Exam 4- Obstructive Respiratory Disease - organize Flashcards
(183 cards)
1
Q
What are the 5 most common viral pathogens responsible for URIs?
A
rhinovirus, coronavirus, influenza virus, parainfluenza virus, and respiratory syncytial virus (RSV)
3
2
Q
Noninfectious nasopharyngitis can be ____ or ____ in origin.
A
allergic or vasomotor
3
3
Q
Why is the diagnosis of URIs mainly based on just clinical s/sx? (as opposed to labs/tests)
A
Viral cultures & lab tests lack sensitivity, and are time and cost consuming
* impractical in a busy clinical setting
3
4
Q
what accounts for ̴95% of all URIs?
A
Infectious (viral or bacterial) nasopharyngitis
3
5
Q
A
6
Q
Who is at a much higher risk of perioperative respiratory adverse events (PRAEs) s/a transient hypoxemia, laryngospasm, breath holding, and coughing?
A
Children with URI’s
7
Q
Should we postpone surgery for a pt who has had a chronic URI and is stable?
A
No, a pt who has had a URI for days-weeks and is stable or improving can be safely managed without postponing surgery
4
8
Q
for how long may airway hyperreactivity persist?
A
6 weeks
So if surgery is delayed bec of an URI, pts should not be rescheduled within 6 weeks
4
9
Q
What is used to determine risk of proceeding with surgery for a pt w/ URI?
A
COLDS scoring system
4
10
Q
What 5 things does the COLDS scoring system take into account?
A
current sx’s
onset of symptoms (higher risk <2 weeks ago)
presence of lung disease
airway device (higher risk with ETT)
surgery (higher risk with major airway surgery)
4
11
Q
Anesthetic management of pts w/URI’s should include (3 things):
A
adequate hydration, reducing secretions, and limiting manipulation of the sensitive airway
5
12
Q
What type of local anesthetic can reduce upper airway sensitivity?
A
Nebulized or topical local anesthetic on the vocal cords
5
13
Q
Use of what airway may help reduce the risk of laryngospasm?
A
Use of a LMA rather than an ETT
5
14
Q
Considerations for induction and maintenance for pts with acute URI are similar to those with _____.
A
asthma
5
15
Q
if there are no contraindications, what may result in smoother emergence?
A
deep extubation
5
16
Q
Adverse respiratory events in pts w URI include (6 things):
A
bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis
6
17
Q
Whats common in pts with Acute URI that can be treated easily w supplemental O2?
A
Intraoperative and postoperative hypoxemia
6
18
Q
What are some differentials between Acute URI vs Influenza?
A
Acute URI: earache, runny nose, nasal congestion, sore throat, hoarseness
All other sx are seen in both URI and flu!
6
19
Q
Asthma is considered chronic inflammation of the mucosa of the ____ airways.
A
lower airways
7
20
Q
In asthma, activation of the inflammatory cascade leads to infiltration of airway mucosa with:
This results in airway edema, especially in the ______.
A
- infiltration of the airway mucosa with eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes
- bronchi
7
21
Q
What are the 3 main inflammatory mediators in asthma?
A
histamine, prostaglandin D2, and leukotrienes
7
22
Q
What are 5 asthma provoking stimulators?
A
- allergens
- pharmacologic agents: ASA, BB, some NSAIDs, sulfaring agents
- infections
- exercise
- emotional stress
7
23
Q
What are some sx of asthma (6)?
A
expiratory wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia
8
24
Q
What is status asthmaticus?
A
life-threatening bronchospasm that persists despite treatment
8
25
What 4 factors should attention be focused on when obtaining hx from an asthma pt?
previous intubation, ICU admission, 2+ hospitalizations for asthma in the past year, and the presence of coexisting diseases
## Footnote
8
26
When is asthma diagnosed? (like what pt reports and what does PFT show)
when a pt reports symptoms of wheezing, chest tightness, or SOB and demonstrates airflow obstruction on PFT that is at least partially reversible with bronchodilators
## Footnote
9
27
What does classification of asthma severity depend on?
symptoms, PFTs, and medication usage
## Footnote
9
28
What is maximum voluntary ventilation?
max air that can be inhaled and exhaled within 1 min
males: 140-180 L; females 80-120 L
## Footnote
10
29
FEV1, FEF (forced expiratory flow) and midexpiratory phase flow are direct measurements of the severity of what?
expiratory obstruction
*These are used to assess the severity of an asthma attack*
## Footnote
11
30
During an asthma attack, what type of results are seen in FEV1?
Flow volume loop? Lung volumes?
Diffusing capacity for CO?
FEV1 <35%
Flow volume loops show a downward scooping of expiratory part
FRC increases, but TLC remains normal
Diffusing capacity for CO not changed
## Footnote
11
31
In pt w/ expiratory obstruction, what suggests the diagnosis of asthma?
relief of obstruction after bronchodilator
| abnormalities in PFT seen for days even w/ absence of symtpoms!
## Footnote
11
32
In a pt w/ bronchospasm, FEV1 is _____ than 80%.
