Exam 4 Obstructive lung disease part I Flashcards
(66 cards)
1
Q
____ contribute to the risk of perioperative pulmonary complications
A
Obstructive respiratory diseases
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2
Q
- ____ complications play an important role in determining long-term mortality after surgery
- Patient optimization prior to surgery can significantly decrease the incidence of these complications
A
- Pulmonary
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3
Q
Obstructive respiratory diseases can be divided into 4 groups regarding their influence on anesthetic management:
A
- Acute upper respiratory tract infection (URI)
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Miscellaneous respiratory disorders
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4
Q
Acute upper respiratory tract infection
- Ages ____ experience the “common cold” at a rate of 19% per year
- Ages ____ experience it at a rate of 16% per year
A
- Ages 25-44 experience the “common cold” at a rate of 19% per year
- Ages 45-65experience it at a rate of 16% per year
Consequently, a fraction of scheduled surgery pts will have an active URI
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5
Q
Infectious (viral or bacterial) nasopharyngitis accounts for ̴____% of all URIs
A
95%
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6
Q
Most common responsible viral pathogens of acute URI’s
A
- rhinovirus
- coronavirus
- influenza virus
- parainfluenza virus, and
- respiratory syncytial virus (RSV)
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7
Q
Noninfectious nasopharyngitis can be ____ or ____ in origin
A
- allergic or vasomotor
Diagnosis is usually based on clinical signs and symptoms
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8
Q
____ and ____ lack sensitivity, and are time and cost consuming
making them impractical in a busy clinical setting
A
Viral cultures & lab tests
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9
Q
- Most studies on the effects of URI involve pediatric patients
- Children with URI’s are at much higher risk of perioperative respiratory adverse events such as:
A
- transient hypoxemia
- laryngospasm
- breath holding, and
- coughing
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10
Q
- Data on adults with URI’s undergoing anesthesia is limited
- A pt who has had a URI for ____ and is stable or improving can be safely managed without postponing surgery
A
weeks
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11
Q
If surgery is delayed, pts should not be rescheduled within ____ weeks as studies indicate that airway hyperreactivity may persist for that duration
A
6
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12
Q
- The COLDS scoring system is used to determine risk of proceeding with surgery
- COLDS takes into account what?
A
- current sx’s
- onset of symptoms (higher risk w/n 2 weeks)
- presence of lung disease
- airway device (higher risk with ETT)
- surgery (higher risk with major airway surgery)
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13
Q
Anesthetic management of pts w/URI’s should include:
A
- adequate hydration
- reducing secretions
- limiting manipulation of the sensitive airway
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14
Q
Acute URI
- Nebulized or topical local anesthetic on the vocal cords may reduce ____
- Use of a LMA rather than an ETT may reduce the risk of ____
- Considerations for induction and maintenance are similar to those with ____
- When there are no contraindications, ____ may result in smoother emergence
A
- upper airway sensitivity
- laryngospasm
- asthma
- deep extubation
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15
Q
Adverse respiratory events in pts with URIs include:
A
- bronchospasm
- laryngospasm
- airway obstruction
- postintubation croup
- desaturation
- atelectasis
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16
Q
____ and ____ hypoxemia are common in acute URI and amenable to treatment with supplemental O2
A
Intraoperative and postoperative
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17
Q
symptoms of acute respiratory infection vs influenza
A
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18
Q
what disease has chronic inflammation of the mucosa of the lower airways? and is an episodic disease with acute exacerbations and asymptomatic periods?
A
Asthma
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19
Q
In Asthma:
- Activation of the inflammatory cascade leads to infiltration of the ____ with eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes
- This results in ____, especially in the bronchi
- There is also ____ that leads to thickening of the basement membrane and smooth muscle mass
A
- airway mucosa
- airway edema
- airway remodeling
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20
Q
The main inflammatory mediators implicated in asthma include:
A
- histamine
- prostaglandin D2
- leukotrienes
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21
Q
What are asthma provoking stimulators?
A
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22
Q
symptoms of asthma include:
A
- expiratory wheezing
- productive or nonproductive cough
- dyspnea
- chest tightness that may lead to air hunger
- eosinophilia
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23
Q
Most asthma attacks are short lived, lasting how long?
A
minutes to hours
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24
Q
pt’s can experience periods of daily airway obstruction, ranging from ____ to ____
A
mild to severe
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25
what is status asthmaticus?
dangerous, life-threatening bronchospasm that persists despite treatment
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26
When the history is obtained from an asthma pt, attention should focus on:
* previous intubations
* ICU admission
* 2+ hospitalizations for asthma in the past year
* the presence of coexisting diseases
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* Diagnosis of asthma d/o clinical history, symptoms, and objective measurements of airway obstruction
* Asthma is diagnosed when a pt reports ____, ____, or ____ and demonstrates airflow obstruction on PFT that is at least partially reversible with ____
* wheezing, chest tightness, or SOB
* bronchodilators
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Classification of asthma severity depends on:
* the symptoms
* PFTs
* medication usage
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29
what is the most clinically usefull spirometric test of lung function?
* FEV1
* FVC
* FEV1/FVC ratio
* maximum voluntary ventilation (MVV)
* diffusing capacity
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30
what are direct measures of the severity of expiratory obstruction?
* Forced expiratory volume in 1 second (FEV1)
* forced expiratory flow (FEF)
* midexpiratory phase flow
These measurements can be used to assess the severity of an asthma attack
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31
The typical symptomatic asthmatic pt who comes to the hospital has an FEV1 of what?
< 35%
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32
how wil flow volume loop look like with asthmatic pt?
