Exam 4 Obstructive lung disease part III Marlea

Question 1

Major risk factors for Development of postop pulmonary complications
- pt related (5)

Answer 1

• Pt related:
  -age>60yo
  -ASA class>II
  -CHF
  -preexisting pulmonary disease (COPD)
  -cigarette smoking

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Question 2

Major risk factors for Development of postop pulmonary complications
- Test procedures (1)

Answer 2

• Albumin level of <3.5g.dL

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Question 3

Intraoperatvie strategies to reduce post-op compications

Answer 3

• use minimally invasive surgery (endoscopic) techniques when possible
• consider regional anesthesia
• avoid surgical procedures likely to last more than 3 hours

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Question 4

Postoperative strategies to reduce post-op complications

Answer 4

• institute lung volume expansion maneuvers (voluntary deep breathing, incentive spirsmetry, continuous positive airway pressure)
• maximize analgesia (nerve blocks, neuraxial opioids, PCAs)

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Question 5

Smoking cessation:
- ~20% adults smoke, of whom ____ - ____ undergo surgery with GA

Answer 5

• 5-10%

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Question 6

• the maximum benefit of smoking cessation usually isn’t seen unless smoking has been stopped for ____ weeks prior to surgery
• smoking is the simgle most important risk factor for developing ____ and ____ caused by lung disease

Answer 6

• 8 weeks
• COPD and death

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Question 7

• The adverse effects of carbon monoxide on O2 carrying capacity and nicotine on the CV system are ____
• Nicotine causes ____ effects on the heart for ____ - ____ min
• E1/2 of carbon monoxide:

Answer 7

• short lived
• sympathomimetic; 20-30min
• 4-6 hours

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Question 8

• within ____ hours after smoking cessation, the P50 increases from ____ to ____ and the plasma levels of carboxyhemoglobin decrease from ____ to ____

Answer 8

• 12 hours; 22.9 to 26.4mmHg; 6.5% to 1%

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Question 9

How long does it take to see lung improvement after smoking cessation?

Answer 9

• return of normal immune function requires at least 6 weeks
• it may take 6 weeks or longer for hepatic enzymes to return to normal

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Question 10

Things to help with smoking cessation

Answer 10

• optimal timing of quitting before surgery is 6-8 weeks, if a pt is scheduled for surgery in <4 weeks should be advised to quit and offered behavioural support and pharmacotherapy
• Nicotine replacement therapy
• sustained release bupropion (started 1-2 weeks before smoking is stopped)

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Question 11

Although long term smoking cessation offers clear advantages, what are the disadvantages in the immediate postop period?

Answer 11

• increased sputum production
• inability to handle stress
• nicotine withdrawal
• irritability
• restlessness
• sleep disturbances
• depression

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Question 12

Bronchiectasis
- associated with
- prevalance

Answer 12

• associated with irreversible airway dilation, inflammation, and chronic bacterial infection
• Prevalence is highest in pts >60 with chronic pulmonary disease, COPD & asthma, and in women

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Question 13

Bronchiectasis
- S/S

Answer 13

• Chronic productive cough with purulent sputum
• hemoptysis
• clubbing
• vicious cycle of recurrent bacterial infection

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Question 14

Bronchiectasis
- diagnosis

Answer 14

• baseline chest XR
• sputum culture check to determine active infection
• CT is the gold standard - it will also show dialated bronchi

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Question 15

Bronchiectasis treatment

Answer 15

• Treatment: abx and chest physiotherapy are key
• other treatments = yearly flu vaccine, bronchodialators, systemic corticosteroids, O2
• surgery is only considered when severe symptomes persist or recurrent complications

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Question 16

Cystic Fibrosis
- definition

Answer 16

• autosomal recessive disorder of chloride channels leading to abnormal secretion production and clearance
• caused by a mutation of a single gene on chromosome 7 that encodes the cystic fibrosis transmembrane conductance regulator (CFTR)

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Question 17

What does the CFTR usually do under normal conditions, and what does it do with Cystic fibrosis?

Answer 17

• Normally, CFTR produces a protein, which aids in salt and water movement in and out of cells.
• However, in CF, the mutated CFTR gene results in the production of abnormally thick mucus outside of epithelial cells
• Decreased chloride transport is accompanied by decreased transport of sodium and water = dehydrated viscous secretions, luminal obstruction, and destruction and scarring of various glands and tissues
• The end result is severe organ damage

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Question 18

What does end organ damage in CF manifest?

