotrauma)
77
Q

characteristic of extrinsic restrictive disease

A

most often d/t disorder of thoracic cage
lungs compressed, volumes reduced
increased WOB

78
Q

Mediastinal mass: what should be done prior to anesthesia?

A

CT

79
Q

Acute/severe condition - chronic extrinsic restrictive lung disease; elective surgery ?

A

postpone

*if necessary surgery: optimize patient preop

80
Q

Pre-op optimization for lung disease

A

Rx: stress dose steroids, bronchodilators, antbx, diuretics
O2: supplemental, PEEP, vent
Intvn: drain pleural effusions/ascites, NGT/OGT for decompression, pulm toilet, smoking cessation

81
Q

Patients at increased risk for periop pulm complications

A

> 60 y/o
ASA physical class II+
Functionally dependent

82
Q

Procedures that increase risk of periop pulm complications

A

GA
>2.5h
emergency surgery
type of surgery

83
Q

Acute respiratory failure: dx

A

PaO2 < 60 mmHg despite O2 supplementation
(-) R-L cardiac shunt
Increased PaCO2, decreased pH

84
Q

Chronic resp failure: dx

A

Increased PaCO2

normal pH

85
Q

ARDS characterized by

A

ALI (+ inflammation)

+ arterial hypoxemia

86
Q

mortality rate: ARDs

A

50%

87
Q

Phases of ARDS

A
  1. exudative (7d)
  2. Proliferative (8-21d)
  3. Fibrotic (After 3w)
88
Q

Exudative phase - ARDS

A

high permeability pulm edema

89
Q

proliferative phase - ARDS

A

interstitial inflammation

90
Q

fibrotic phase - ARDS

A

fibrosis

91
Q

Single most important factor for developing VAP

A

tracheal intubation

92
Q

ARDS Treatment

A

ACPC
TV 6-8mL/kg
PEEP if FiO2 > 50%
Maintain UO > 0.5 mL/kg/hr

93
Q

PE - s/s

A
  1. acute dyspnea
  2. tachypnea
  3. pleuritic chest pain
  4. rales
94
Q

Pohlmans sign

A

calf pain (DVT)

95
Q

PE - diagnosis

A

spiral CT

*gold standard but invasive/$$$ - pulm arteriography

96
Q

EtCO2: PE

A

sharp + sudden decrease

97
Q

PE Tx

A
  1. anticoag: heparin gtt
  2. inferior vena cava filter
  3. thrombolytic therapy: if unstable
  4. HD support: inotropic
  5. analgesia
  6. surgical embolectomy - for severe, refractory cases
98
Q

Anesthetic management: PE

A

Cardiac inotrope/pulm dilator: milrinone

99
Q

Fat embolism s/s

A

12-72h post long bone fx (tibia/femur)

Hypoxemia, Mental confusion, petechiae (neck, shoulders/chest)

100
Q

Treatment: fat embolism

A

management of ARDS, immobilization of long bone fracture, corticosteroids

Anesthesia & Coexisting Disease (23 decks)

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