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AP EXAM 3 brainscape Flashcards

1
Q

factors affecting post-op hypoxia

A

atelectasis (sit upright ,cough, breath deeeply)

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2
Q

pulmonary embolism and EtCO2

A

etCO2 decreases

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3
Q

ventilatory drive

A

relaxant? Opioid? Gas on board?

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4
Q

asthma, pathologic findings

A

airway remodelng, bronchoconstriction included, structural changes (hyperplasia, metaplasia, bronchial angiogenisis)

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5
Q

determinants of FRC

A

FRC is the volume in the lungs at the end of passive expiration, it is determined by opposing forces of the expanding chest wall and the elastic recoil of the lung, Normal FRC is 1.7-3.5 / FRC changes with body size, age, certain lung diseases, sex, diaphragmatiic muscle tone, posture, increased abdominal pressure

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6
Q

causes of obstructive sleep apnea

A

obesity

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7
Q

bronchiectasis, definition

A

destruction and widening of large airways that become easily collapsible, can begin in early childhood (similar to emphysema but in large aiways)

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8
Q

COPD, vent settings

A

controlled MV, large tidal volumes (10-15ml/kg) combine with a slow insp flow will minimize turbulent flow and help maintain optimal vent to perfusion matching, slow RR provide sufficent time for complete exhalation

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9
Q

calculating transmural CVP

A

Transmural CVP = CVP - Pleural pressure

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10
Q

chest tube maintenance

A

leave it clamped

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11
Q

asthma, induction agents

A

ketamine is a bronchodilator

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12
Q

asthma, exacerbating factors

A
  1. GERD (30-80% of asthma patients have GERD, frequently silent, 07% of asthmatics improve with antireflux therapy) GERD causes asthma/bronchospasm (aspiration of refluxed gastric contents, vagal response, esophageal muscosal receptors), Asthma causes GERD (autonomic dysregulation, bronchodilators, theophyline, steroids lower LES tone); 2. Aspirin, 5-20% of adult asthmatics have AIA
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13
Q

severe emphysema, lung lucency on CXR

A

hyperlucent bc lungs chronically inflated, flat diaphragm

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14
Q

severe emphysema, lung compliance

A

high lung compliance due to poor elastic recoil

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15
Q

V/Q relationships, upright lung

A

deadspace in upright lung, shunt in dependent lung

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16
Q

calculation, ideal alveolar oxygen tension

A

PAO2 = FiO2 x 713 - (40/0.8)

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17
Q

chronic restrictive disease, clinical findings

A

on room air, A-a gradient should be less than or equal to 4 + age/4

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18
Q

6 Intrathoracic vascular pressures

A

RA, CVP, PA systolic, PA diastolic, PA mean, LA pressure, RVEDP

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19
Q

Difference bt intra and extra thoracic pressures

A

extra would be atmospheric

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20
Q

Compliance=

A

change in volume/change in pressure

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21
Q

Which of the compliances can be measured on an anesthesia ventilator

A

Total (lung and thorax comp) TV/airway pressure

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22
Q

Normal lung-thorax compliances

A

total= 100, lung=200 thorax=200

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23
Q

post -op avg lung/thorax compliance

A

50ml/cmH2O

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24
Q

lungs and chest wall in series or parallel?

A

series

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25
Q

when during a spontaneus resp cycle do you measure hemodynamics

A

end-expiration, bc of steady state and more equilibrium

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26
Q

Transmural filling pressure?

A

measuring inside pressure and subtracting the outside pressure so you are getting the filling pressure

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27
Q

P(pl)=

A

P(pl) = P(aw) * C(L)/(C(L) + C(T))

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28
Q

Types of COPD

A

asthma, bronchitis, emphysema, bronchiectasis, bronchiolitis

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29
Q

Bronchitis

A

inflammation of large airways, causes: smoking, pollution, allergies, job hazards, symptoms: cough, mucus production, shortness of breath, wheezing, may be cyanotic

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30
Q

Tx of Bronchitis

A

minimize inflammation with short-term steroid therapy, bronchodilators using albuterol, hydration, antibiotics if there is a bacterial infection

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31
Q

Emphysema

A

One of the most common lung diseases, causes lung destruction of the terminal bronchioles to alveoli, slowly and irreversibly destroys the elastic fibers that hold open the small airways

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32
Q

Causes of emphysema

A

smoking most common, brochitis

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33
Q

Symptoms of emphysema

A

shortness of breath, impaired abilty to exhale

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34
Q

Pursing lips with emphysema

A

fxns as auto-peep

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35
Q

Treatment of emphysema

A

short acting bronchodilators (both B2 albuteraol and anticholinergic (atrovent)), long acting anticholinergic (spiriva), inhaled corticosteroids with long acting bronchodilator (advair), oral steroids (prednisone), antibiotics, oxygen in end stage, lung reduction surgery

