Ex2 Respiratory Dx Flashcards
(100 cards)
1
Q
75% of inspiration consists of
A
active contraction of diaphragm
2
Q
25% of inspiration consists of
A
external intercostal muscles
3
Q
expiration occurs as a result of
A
passive recoil of ribcage
4
Q
forced expiration uses
A
internal intercostals/abdominal muscles
5
Q
95% of URIs are
A
infective nasopharyngitis
6
Q
safe to give anesthesia after URI after ____
A
4 weeks post-URI
**6w+ for reactive airways
7
Q
Elective surgery 2 weeks after URI - proceed, postpone, cancel?
A
Cancel - reschedule in 2 weeks
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
9
Q
intrinsic lung dx
-characteristics
A
- cause either:
1. inflammation/scarring of lung tx
2. fill air spaces w/ exudate/debris
10
Q
intrinsic lung dx - examples
A
asthma, COPD
11
Q
extrinsic lung dx
-characteristics
A
chest wall, pleura, resp muscles = disordered
–> cause lung restriction + ventilatory dysfunction
12
Q
Asthma is more common in
A
Females > males
13
Q
asthma is characterized by
A
- chronic inflammation
- reversible expiratory airflow obstruction
- bronchial hyperreactivity
14
Q
asthma alternative explanation
A
abnormal autonomic regulation of neural fxn imbalance between bronchoconstrictor/dilator neural imput
15
Q
FEV1
A
Volume of air that can be forcefully exhaled in 1 second
16
Q
FVC
A
max amount of air that can be expelled after deep inhalation
17
Q
normal M/F FVC
A
M = 4.8L F = 3.7L
18
Q
FEV1/FVC
A
75-80%
19
Q
direct measures of severity of asthma
A
FEV1
MMEF
20
Q
MMEF
A
Forced expiratory flow at 25-75% of vital capacity (FEF 24-75%)
-measurement of flow thru midpoint of forced expiration
21
Q
MVV
A
max voluntary ventilation
-measured over 15 seconds
22
Q
Normal MVV
A
F: 80-120 L/min
M: 140-180 L/min
23
Q
flow volume loop - asthma
A
downward scooping of exp.l limb (ice cream cone with scoop missing)
-Increased total lung capacity
24
Q
Asthma: how severe?
FEV1 65-80%
A
mild asymptomatic
25
Asthma: how severe?
| FEV1 50-64%
moderate
26
Asthma: how severe?
| FEV1 35-49%
marked
27
Asthma: how severe?
| FEV1 < 35%
severe
28
Asthma ABG
hypocarbia
| respiratory alkalosis
29
CXR/ECG findings: asthma
CXR: hyperinflation
ECG: RH strain, irritability
30
When is PaO2 abnormal in asthma?
Marked + severe
| < 60
31
FEV1 < 80%
obstructive airway disease
32
asthma tx
1. controllers
| 2. relievers
33
Asthma controllers
-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)
34
Asthma Relievers
rescue agents
- beta agonists (albuterol, metaproterenol)
- anticholinergics (ipratropium, atropine, glycopyrrolate)
35
Asthmatic may become hypercarbic if
impending fatigue + respiratory failure
36
status asthmaticus tx
- continuous inhaled B-agonist
- IV corticosteroids
- Magnesium, leukotriene inhibitors, terbutaline, epi
37
Epi dosage - status asthmaticus
SubQ 0.4mL of 1:1000
38
Terbutaline dosage - status asthmaticus
SubQ 0.25 mg
q15-30m
max dose 0.5mg in 4h
39
indicative of risk factors peri-op in asthma patients
Decreased FEV1
or FVC < 70%
+
FEV1/FVC < 65%
40
Major elective surgery should be postponed if
+ wheezing
| Peak expiratory flow < 80% or less than personal best
41
VA choice for asthma
Sevoflurane
42
How to prevent auto-PEEP in asthma
I:E from 1:2 to 1:3 or 1:4
43
Best anesthetic for asthma
regional
*if GA: LMA > ETT
LMA risk: less control over expiratory phase
44
DOC for asthma induction/GA
1. propofol
| 2. ketamine
45
After induction with IV agent, what other Rx (asthma)?