Flow-volume loops show a downward scooping of the expiratory limb of the loop
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33
During moderate or severe asthma attacks, what happens to FRC and TLC?
the functional residual capacity (FRC) may increase substantially, but total lung capacity (TLC) usually remains normal
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34
in asthma is diffusing lung capacity for carbon monoxide changed?
Diffusing lung capacity for carbon monoxide is not changed
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35
# asthma
* In pts with ____ obstruction, relief of obstruction after a bronchodilator suggests the dx of asthma
* Abnormalities in PFTs may persist for several days after an attack despite the absence of ____
* Since asthma is an episodic illness, its diagnosis may be suspected even w/ normal ____
* expiratory obstruction
* symptoms
* PFT results
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36
What is happening in graph B compared to A
B= bronchospasm. FEV1 < 80% of VC
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37
how does a volume flow loop look like in obstructive vs restrictive diease?
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38
with mild asthma how will abg look?
Mild asthma is usually accompanied by a normal PaO2 and PaCO2
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39
During an attack, tachypnea and hyperventilation is caused by ____ not hypoxemia
neural reflexes of the lungs,
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40
what are the most common ABG findings of symptomatic asthma
Hypocarbia and respiratory alkalosis
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41
* As the severity of expiratory obstruction increases, the associated ventilation/perfusion mismatching may result in a PaO2 of < ____ mmHg
* The PaCO2 is likely to increase when the FEV1 is < ____% of predicted
* < 60mmhg
* < 25%
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42
in asthma fatigue of the skeletal muscles necessary for breathing may contribute to the development of ____
hypercarbia
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43
* Pts w/severe asthma may demonstrate hyperinflation and hilar vascular congestion due to ____ and ____
* ____ can be helpful in determining the cause of an asthma exacerbation and ruling out other causes
* ____ may show signs of RV strain or ventricular irritability during an asthma attack
* mucous plugging and pulmonary HTN
* CXR’s
* EKG
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The differential diagnosis of asthma includes:
* viral tracheobronchitis
* sarcoidosis
* rheumatoid arthritis w/bronchitis
* extrinsic or intrinsic AW compression
* vocal cord dysfunction
* tracheal stenosis
* chronic bronchiti
* COPD
* and foreign body aspiration
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45
the aim of asthma treatment lie in controlling s/s and reducing exacerbations. What medications can be used?
* short acting inhaled β2 agonist
* daily inhaled corticosteroids
* inhaled muscarinic antagonists
* leukotriene modifiers
* mast cell stabilizers
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46
what is the 1st line of tx in pts with milde asthma?
short-acting inhaled β2 agonist.
*This is only recommended in those w/ < 2 exacerbations/month*
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47
what do inhaled coritcosteroids do for asthma?
improve sx’s, reduce exacerbations and decrease risk of hospitalization
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48
if sx remain uncontrolled what can be added?
daily inhaled β2 agonist
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49
* ____ are reserved for severe asthma, uncontrolled with inhalational medications
* Studies show that ____ decreases use of long-term medications and may improve quality of life
* Systemic corticosteroids
* SQ immunotherapy
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50
____ is recently approved and the only nonpharmacologic tx for refractory asthma
Bronchial thermoplasty (BT)
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51
* BT uses bronchoscopy to deliver radiofrequency ablation of airway smooth muscles to all lung fields except the ____
* The procedure is performed in three sessions and uses intense heat, which carries a risk of ____
* right middle lobe
* airway fire
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52
* Loss of airway smooth muscle mass is thought to reduce ____
* Serial PFTs can be useful for?
* When the FEV1 improves to about ____% of normal, pts usually have minimal or no symptoms
* bronchoconstriction
* monitoring response to treatment
* 50%
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53
what disease happens when bronchospasm doesn’t resolve despite usual treatmenat and is considered life threatening
Acute severe asthma
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54
how do you treat acute severe asthma?
Emergency tx consists of:
* high-dose, short-acting β2 agonists
* systemic corticosteroids
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55
INH β2 agonists can be administered every ____ min for several doses w/o adverse hemodynamic effects, although pts may experience unpleasant sensations resulting from ____
* 15-20 min
* adrenergic overstimulation
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56
* IV corticosteroids are administered early, why?
* The 2 corticosteroids most commonly used:
* because onset takes several hours
* hydrocortisone & methylprednisone
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57
* in acute severe asthma Supplemental O2 is given to help maintain O2 saturation >____%
* Other drugs used in more severe cases include:
* > 90%
* magnesium and oral leukotriene inhibitors
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58
What is the treatment for acute severe asthma?
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59
* Bronchospasm has been reported in ____% of asthmatics undergoing GA
* Risk of bronchospasm is correlated with ____ and ____.
* 0.2-4.2%
* the type of surgery (**higher with upper abdominal and oncologic surgery**) and how recent the last attack occurred
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60
GA mechanisms that increase airway resistance:
* 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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61
Other factors that play a role in bronchospasm include:
* airway stimulation by intubation
* PNS activation
* and/or release of neurotransmitters such as substance P and neurokinins
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62
Preop evaluation of pts with asthma requires an assessment of:
* disease severity
* effectiveness of current tx
* and the need for additional therapy before surgery
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what should we make note of when assessing asthmatic pt?
* history of symptom control
* frequency of exacerbations
* need for hospitalization or intubation
* previous anesthesia tolerance
* Physical appearance
* use of accessory muscles
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64
why is auscultation of the chest important when assessing an asthmatic?
to detect wheezing or crepitations
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65
what often mirror the degree of airway inflammation?
eosinophil counts
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66
# Asthma Preop Assessment
* Preop PFTs (esp FEV1) before and after bronchodilator may be indicated
* A reduction in FEV1 or forced vital capacity (FVC) to < ____% of predicted, and/or FEV1:FVC ratio < ____% of predicted, is a risk for periop respiratory complications
* < 70%
* < 65%
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