Peak flow and maximum flow rate (FEF 25%-75%) are also ____
lower than 80%
decreased
## Footnote
12
33
Flow volume loops
obstructuve: O
restrictive w/ limitation on inspiration and expiration: R(E)
and paraenchymal restrictive (RP)
## Footnote
13
34
What causes an tachypnea and hyperventilation during an asthma attack?
neural reflexes of lungs, not hypoxemia
## Footnote
14
35
What are common ABG findings in symptomatic asthma?
hypocarbia and respiratory alkalosis!
*however a mild asthma attack = normal PaO2 and normal PaCO2 *
## Footnote
14
36
As expiratory obstruction worsens, V/Q mismatching may result in a PaO2 of ____?
The PaCO2 will increase when FEV1 is what percentage?
<60 mmHg
25% of predicted
| fatique of breathing skeletal muscles contributes to hypercapnea
## Footnote
14
37
Due to mucous plugging and pulm HTN, pt w/ severe asthma demonstrate what 2 symptoms?
hyperinflation and hiliar vascular congestion
## Footnote
15
38
During an asthma attack, what might the EKG show?
RV strain or ventricular irritability
## Footnote
15
39
What is the 1st line of treatment for patient with mild asthma?
What other medication can be added to help improve the symptoms of asthma, reduce exacerbations and decrease risk of hospitalization?
* short-acting inhaled β2 agonist
* daily inhaled corticosteroids
*This is only recommended in those w/ < 2 exacerbations/month *
## Footnote
16
40
True or false: if asthma symptoms remain uncontrolled, daily inhaled β2 agonist
True
## Footnote
16
41
What medication can be use to decrease the use of long -term medications for asthma ?
*base of a study*
SQ immunotherapy
## Footnote
16
42
What other therapies that can be use as treatment for asthmas?
* inhaled muscarinic antagonists
* leukotriene modifiers
* mast cell stabilizers
## Footnote
16
43
What medication is reserved for severe asthma that is uncontrolled with inhalational medications?
Systemic corticosteroids
## Footnote
16
44
What is the name of the only nonpharmacologic treatment for refractory asthma?
Bronchial thermoplasty (BT)
## Footnote
17
45
How is Bronchial thermoplasty (BT) utilize to treat refractory asthma?
uses a bronchoscopy to deliver radiofrequency ablation of airway smooth muscles to all lung fields except the right middle lobe
*procedure is performed in three sessions and uses intense heat, which carries a risk of airway fire
## Footnote
17
46
Loss of airway smooth muscle mass can reduce what ?
bronchoconstriction
## Footnote
17
47
What is useful in monitoring the reponse to treatment?
Serial PFTs
*FEV1 improves to about 50% of normal, pts usually have minimal or no symptoms*
## Footnote
17
48
What is the emergency treatment for acute severe asthma?
* consists of high-dose
* short-acting β2 agonists
* systemic corticosteroids
## Footnote
18
49
What is the difference in asthma vs acute severe asthma ?
* bronchospasm doesn’t resolve despite usual treatment
* considered life threatening
## Footnote
18
50
How often can INH β2 agonists be adminstered?
every 15-20 min for several doses without adverse hemodynamic effects
*although pts may experience unpleasant sensations resulting from adrenergic overstimulation*
## Footnote
18
51
Why is IV corticosteroides adminstered early for treatment of acute severe asthma?
What are the 2 corticosteroids most commomly used
onset takes several hours
Hydrocortione and methlprednisone
## Footnote
18
52
Why is supplemential O2 given to a patient that is experiencing acute severe asthma attack?
to help maintain 02 saturation >90%
## Footnote
18
53
What other drugs can be administered to patietnts that are experiencing acute severe asthma?
* magnesium
* oral leukotriene inhibitors experiencing
## Footnote
18
54
# Treatment of Acute Severe Asthma
Fill in the blanks:
* Supplemental oxygen to maintain SaO2 > ____%
* ____ agonists by metered- dose inhaler every ____ - ____ or by ____ nebulizet administration
* intervenous ____ ( hydrocotisone or ____)
* IV fluids to maintain ____
* ____ broad -spectrum antibiotics
* Anticholinergiv (____) by inhalation
* IV ____ sulfate
* ____ intubation and mechanical ventilation (when PaCO2 is > ____ mmhg)
* Sedation and _____
* Mechanical ventialation parameters:
* Gernal ansthesia with a ____ ____ to produce _____
* _______ _______ _______ _______ (ECMO) as a last resort
## Footnote
19
55
What are the risk factors that would contribute to bronchospasms during surgery?
* type of surgery (higher with upper abdominal and oncologic surgery)
* how recent the last attack occurred
## Footnote
20
56
How does General Anesthesia effects a patient with asthma?
* depression of cough reflex
* impairment of mucociliary function
* reduction of palatopharyngeal muscle tone
* depression of diaphragmatic function
* increased fluid in the airway wall
## Footnote
20
57
What other factors can affect an asthmatic receiving anesthesia
airway stimulation by intubation,
PNS activation, and/or release of neurotransmitters
*such as substance P and neurokinins also play a role percentage *
## Footnote
20
58
What are some pre-op assessment that need to be done for a patient that that has Asthma ?