Answer 18

• Bronchiectasis
• COPD (present is nearly all CF - relentless downhill course)
• sinusitis (chronic is pretty universal)
• diabetes
• cirrhosis
• meconium ileus in children
• azoospermia
• pancreatic insufficiency manifests with malabsoption of fats and fat-soluble vitamins
• primary cause of mortaility is chronic pulmonary infection

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Question 19

Diagnosing CF

Answer 19

• presence of sweat chloride concentration >60mEq/L along with clinical manifestations or family history
• DNA analysis can identify >90% of the CFTR mutation

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Question 20

Treatment of CF

Answer 20

• Treatment is directed toward symptom control, pancreatic enzyme replacement, oxygen therapy, nutrition, prevention of intestinal obstruction

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Question 21

Treating CF nonpharmacoligically

Answer 21

-main nonpharmacologic approach is chest physiotherapy and postural drainage
-high frequency chest compressions with an inflatable vest or airway oscillation

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Question 22

CF pharmacologic treatments

Answer 22

Bronchodialators
-a postitive response is defined as an increase of 10% or more in FEV1 after bronchodialator administration.

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Question 23

• the abnormal viscosity of airway secretions is caused by ____

Answer 23

• the presence of neutrophils and their degradation products

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Question 24

• CF pts have periodic exacerbations causing ____
• if cultures show no ____, a ____ to remove lower airway serections may be indicated
• many CF pts are given long-term ____ to suppress chronic infections

Answer 24

• increased sputum production
• pathogens; bronchoscopy
• antibiotics

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Question 25

CF anesthesia implications

Answer 25

• Vit K may be necessary if hepatic function is poor or exocrine pancreatic function is inpaired
• humidify inspired gasses, hydration, avoid anticholinergic drugs = less viscous secretions
• frequent tracheal suctioning
• postop pain control is important to have deep breathing, coughing and early ambulation

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Question 26

Primary ciliary dyskinesia
- definition

Answer 26

• Congenital impairment of ciliary activity in respiratory tract,epithelial cells and sperm tails and ciliated ovary ducts
• Impaired ciliary activity leads to chronic sinusitis, recurrent respiratory infections, bronchiectasis and infertility

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Question 27

Primary Ciliary dyskinesia (triad and what its called)

Answer 27

• Kartagener syndrome
• triad of: chronic sinusitis, bronchiectasis and situs inversus (chest organ position in inverted)

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Question 28

• Approximately ____ of pts with congenitally nonfunctioning cilia exhibit situs inversus
• isolated ____ is almost always associated with congenital heart disease

Answer 28

• 1/2
• dextrocardia

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Question 29

Primary Ciliary Dyskinesia
- anesthesia considerations

Answer 29

• RA is preferred to GA - this decreases pulmonary complicaitons
• with dextrocardia EKG position needs to be reversed for accurate interpretation
• because of increased risk of sinusitis, nasopharyngeal airways should be avoided

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Question 30

Dextrocardia anesthesia considerations
- great vessels
- preggers
- double lumen ETT

Answer 30

• Inversion of great vessels is the reason to select the left IJ vein for CVC
• Uterine displacement in pregnant womane should be to the right to keep the baby off the IVC
• double-lumen ETT, pulmonary inversion may indicate a Right double lumen tube placement (DLT)

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Question 31

Bronchiolitis obliterans
- from what?
- risk factors

Answer 31

• results from epithelial and subepithelial inflammation leading to bronchoilar destruction and narrowing
• risk factors: viral respiratory infections, environmental exposures, lung transplant and stem cell tansplant

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Question 32

Bronchiolitis obliterans

• PFTs show…
• CT scans show…

Answer 32

• PFTs: usually show obstructive disease and include reduced FEV1 and FEV1/FVC ratio (this is likely unresponsive to bronchodialators)
• CT shows air trapping and bronchiectasis in severe cases

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Question 33

Central Airway obstruction
- includes
- what percent of cancer pts are affected?
- obstruction can be from what things?

Answer 33

• includes obstruction of airflow in the tracheal and mainstem bronchi
• 20-30% of cancer pts can be affected
• obstrution is caused by: tumors, granulation from chronic infections, airway thinning from cartilage destruction

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Question 34

In central airway obstruction, when does tracheal stenosis become symptomatic?
what re the S/S?

Answer 34

when lumen is decreased to <5mm in diameter

• s/s of dyspnea is prominant even at rest, accessory muscles are used constantly, stridor

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Question 35

What do the flow volume loops look like in central airway obstruction?

Answer 35

• display flattened inspiratory and expiratory curves - this is characteristic of a fixed airway obstruction
• CT will illustrate tracheal narrowing

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Question 36

Tracheal Stenosis
- what can be used as a temporary treatment?

Answer 36

• Tracheal Dialation can be used as temporary treatment
• this can be done bronchoscopically with balloon dialators, surgical dialators or laser resection

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Question 37

Tracheal Stenosis
- long-term solutions

Answer 37

• tracheobronchial stent can be temporarty or long-term
• most successful treatment is surgical resection and reconstruction with primary re-anastomosis
• translaryngeal intubation is necessary for this surgery

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