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36
Q

define Bronchiolitis, and causes

A

swelling and build up in the bronchioles due to a viral infections, seen in children under 2, has a seasonal pattern usually fall and spring

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37
Q

symptoms of bronchiolitis

A

shortness of breath, cough, wheezing

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38
Q

TX of Bronchiolitis

A

antibiotics for recuurent infections, hydration, chest physical therapy, steroid therapy, bronchodilators

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39
Q

Causes of bronchiectasis

A

recurrent infections and inflammation, cystic fibrosis (50% of cases) TB

40
Q

symptoms of bronchiectasis

A

shortness of breath, cyanosis, breath odor, chronic cough with foul sputum, finger clubbing

41
Q

Tx of bronchiectasis

A

hydration, antibiotics if there is a secondary infection, antiviral drugs such as rebetol in severe cases, if hospitalized then humidified oxygen and IV fluids

42
Q

6 risk factors for post-op pulmonary dysfuction

A

1) preexisting pulmonary disease 2) thoracic or upper ab surgery 3) smoking (risk of death 30x higher for heavy smokers) 4) obesity 5) age >60 years 6) prolonged general anestheisa ( >3 hrs)

43
Q

obstructive pulmoary disease

A

total lung capacity is increase but there is a loss of expiratory reserve volume

44
Q

COPD

A

_Elevated airway resistance and air trapping increase the work of breathing _Respiratory gas exchange is impaired because of ventilation/perfusion (V/Q) imbalance _The predominance of expiratory airflow resistance results in air trapping: residual volume and total lung capacity (TLC) increase.

45
Q

COPD exacerbations

A

respiratory infections, allergens, pungent odors like perfumes, dust or mold

46
Q

COPD, pre-op mgmt

A

_Patients with COPD should be optimally prepared prior to elective surgical procedures - Pt_s should be questioned about recent changes in dyspnea on exertion, sputum, and wheezing. -Smoking should be discontinued for at least 6-8 weeks before the operation to decrease secretions and to reduce pulmonary complications. Cigarette smoking increases mucus production and decreases clearance.

47
Q

COPD treatments

A

acute exacerbation best treated with B2 adrenergic agents, other treatments include prednisone, ipratropium, leukotriene inhibitors, or theophylline

48
Q

COPD pre-op assessment

A

smoke? Exercise tolerance? Last hospitalized for lung dz? Productive cough? Colored sputum? Medications? Listen. Pulmonary fxn studies. SpO2? On oxygen?

49
Q

COPD, anesthetic mgmt

A

preox essential due to rapid desat, sevo or des preferred bc rapidly eliminated, controlled mechanical vent will optimize lung fxn, large tidal volumes (10-15cc/kg) with a slow insp flow will minimize turbulent flow and help maintain optimal ventilation to perfusion matching, slow RR (6-8) provide sufficient time for complete exhalation to occur

50
Q

COPD post-op considerations

A

Patients with thoracic and upper abdominal surgery are at increased risk for postop complications like prolonged ventilatory support and pneumonia. Both these surgical locations prevent the patient from taking deep breaths and coughing to clear secretions. All COPD patients should be told of the possibility of having the endotracheal tube remain in place until their lungs are ready to have it removed as well as the possibility of postop ventilation. Pain is a major part of this problem and the use of epidural for pain management may allow the patient to take deeper breaths and cough. Oxygen administration is usually needed into the immediate postop period. A liter flow to maintain a Po2 of between 60-80 mmHg of a Spo2 of 90-95%.

51
Q

Asthma

A

chronic inflammatory disorder (episodic, reversible bronchospasm, bronchial hyper-responsiveness to stimuli, airway remodeling, severity tends to increase with time) may not be a single clinical disorder; prevalance 6.7% in US

52
Q

Asthma and death

A

50% of asthma deaths occur in patients over 65, underdiagnosed in the elderly

53
Q

Asthma, preop mgmt

A

history (age of onset, triggers, hospitilzations, recent symptoms, medications) other history (recent uri, smoking, gerd, aspririn or NSAID sensitivity, response to prior anesthetics) BUT history can be misleading bc symptoms do not correlate with lung fxn, test peak expiratory flow rate (handheld meters, effort-dependent, 20% variability in baseline, diurnal variation)

54
Q

Spirometry

A

can assess occult broncospasm (dyspnea, nocturnal cough, chest tightness); new diagnosis (can assess resolution of acute exacerbation, can predict response to bronchdilators); selective use is appropriate (quick and inexpensive, effort dependent, no advantage in predicting postop complications)

55
Q

Asthma, volume loop

A

classic flow-volume loop shows reduced exp flow and vital capacity; concave shape of expiratory portion; FEV1 is the most reprodcible PFT parameter