* assessment of disease severity
* current treatment, and the
* need for additional therapy before surgery
* history of symptom control
* frequency of exacerbations
* Physical appearance and use of accessory muscles
* Auscultation of the chest to detect wheezing or crepitations is important
* Eosinophil counts
## Footnote
21
59
During a pre-op Assessment for a patient that as asthma, what type of test and mediation should be taken in consideration?
* Preop PFTs (esp FEV1) before and after bronchodilator may be indicated
*( A reduction in FEV1 or forced vital capacity (FVC) to <70% of predicted, and/or FEV1:FVC ratio <65% of predicted, is a risk for periop respiratory complications)*
* Preop chest physiotherapy, antibiotics, and a bronchodilators can often improve reversible components of asthma
* ABGs *(if there is any question about the adequacy of ventilation or oxygenation)*
* Anti-inflammatories and bronchodilators should be continued until induction
* If the pt is has been on systemic corticosteroids within the past 6 months, a stress-dose hydrocortisone or methylprednisolone is indicated
* Pts should be free of wheezing and have a PEFR of >80% of predicted or their personal best value before surgery
## Footnote
22
60
* symptoms = emphysema characterized by lung _____ damage ,, chronic ____ ,, productive _______ ,, small airway dz
* _____ leading cause of death
## Footnote
COPD
* parenchymal ,, bronchitis ,, cough
* 3rd
## Footnote
24
61
COPD risks (long list)
o **smoking**, **occupational** exposure, asbestos, gold mining, biomass fuel, air **pollution**, genetic factors, age, **female** gender, **poor lung development during gestation**, low birth weight, recurrent childhood respiratory infections, **low socioeconomic class**, and asthma
## Footnote
24
62
COPD leads to ?? (5)
1. deterioration in recoil/elasticity
2. decrease bronchiolar wall structure
3. increased velocity through narrowed bronchi
4. active bronchospasm + obstruction from secretions
5. destruction of lung parenchyma + enlarge air sacs
*emphysema
## Footnote
25
63
COPD Symptoms ::
* vary with ___________
* __________ at rest ,, chronic __________ and __________ production
* exacerbations >>> _________ and prolonged ___________ times
* breath sounds are ____________ and __________ wheezes
* as progresses :: exacerbations are more _________ and triggered by _____________ resp infx
* severity
* dyspnea ,, cough ,, sputum
* tachypnea ,, expiratory
* decreased ,, expiratory
* frequent ,, bacterial
## Footnote
26
64
# COPD Diagnosis:
* Definitive diagnosis is made with ______________
* PFTS = decrease in ______ and ________
* increase in _______ volume d/t gas trapping which causes a _______ airway diameter
* spirometry
* FEV1/FVC ratio + FEF25-75
* residual
* enlarged
## Footnote
27
65
Common findings of COPD include
* FEV1:FVC <_____%
* increased _____ and _____
* reduced ______
* <70%
* FRC + TLC
* DLCO
## Footnote
27
66
# COPD Diagnosis:
* CXR findings = may be ______ even with severe COPD
* ________ suggests emphysema
* ______ confirms emphysema
* minimal
* hyperlucency
* bullae
## Footnote
30
67
# COPD Diagnosis:
Most Sensitive to diagnose COPD
CT
## Footnote
30
68
# COPD Diagnosis:
* Multi Organ Loss of Tissue (MOLT) is a ____ of COPD
* high rates of _____ cancer
* Sx = ______ enlargement , ______ destruction , loss of _______, muscle, fat tissues
* phenotype
* lung
* airspace , alveolar , bone
## Footnote
30
69
# COPD Diagnosis:
Bronchitic Phenotype = _________ narrowing and _______ thickening
* accompanied by _______ syndrome and ______ disease
* bronchiolar + wall
* metabolic + cardiac
## Footnote
30
70
____________ eosinophil levels indicate the need for inhaled ____________.
____________ eosinophil levels are associated with poor response and increased risk of ___________.
**high** eosinophil indicate the need for inhaled **glucocorticoids**
**low** levels are associated with poor response and increased risk of **pneumonia**
## Footnote
31
71
ABGs often remain normal until COPD is severe
Pa02 doesn't usually decrease until the FEV1 is ____________% of predicted, and PaC02 may not increase until the FEV1 is even _________.