Ventilation with VA (Sevo)
+ Lido IV
+ opioids (Remifentanil)
46
Remifentanil infusion
0.05 - 0.1 mcg/kg/min
47
COPD is characterized by
- progressive airflow limitation *NOT fully reversible*
| - expiratory flow obstruction
48
COPD - primary ventilatory drive
Chronic hypercarbia blunts drive; dependent on Oxygen
49
Risk factors - COPD
```
#1- smoking
resp infxn, occupational exposure, genetic factors (antitrypsin-1 deficiency)
```
50
S/S COPD
hallmark - chronic productive cough + progressive exercise limitation
51
PFT - COPD
Decreased:
FEV1, FEF25-75%, ERV
Increased: FRC, RV (air trapping)
52
Treatment of COPD
Smoking cessation***
short term: increased sputum production
long term: O2 therapy
53
O2 therapy - COPD
Supplementation if:
PaO2 < 55mmHg
Hct > 55%
or evidence of cor pulmonale
54
Goal in O2 therapy for COPD
PaO2 60-80 mmHg
55
Rx therapy - COPD
B2 agonists, corticosteroids, diuretics
56
Predictive of post op pulmonary complications
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
PFTs useful for ____ (COPD)
thoracic surgery
58
Preoperatively - COPD pt to reduce risk can do____
clear bacterial infxn
smoking cessation
tx bronchospasm
59
Regional preferred for COPD patients if ____
do not require above T6 (ventilatory dysfunction)
60
Ventilation of COPD
Low RR, TV 6-8mL/kg, slow inspiratory flow rate
| *Air trapping: decreased recoil leads to retained air that should be exhaled
61
detection of air trapping
1. capnography upslope
2. exp flow rate does not reach 0
3. PEEP develops/increases
4. BP falls as PEEP increases
62
bronchiectasis
localized, irreversible dilation of a bronchus
| -d/t infxn
63
s/s bronchiectasis
productive cough, large amounts of sputum, clubbing of fingers
64
CF - clinical manifestations
cough, purulent sputum production, exertional dyspnea
65
diagnosis: CF
Sweat test: Sweat Cl > 80 mEq/L
66
Tracheal Stenosis - symptomatic when?
trachea < 5 cm
67
Restrictive Lung Disease: PFTs show
Decreased lung volume, compliance, with preservation of expiratory flow rates
Decreased FRC, FEV1
Normal/increased FEV1/FVC
68
*Acute* intrinsic restrictive lung disease
```
pulmonary edema
atelectasis
ARDs
Aspiration
Neurogenic problems
```
69
*Chronic* intrinsic restrictive lung disease
Interstitial lung disease - fibrosis
| -sarcoidosis, hypersensitivity pneumonitis, eosinophilic granuloma, lymphangioleiomyomatosis
70
Chronic extrinsic restrictive lung disease
chest wall, pleura, mediastinum
-scoliosis, pneumothorax, mediastinal mass
muscular dystrophy, guillain-barre, myasthenia gravis
spinal cord transection (at or below C5)
71
Pt presents to elective surgery with pulm edema - proceed?
Postpone + treat symptoms
* all acute restrictive disease
- i.e. drain large pleural effusion, persistent hypoxemia
72
intra-op management of pulmonary edema
Lower TV
Higher RR
goal: end insp plateau pressure < 30
Consider sending to ICU on vent
73
Interstitial Lung disease
Chronic intrinsic lung disease
| -pulm fibrosis: loss of pulm vasculature, + pHTN, cor pulmonale, dyspnea, tachypnea
74
Preoperative management: chronic intrinsic restrictive lung disease
Infection: treat
Secretions: clear
smoking cessation
75
indicative of severe pulmonary dysfxn (chronic restrictive dx)
Vital capacity < 15 mL/kg
76
Intraop considerations - chronic restrictive lung dx
```
*use ACPC
Hypoxemia + normocarbia
apneic periods not tolerated
GA, supine position, controlled ventilation=decreased FRC
**VA uptake = faster*
lower PIP (prevent barotrauma)
```
77
characteristic of extrinsic restrictive disease
most often d/t disorder of thoracic cage
lungs compressed, volumes reduced
increased WOB
78
Mediastinal mass: what should be done prior to anesthesia?
CT
79
Acute/severe condition - chronic extrinsic restrictive lung disease; elective surgery ?
postpone
| *if necessary surgery: optimize patient preop
80
Pre-op optimization for lung disease
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
Patients at increased risk for periop pulm complications
> 60 y/o
ASA physical class II+
Functionally dependent
82
Procedures that increase risk of periop pulm complications
GA
>2.5h
emergency surgery
type of surgery
83
Acute respiratory failure: dx
PaO2 < 60 mmHg despite O2 supplementation
(-) R-L cardiac shunt
Increased PaCO2, decreased pH
84
Chronic resp failure: dx
Increased PaCO2
| normal pH
85
ARDS characterized by
ALI (+ inflammation)
| + arterial hypoxemia
86
mortality rate: ARDs
50%
87
Phases of ARDS
1. exudative (7d)
2. Proliferative (8-21d)
3. Fibrotic (After 3w)
88
Exudative phase - ARDS
high permeability pulm edema
89
proliferative phase - ARDS
interstitial inflammation
90
fibrotic phase - ARDS
fibrosis
91
Single most important factor for developing VAP
tracheal intubation
92
ARDS Treatment
ACPC
TV 6-8mL/kg
PEEP if FiO2 > 50%
Maintain UO > 0.5 mL/kg/hr
93
PE - s/s
1. acute dyspnea
2. tachypnea
3. pleuritic chest pain
4. rales
94
Pohlmans sign
calf pain (DVT)
95
PE - diagnosis
spiral CT
| *gold standard but invasive/$$$ - pulm arteriography
96
EtCO2: PE
sharp + sudden decrease
97
PE Tx
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
Anesthetic management: PE
Cardiac inotrope/pulm dilator: milrinone
99
Fat embolism s/s
12-72h post long bone fx (tibia/femur)
| Hypoxemia, Mental confusion, petechiae (neck, shoulders/chest)
100
Treatment: fat embolism
management of ARDS, immobilization of long bone fracture, corticosteroids