56
Q

Asthma, ABG

A

Hypercarbia or hypoxia indicative of severe disease, beware of CO2 normalization, abnormal postop in normal controls, chest x-ray is the only way to rule out confounding diagnoses

57
Q

dead space lung

A

ventilation > perfusion

58
Q

shunt lung

A

perfustion > ventilation

59
Q

effects of prolonged shunt

A

hypoxic vasoconstriction kicks in; low BP decreased CO2 due to decreased CO

60
Q

3 causes of A-a gradient abnormality

A

1) Right to left shunt 2) V/Q mismatch 3) diffusion abnormality

61
Q

Right to left shunt

A

areas of the lung that are perfused by not ventilated; basically mixed venous blood getting back to arterial circulation without being oxygenated- therefore lowering overal PaO2

62
Q

determining PaO2 not on room air

A

patients PaO2 should be around FiO2 x 5

63
Q

ratio of meausred PaO2 to FiO2 should be

A

300-500; less than 250 indicates a clinically significant gas exchange problem

64
Q

negative pressure in chest drainage systems

A

the maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) the vent tube is below the water line (this can be adjusted)

65
Q

life threatening thorax

A

air tension

66
Q

how does air normally get into the chest

A

central line

67
Q

structure of a chest tube

A

side holes to optimize drainage, radiodense line to help find on x-ray (line interrupted by most proximal hole in chest tube (the sentinal eye)

68
Q

chest tube placement

A

over the rib to avoid vein, artery, nerve / aimed toward posterior portion of chest cavity since pts are supine, this helps with drainage / removal? When prob is fixed and chest no longer needs to be drained

69
Q

chest tube 1 bottle drainage

A

2-4cm water at bottom, drainage enters bottle, if air- bubbles exit to atm, if fluid- fills fluid lecel

70
Q

chest tube 2 bottle

A

bottle 1 is collection, bottle 2 keeps pt from introducing room air into chest cavity

71
Q

surgeon places chest tube, when do you hook up tube?

A

before chest is closed, don_t want to cause a tension pneumo from PPV

72
Q

chest tube with pneumonectomy

A

balance chest/mediastunum to avoid shifting

73
Q

RLD

A

lung expansion is restriced but airway resistance and exp flow rates are normal; results in decreases lung volumes and decreased compliance

74
Q

Resp compliance =

A

Lung + Pleura + Chest wall

75
Q

RLD pathophysiology

A

Low lung volumes lead to atelectasis, V/Q mismatch and hypoxemia, decrease O2 diffusion, reduced FRC, reduced compliance, MV must be maintained by increasing RR

76
Q

definition of RLD

A

spectrum of disorders characterized by a decrease in TLC

77
Q

TLC meaured by

A

helium dilution or body plethysmography

78
Q

Intrinsic RLD

A

pulmonary parenchymal or airspace disease (lung problem)

79
Q

Extrinsic RLD

A

impaired lung expansion but normal lungs (extrapulmonary problem)

80
Q

Acute Intrinsic examples

A

ARDS, aspiration pneumonitis

81
Q

ARDS

A

acute inflammatory response to the lung resulting in noncardiogenic pulmonary edema (diagnostic criteria: acute onset, bilateral infiltrates on CXR PaO2/FiO2 < 18

82
Q

ARDSNet vent protocol

A

avoid volutrauma and barotrauma (tidal volume 6cc/kg, PEEp at least 5, SpO2 88-95, PaO2 55-80 permissive hypercapnia

83
Q

Chronic Intrinsic RLD

A

Interstitial lung diseases, sarcoidosis; insidious onset, chronic inflammation and progressive pulmonary fibrosis, disease my be confined to lungs or multiorgan (anesthetic technique doesn_t lead to exacerbations, work with what we’ve got)

84
Q

Acute Extrinsic RLD

A

disorders of the pleura or mediastinum, pleural effusion, pneumothorax, pneumomediastinum

85
Q

Chronic extrinsic RLD causes

A

obesity, pregnancy, ascites

86
Q

Cobbs angle

A

> 100 resp failure

87
Q

Tidal volume

A

about 500ml

88
Q

Inspiratory Reserve Volume

A

3100ml

89
Q

Expiratory Reserve Volume

A

about 1200

90
Q

Residual Volume

A

about 1200

91
Q

TLC

A

about 6000ml

92
Q

VC

A

about 4800ml

93
Q

Inspiratory Capacity

A

about 3600ml (TV+IRV)

94
Q

FRC

A

about 2400ml (FRC =RV+ERV)

95
Q

Normal FEV1/FVC ratio

A

80%

96
Q

What to expect perioperatively with RLD

A

rapid desaturation, high airway pressues, sensitivity to respiratory depressants, and need for postop ventilatory support

AP (1 decks)

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