ABGs often remain normal until COPD is severe
Pa02 doesn't usually decrease until the FEV1 is **<50% **of predicted, and PaC02 may not increase until the FEV1 is even **lower**
## Footnote
31
72
________________deficiency is an inherited disorder associated with premature development of COPD
This deficiency indicates genetic disease and need for lifelong ____________therapy
**α1-antitrypsin **deficiency is an inherited disorder associated with premature development of COPD
low α1-antitrypsin indicates genetic disease and need for lifelong **replacement **therapy
## Footnote
31
73
____________should be measured in pts with uncontrolled disease despite adequate bronchodilator treatment
** Eosinophils** should be measured in pts with uncontrolled disease despite adequate bronchodilator treatment
## Footnote
31
74
T/F
COPD treatment is designed to alleviate symptoms and slow progression
TRUE
COPD treatment is designed to alleviate symptoms and slow progression
## Footnote
32
75
The 1st step in treating COPD is reducing exposure to ____________and ________________pollutants
The 1st step in treating COPD is reducing exposure to **smoking** and **environmental** pollutants
## Footnote
32
76
Smoking cessation can decrease COPD disease progression and lower mortality by up to:
a. 20%
b. 8%
c. 18%
d. 32%
C. 18%
* Chronic bronchitis and lung degeneration may also diminish or disappear*
## Footnote
32
77
The first medical treatment for COPD begins with inhalers, specifically long-acting:
a. muscarinic antagonist
b. muscarinic agonist
A. Muscarinic antagonists
## Footnote
32
78
If dyspnea persists with COPD, the second treatment that can be added is a long-acting:
a. β2 agonist
b. β2 antagonist
a. β2 agonist
## Footnote
32
79
The third treatment for COPD, inhaled ________________, is most effective with associated ____________, rhinitis, elevated eosinophils, and history of _______________
The third treatment, inhaled **glucocorticoids**, is most effective with associated **asthma**, rhinitis, elevated eosinophils, and history of **exacerbations **
## Footnote
32
80
Correctly using inhaled tx’s can improve sx, improve FEV1, and reduce exacerbations
Other tx’s include ____________& ____________ vaccines, and ____________ (when RHF or CHF has developed)
Correctly using inhaled tx’s can improve sx, improve FEV1, and reduce exacerbations
Other tx’s include **flu & pneumonia** vaccines, and **diuretics** (when RHF or CHF has developed)
## Footnote
33
81
During exacerbations, antibiotics, corticosteroids, and ____________ may be necessary
Pulmonary rehab programs are beneficial as they can increase ____________ capacity
During exacerbations, antibiotics, corticosteroids, and **theophylline** may be necessary
Pulmonary rehab programs are beneficial as they can increase **exercise** capacity
## Footnote
33
82
T/F
COPD Exacerbations may be due to URI’s and antibiotics are always warranted
FALSE
Exacerbations may be due to URI’s or may be *noninfective *
* so antibiotics **are not** always warranted
## Footnote
33
83
The 02 flow rate can be titrated as needed according to ____ or _______.
The 02 flow rate can be titrated as needed according to **ABG or Sp02**
## Footnote
34
84
The goal of supplemental 02 is to achieve a Pa02 >________mmHg, which can usually be accomplished w/ NC @ ____L/min
The goal of supplemental 02 is to achieve a Pa02 >**60 **mmHg, which can usually be accomplished w/ NC @ **2** L/min
## Footnote
34
85
To decrease the risk of death, long-term home 02 is recommended when the Pa02 is <_______mmHg, the HCT >______%, or if evidence of ___________.
To decrease the risk of death, long-term home 02 is recommended when the Pa02 is **<55mmHg, the HCT >55%**, or if evidence of **cor-pulmonale**
## Footnote
34
86
T/F - Supplemental 02 is ________ effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing _______________
Supplemental 02 is **more** effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing **erythrocytosis**
## Footnote
34
87
Pts should be advised to do deep breathing exercises or ________________ ________________, which may improve respiratory function postoperatively
Pts should be advised to do deep breathing exercises or **incentive spirometry**, which may improve respiratory function postoperatively
## Footnote
34
88
All of the COPD treatments in a chart!
## Footnote
35
89
All of the COPD exacerbation treatments in a chart!
## Footnote
35
90
In pts w/severe refractory COPD and overdistended lung tissue, lung ____________ ____________ surgery may be required
Surgical removal allows more areas of normal lung to ________ and improve function
It is commonly performed via a ________________ sternotomy or a (VATS).
What does VATS stand for?
In pts w/severe refractory COPD and overdistended lung tissue, lung **volume reduction **surgery may be required
Surgical removal of these overdistended areas allows more areas of normal lung to **expand** and improve lung function
Lung volume reduction surgery is most commonly performed via a **median** sternotomy or a **video-assisted thoracoscopic surgery (VATS)**
## Footnote
36
91
Mechanisms for improvement in lung function include:
1) increased _______ ___________, which increases expiratory airflow
2) decreased ____________, which improves diaphragmatic and chest wall mechanics
3) decreased ____________/____________ mismatch, improving alveolar gas exchange
Mechanisms for improvement in lung function include:
1) increased **elastic recoil**, which increases expiratory airflow
2) decreased **hyperinflation**, which improves diaphragmatic and chest wall mechanics
3) decreased **ventilation/perfusion** mismatch, improving alveolar gas exchange
## Footnote
36
92
Anesthesia mgmt for lung-volume reduction surgery includes: a __________-______________ ETT, avoidance of _________ _________, and minimizing excessive airway pressure
________ is an unreliable guide for fluid management in this situation due to surgical alterations that will affect ________________ pressures
Anesthesia mgmt for lung-volume reduction surgery includes: a **double-lumen ETT**, avoidance of **nitrous oxide**, and minimizing excessive airway pressure
**CVP** is an unreliable guide for fluid management in this situation due to surgical alterations that will affect **intrathoracic **pressures
## Footnote
37
93
A complete history, including investigation of the causes, course, and severity of COPD
Note the ____________ history, current meds (esp recent ____________), exercise tolerance, ____________ frequency, and need for hospitalizations
Any previous need for ________________ or mechanical ventilation should be determined
A complete history, including investigation of the causes, course, and severity of COPD
Note the **smoking** history, current meds (esp recent **corticosteroids**), exercise tolerance, **exacerbation** frequency, and need for hospitalizations
Any previous need for **noninvasive positive-pressure ventilation (NIPPV)** or mechanical ventilation should be determined
## Footnote
37
94
Because smoking & COPD are assoc w/ multiple comorbidities, pts should also be questioned on presence of other diseases such as.... 7 things mentioned on this slide.. (hint mostly heart stuff..)
Because smoking & COPD are assoc w/ multiple comorbidities, pts should also be questioned on presence of other diseases such as:
1. DM
2. HTN
3. PVD
4. ischemic heart disease
5. heart failure
6. dysrhythmias
7. lung cancer
## Footnote
37
95
If pt has pulmonary disease, ________ ventricular function should be assessed by clinical exam, along with echocardiogram
If pt has pulmonary disease, **right** ventricular function should be assessed by clinical exam, along with echocardiogram
## Footnote
37
96
Should inhalation therapies be continued until the morning of surgery?
YES - continue inhalation therapies
## Footnote
37
97
What can be done pre-operatively to help reduce pulmonary complications post-operatively?
Preoperative chest physiotherapy such as deep breathing, coughing, incentive spirometry, and pulmonary physical therapy can reduce postop pulmonary complications
## Footnote
37
98
T/F
Clinical findings such as smoking, wheezing, and productive cough are less predictive of pulmonary complications than spirometric tests
FALSE
Clinical findings such as smoking, wheezing, and productive cough are **more** predictive of pulmonary complications than spirometric tests
*The value of routine preop PFTs remains controversial*
## Footnote
37
99
Indications for preop pulmonary evaluation typically include:
1) ____ on room air or the need for home ____ without a known cause
2) a bicarbonate ____ mEq/L or Pco2 ____ mmHg in w/o diagnosed pulmonary dz
3) a history of respiratory ____ due to an existing problem
4) severe ____ __ ____ attributed to respiratory disease
5) planned ____
6) difficulty assessing pulmonary ____ by clinical signs
7) the need to distinguish causes of respiratory ____
8) the need to determine the response to ____
9) suspected pulmonary ____
ndications for preop pulmonary evaluation typically include:
1) **hypoxemia** on room air or the need for home **02** without a known cause
2) a bicarbonate **>33** mEq/L or Pco2 **>50** mmHg in w/o diagnosed pulmonary dz
3) a history of respiratory **failure** due to an existing problem
4) severe **shortness of breath** attributed to respiratory disease
5) planned **pneumonectomy**
6) difficulty assessing pulmonary **function** by clinical signs
7) the need to distinguish causes of respiratory **compromise**
8) the need to determine the response to **bronchodilators**
9) suspected pulmonary **HTN**
## Footnote
38
100
What respiratory test is sufficient to assess COPD lung disease?
spirometry with FEV1
## Footnote
38
101
What are expected to show in the flow volume loop of a COPD pt?
* decreased expiratory flow rate at any given lung volume
* expiratory curve is concave
* RV is increased because of air trapping
## Footnote
39
102
How are flow-volume loops obtained with COPD?
* assessed **under dynamic conditions** by measuring *airflow related to lung volume*
* **Expiratory flow rates**can be plotted against lung volumes to produce flow-volume curves
-*Start at TLC and force expire to RV*
* **Inspiration flow rates** are added to these curves
-*Max inspire from RV to TLC*
-flow is *most rapid at midpoint* = curve
is U shaped
| i summarized the slide
## Footnote
39
103
What test predictor show risk factors for development of postoperative pulmonary complications?
Albumin level < 3.5 g/dL
## Footnote
40
104
What are patient related risk factors for development of postoperative pulmonary complications?
* Age > 60 yr
* ASA > 2
* CHF
* Pre-existing pulmonary disease
* Cigarette smoking
## Footnote
40 - table
105
What are procedure related risk factors for development of postoperative pulmonary complications?
Surgeries
* emergency sx
* abdominal or thoracic sx
* head & neck sx
* neurosurgery
* vascular/aortic aneurysm sx
Anesthesia
* prolonged anesthesia (>2.5h)
* General anesthesia
## Footnote
40 - table
106
What pre-op strategies to do to reduce post-op complications?
* **smoking cessation** for at least 6 weeks
* **treat** evidence of **Expiratory airflow obstruction**
* **treat respiratory infection** with ABX
* Pt **education** regarding **lung volume expansion maneuvers**
## Footnote
41 table
107
What intraop strategies to do to reduce post-op complications?
* use **minimally invasive sx techniques** (if possible)
* consider **Regional Anesthesia**
* **avoid sx procedure > 3 hours**
## Footnote
41 - table
108
What post-op strategies to do to reduce post-op complications?
* institute lung volume expansion maneuvers
* maximize analgesia
## Footnote
41 - table
109
How long does it take for benefit of smoking cessation to be seen?
**stopped more than 8 weeks prior to surgery**
(that the earlier the intervention, the more effective it is in reducing postop complications and maintaining cigarette abstinence
The American Society of Anesthesiologists has a Stop Smoking Initiative and provides resources to help practitioners encourage smoking cessation)
| I tried tosummarize-ish the slide
## Footnote
42
110
What is the single-most important risk factor for developing COPD and death caused by lung disease?
smoking
## Footnote
42
111
How long do the adverse effects of carbon monoxide on 02-carrying capacity and of nicotine on the CV system?
What is the time frame for CO and Nicotine?
**it is short lived**
Nicotine on heart: **20-30 mins**
E1/2 of Carbon Monoxide: **4-6 hours**
## Footnote
43
112
Within 12 hours after cessation of smoking, the Pa02 at which HGB 50% saturated with oxygen (P50) *increases* from 22.9 to ____ mmHg, and the plasma levels of carboxyhemoglobin *decrease* from 6.5% to ____
**26.4 mmHg**
**1%**
## Footnote
43
113
Despite of favorable effects, does **short-term abstinence from cigarettes** has been proven to decrease the incidence of postoperative pulmonary complications?
NO!
## Footnote
43
114
What does cigarette smoking cause?
* mucous hypersecretion
* impairment of mucociliary transport
* narrowing of small airways
## Footnote
44
115
How long does it take to see improved ciliary and small airway function and decreased sputum production after smoking abstinence?
takes **weeks** of abstinence from smoking
## Footnote
44
116
What does smoking do to normal immune responses?
How long does it take to return to normal after smoking abstinence?
**interfere with normal immune responses**
(affects responsd to pulmonary infection after sx)
requires **at least 6 weeks** of abstinence from smoking
## Footnote
44
117
How does some components of cigarette smoke affect the liver?
How long does it take to return to normal after smoking cessation?
**stimulate hepatic enzymes**
**may take 6 weeks or longer** for hepatic enzyme activity to return to normal
## Footnote
44
118
# Smoking Cessation:
* Cigarette smoking causes mucous __________, __________ of mucociliary transport, and ___________ of small airways
* It takes weeks of ____________ from smoking to see improved ciliary and small airway function and decreased sputum production
* hypersecretion
* impairment
* narrowing
* abstinence
## Footnote
45
119
# Smoking Cessation:
* Smoking may also interfere with normal ________ responses and the ability to respond to _________ infection following surgery.
* Return of normal immune function requires at least __ weeks of __________ from smoking
* immune
* pulmonary
* 6
* abstinence
## Footnote
45
120
# Smoking Cessation:
* Some components of cigarette smoke stimulate _______ enzymes
* It may take ___ weeks or longer for hepatic enzyme activity to return to normal.
* liver
* 6
## Footnote
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121
# Smoking Cessation:
* The optimal timing of smoking cessation before surgery to reduce postop pulmonary complications is ___ - ____ weeks (max benefit @ ____ weeks)
* Smokers scheduled for surgery in < ___ weeks should be advised to quit and offered interventions such as _________ support and _______________.
* 6-8
* 8
* <4
* behavioral
* pharmacotherapy
## Footnote
46
122
# Smoking Cessation:
* ____________ replacement therapy (patches, inhalers, nasal sprays, lozenges, gum), is generally well tolerated
* Sustained release ___________ can also help
The drug is typically started __ - ___ weeks before smoking is stopped.
* Nicotine
* Wellbutrin
* 1-2
## Footnote
46
123
# Smoking Cessation:
* Although long-term smoking cessation offers clear advantages, there can be ___________ in the immediate preop period.
* These include increase in _______ production, inability to handle ______, nicotine withdrawal, irritability, restlessness, _________ disturbances, and depression
* disadvantages
* sputum
* stress
* sleep
## Footnote
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124
______________ is associated with irreversible airway dilation, inflammation, and chronic bacterial infection
* Prevalence is highest in pts >____ with chronic pulmonary dz s/a ________ & __________ , and in women
* Symptoms : chronic __________ cough with purulent sputum, __________, clubbing.
* Bronchiectasis
* >60
* COPD
* Asthma
* Productive
* Hemoptysis
## Footnote
47
125
# Bronchiectasis:
* poor ________ activity and mucous pooling leads to a vicious cycle of recurrent __________ infection causing further inflammation, bronchial dilation, airway collapse, airflow obstruction, and the inability to clear secretions.
* Once a bacterial ____________ is established, it is nearly impossible to ___________, and daily expectoration of sputum persists
* mucociliary
* bacterial
* superinfection
* eradicate
## Footnote
47
126
# Bronchiectasis:
* Baseline _____ and _____ should be obtained on all suspected pts
* Sputum culture should be checked for any _______ infection
* _____ is the **gold standard** for diagnosis; It usually shows ________ bronchi.
* CXR
* PFT
* active
* CT
* dilated
## Footnote
48
127
# Bronchiectasis Treatments:
* key treatments involve _____ and chest _________ to improve expectoration.
* Other treatments: yearly _____ vaccine, bronchodilators, systemic ______________, and 02 therapy
* Results of _________ cultures guide antibiotic selection
* Surgery is considered only in the ______ instance where severe symptoms ________, or recurrent complications occur.
* Antibiotics
* physiotherapy
* flu
* corticosteriods
* sputum
* rare
* persist
* recurrent
## Footnote
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128
# Cystic Fibrosis:
* autosomal recessive disorder of the ________ channels leading to abnormal ___________ and clearance of secretions.
* affects 30,000 people in the US
* caused by a mutation of a gene on chromosome __ that encodes the cystic fibrosis transmembrane conductance regulator (CFTR).
* Normally, CFTR produces a protein, which aids in _____ and ______ movement in and out of cells.
* In CF, the mutated CFTR gene results in the production of abnormally thick mucus outside of _______ cells
* chloride
* production
* 7
* salt
* water
* epithelial
## Footnote
49
129
# Cystic Fibrosis:
* Decreased _________ transport is accompanied by decreased transport of sodium and water, which leads to ________ viscous secretions, luminal obstruction, and destruction and _________ of various glands and tissues
* The end result can lead to severe ________ damage manifested as bronchiectasis, COPD, sinusitis, diabetes, cirrhosis, meconium ileus in _________, and azoospermia
* Exocrine __________ insufficiency leads to malabsorption of _____ & fat-soluble ________.
* The primary cause of morbidity and mortality is chronic __________ infection
* chloride
* dehydrated
* scarring
* organ
* children
* pancreatic
* fat
* vitamins
* pulmonary
## Footnote
49
130
# Cystic Fibrosis:
* Diagnostic criteria: a sweat chloride concentration >___ mEq/L along with ________ sx (cough, purulent sputum, exertional dyspnea) or family history of the disease
* Deoxyribonucleic acid (DNA) analysis can identify >____% of pts with CFTR _________.
* >60
* clinical
* 90
* mutation
## Footnote
50
131
# Cystic Fibrosis:
* Chronic __________ is almost universal.
* Malabsorption with a __________ to pancreatic enzyme tx is evidence of pancreatic ___________ insufficiency associated with CF.
* Obstructive azoospermia, confirmed by _________ biopsy, is also strong evidence of CF.
* Bronchoalveolar lavage typically shows a high percentage of __________, which is a sign of airway inflammation.
* pansinusitis
* enzyme
* testicular
* neutrophils
## Footnote
50
132
# Cystic Fibrosis:
* __________ is present in virtually all adult CF pts.
* Treatment: Sx control, __________ enzyme replacement, 02 therapy, ___________, prevention of __________ obstruction.
* Gene therapy is currently being investigated.
* COPD
* pancreatic
* nutrition
* intestinal
## Footnote
50
133
# Cystic Fibrosis:
* The ___________ abnormalities of the sputum causes retention resulting in airway obstruction.
* The main nonpharmacologic approach to enhancing clearance of secretions is _________ ____________ with postural drainage.
* ________ -frequency chest compression with an inflatable vest and airway ___________ devices are alternative methods of physiotherapy.
* Viscoelastic
* chest
* High
* oscillation
## Footnote
51
134
# Cystic Fibrosis:
*__________ can be considered if pts are known to have a beneficial response to inhaled bronchodilators.
* beneficial response is defined as an increase of ____% or more in _______ after administration of bronchodilator.
* Bronchodilators
*10%
* FEV1
## Footnote
51
135
In cystic fibrosis, what causes the thick viscosity of secretions?
presence of neutrophils and degradation products that release DNA forming long fibrils that add to viscocity.
## Footnote
52
136
What is given based on identification of bacteria isolated from sputum?
antibiotics
## Footnote
52
137
What is indicated if cultures show no pathogens?
bronchoscopy
## Footnote
52
138
What is given to pts w/ CF long-term to suppress chronic infection?
Antibiotics
## Footnote
52
139
What would be the goal after delaying elective surgery in someone w/ CF?
Optimal pulmonary function is ensured by controlling infection and facilitating removal of airway secretions
## Footnote
53
140
Which vitamin may be necessary if hepatic fx is poor or exocrine pancreatic function is impaired?
Vitamin K
## Footnote
53
141
What are the important steps in maintaining less- viscous secretions?
Humidification of inspired gases, hydration, and avoidance of anticholinergic drugs.
Frequent tracheal suctioning may be necessary
## Footnote
53
142
What should pts regain prior to extubation?
full airway reflexes, adequate TV & RR
## Footnote
53
143
What is important to have in control to allow for deep breathing, coughing, and early ambulation?
Postop pain control to minimize pulmonary complications
## Footnote
53
144
What are the consequences of the impaired ciliary activity?
chronic sinusitis, recurrent respiratory infections, bronchiectasis and infertility
## Footnote
54
145
What is Kartagener syndrome?
Triad of chronic sinusitis, bronchiectasis, and situs inversus (chest organ position is inversed)
## Footnote
54
146
How many patients with congenitally nonfunctioning cilia exhibit situs inversus?
Approximately 1/2 of pts
## Footnote
54
147
What is isolated dextrocardia almost always associated with?
congenital heart disease
## Footnote
54
148
What is primary ciliary dyskinesia?
Congenital impairment of ciliary activity in respiratory tract, epithelial cells and sperm tails and ciliated ovary ducts
## Footnote
54
149
What is the preop preparation directed at to determine if significant organ inversion is present?
directed at treating pulmonary infection
## Footnote
55
150
What type of anesthesia is preferred for primary ciliary dyskinesia?
Regional anesthesia
## Footnote
55
151
When would EKG position be reversed for accurate interpretation in case of primary ciliary dyskineasia?
Presence of dextrocardia
## Footnote
55
152
In what case would you select the left IJ vein for CVC?
Inversion of the great vessels
*Normally the right IJ is preferred as it leads straight to the SVC*
## Footnote
55
153
To what side would you see uterine displacement in pregnant women?
To the Right
Normally LUD is implemented to avoid vena cava syndrome
## Footnote
55
154
What would indicate pulmonary inversion in presence of a double- lumen ETT?
R DLT placement
Typically, L DLT is preferred b/c the R mainstem is shorter and RUL more easily obstructed
## Footnote
55
155
What would prompt you to avoid the nasopharyngeal airway?
high incidence of sinusitis
## Footnote
55
156
What is bronchiolitis obliterans?
Results from epithelial and subepithelial inflammation leading to bronchiolar destruction and narrowing
## Footnote
56
157
What are the risk factors for Bronchiolitis Obliterans?
viral respiratory infections, environmental exposures, lung transplant, and stem cell transplant
## Footnote
56
158
What are sx of Bronchiolitis Obliterans?
Sx are nonspecific and include dyspnea and nonproductive cough
## Footnote
56
159
What would PFTs and CT show in someone with Bronchiolitis Obliterans?
PFT: obstructive disease and includes a reduced FEV1 and FEV1:FVC ratio that is unresponsive to bronchodilators.
CT shows air trapping and bronchiectasis in severe cases
## Footnote
56
160
What is central airway obstruction?
Includes obstruction of airflow in the tracheal and mainstem bronchi.
Obstruction c/b tumors, granulation from chronic infection, and airway thinning from cartilage destruction
## Footnote
57
161
How many (%) lung cancer pts can be affected by airflow obstruction?
20-30%
## Footnote
57
162
What is likely to develop after prolonged intubation either with ETT or a tracheostomy tube?
Tracheal stenosis
## Footnote
57
163
What can progress to destruction of cartilaginous rings, and subsequent circumferential scar formation?
Tracheal mucosal ischemia
## Footnote
57
164
How do you minimize Tracheal mucosal ischemia?
By the use of high-volume, low-pressure cuffs on ETTs
## Footnote
57
165
When does tracheal stenosis becomes symptomatic?
when the lumen is decreased to <5mm in diameter
## Footnote
58
166
What symptom of trachea stenosis is prominent even at rest?
Dyspnea
## Footnote
58
167
what muscles are utilized throughout all phases of the breathing cycle?
accessory muscles
## Footnote
58
168
What would you expect to see on flow-volume loops in someone with central airway obstruction? What would CT show?
flattened inspiratory & expiratory curves, which is characteristic of a fixed airway obstruction.
CT will illustrate tracheal narrowing
## Footnote
58
169
What can be used as a temporizing measure to treat tracheal stenosis?
tracheal dilation
## Footnote
59
170
How is tracheal dilation performed?
bronchoscopically using balloon dilators, surgical dilators, or laser resection of the tissue at the stenotic site. A tracheobronchial stent could be inserted as a temporary or long-term solution
## Footnote
59
171
What is the most successful tx for tracheal stenosis?
surgical resection & reconstruction with primary re-anastomosis
## Footnote
59
172
What kind of intubation is neccessary prior to surgical resection & reconstruction with primary re-anastomosis?
translaryngeal intubation
## Footnote
59
173
How do you facilitate the anesthesia for tracheal resection?
by the addition of **helium** to the inspired gases.
This decreases the density of the gas mixture and may improve flow through the area of tracheal narrowing.
## Footnote
59
174
What should be the focus of anesthetic management of a pt with a recent URI?
reducing secretions and limiting manipulation of a potentially hyperresponsive airway
## Footnote
61
175
What is all included into immediate and long-term therapy for asthmatic patients?
Immediate therapy for bronchospasm consists mainly of **short-acting β-agonists.**
Long-term relief may include **inhaled corticosteroids & long-acting bronchodilators, leukotriene inhibitors, monoclonal antibodies, and bronchial thermoplasty**
## Footnote
61
176
What is the goal in asthmatic pts during during induction & maintenance?
depress airway reflexes and avoid bronchoconstriction
## Footnote
61
177
What are the only two interventions in COPD patients that may slow progression of the disease?
smoking cessation and long-term 02 therapy
## Footnote
61
178
What drug therapies are managed with a goal of decreasing exacerbations?
inhaled β-agonists, inhaled corticosteroids, and anticholinergic drugs.
## Footnote
61
179
What type of anesthesia is preferred in pts w/ COPD to decrease the incidence of bronchospasm, barotrauma, and the need for positive pressure ventilation?
RA
## Footnote
62
180
Why should COPD pts receiving GA be ventilated at slow respiratory rates?
to allow sufficient time for exhalation, minimizing the risk of air trapping and auto-PEEP
## Footnote
62
181
What are two goals of prophylaxis against postop pulmonary complications?
restoring lung volumes, especially FRC, and facilitating effective coughing
## Footnote
62
182
How should Intraoperative bronchospasm due to obstructive lung disease be treated?
by deepening the anesthetic, administering bronchodilators and suctioning secretions as needed
## Footnote
62
183
