Exam 4- Obstructive Respiratory Disease - organize COPY

Question 1

What are the 5 most common viral pathogens responsible for URIs?

Answer 1

rhinovirus, coronavirus, influenza virus, parainfluenza virus, and respiratory syncytial virus (RSV)

3

Question 2

Noninfectious nasopharyngitis can be ____ or ____ in origin.

Answer 2

allergic or vasomotor

3

Question 3

Why is the diagnosis of URIs mainly based on just clinical s/sx? (as opposed to labs/tests)

Answer 3

Viral cultures & lab tests lack sensitivity, and are time and cost consuming
* impractical in a busy clinical setting

3

Question 4

what accounts for ̴95% of all URIs?

Answer 4

Infectious (viral or bacterial) nasopharyngitis

3

Question 5

Who is at a much higher risk of perioperative respiratory adverse events (PRAEs) s/a transient hypoxemia, laryngospasm, breath holding, and coughing?

Answer 5

Children with URI’s

Question 6

Should we postpone surgery for a pt who has had a chronic URI and is stable?

Answer 6

No, a pt who has had a URI for days-weeks and is stable or improving can be safely managed without postponing surgery

4

Question 7

for how long may airway hyperreactivity persist?

Answer 7

6 weeks

So if surgery is delayed bec of an URI, pts should not be rescheduled within 6 weeks

4

Question 8

What is used to determine risk of proceeding with surgery for a pt w/ URI?

Answer 8

COLDS scoring system

4

Question 9

What 5 things does the COLDS scoring system take into account?

Answer 9

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

Question 10

Anesthetic management of pts w/URI’s should include (3 things):

Answer 10

adequate hydration, reducing secretions, and limiting manipulation of the sensitive airway

5

Question 11

What type of local anesthetic can reduce upper airway sensitivity?

Answer 11

Nebulized or topical local anesthetic on the vocal cords

5

Question 12

Use of what airway may help reduce the risk of laryngospasm?

Answer 12

Use of a LMA rather than an ETT

5

Question 13

Considerations for induction and maintenance for pts with acute URI are similar to those with _____.

Answer 13

asthma

5

Question 14

if there are no contraindications, what may result in smoother emergence?

Answer 14

deep extubation

5

Question 15

Adverse respiratory events in pts w URI include (6 things):

Answer 15

bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis

6

Question 16

Whats common in pts with Acute URI that can be treated easily w supplemental O2?

Answer 16

Intraoperative and postoperative hypoxemia

6

Question 17

What are some differentials between Acute URI vs Influenza?

Answer 17

Acute URI: earache, runny nose, nasal congestion, sore throat, hoarseness

All other sx are seen in both URI and flu!

6

Question 18

Asthma is considered chronic inflammation of the mucosa of the ____ airways.

Answer 18

lower airways

7

Question 19

In asthma, activation of the inflammatory cascade leads to infiltration of airway mucosa with: (6 inflammatory cells)

This results in airway edema, especially in the ______.

Answer 19

• infiltration of the airway mucosa with eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes
• bronchi

7

Question 20

What are the 3 main inflammatory mediators in asthma?

Answer 20

histamine, prostaglandin D2, and leukotrienes

7

Question 21

What are 5 asthma provoking stimulators?

Answer 21

• allergens
• pharmacologic agents: ASA, BB, some NSAIDs, sulfaring agents
• infections
• exercise
• emotional stress

7

Question 22

What are some sx of asthma (6)?

Answer 22

expiratory wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia

8

Question 23

What is status asthmaticus?

Answer 23

life-threatening bronchospasm that persists despite treatment

8

Question 24

What 4 factors should attention be focused on when obtaining hx from an asthma pt?

Answer 24

previous intubation, ICU admission, 2+ hospitalizations for asthma in the past year, and the presence of coexisting diseases

8

Question 25

When is asthma diagnosed? (like what pt reports and what does PFT show)

Answer 25

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

Question 26

What does classification of asthma severity depend on?

Answer 26

symptoms, PFTs, and medication usage ## Footnote 9

Question 27

What is maximum voluntary ventilation?

Answer 27

max air that can be inhaled and exhaled within 1 min males: 140-180 L; females 80-120 L ## Footnote 10

Question 28

FEV1, FEF (forced expiratory flow) and midexpiratory phase flow are direct measurements of the severity of what?

Answer 28

expiratory obstruction *These are used to assess the severity of an asthma attack* ## Footnote 11

Question 29

During an asthma attack, what type of results are seen in FEV1? Flow volume loop? Lung volumes? Diffusing capacity for CO?

Answer 29

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

Question 30

In pt w/ expiratory obstruction, what suggests the diagnosis of asthma?

Answer 30

relief of obstruction after bronchodilator | abnormalities in PFT seen for days even w/ absence of symtpoms! ## Footnote 11

Question 31

In a pt w/ bronchospasm, FEV1 is _____ than 80%. Peak flow and maximum flow rate (FEF 25%-75%) are also ____

Answer 31

lower than 80% decreased ## Footnote 12

Question 32

Flow volume loops

Answer 32

obstructive: O restrictive w/ limitation on inspiration and expiration: R(E) and paraenchymal restrictive (RP) ## Footnote 13

Question 33

What causes an tachypnea and hyperventilation during an asthma attack?

Answer 33

neural reflexes of lungs, not hypoxemia ## Footnote 14

Question 34

What are common ABG findings in symptomatic asthma?

Answer 34

hypocarbia and respiratory alkalosis! *however a mild asthma attack = normal PaO2 and normal PaCO2 * ## Footnote 14

Question 35

As expiratory obstruction worsens, V/Q mismatching may result in a PaO2 of ____? The PaCO2 will increase when FEV1 is what percentage?

Answer 35

<60 mmHg 25% of predicted | fatique of breathing skeletal muscles contributes to hypercapnea ## Footnote 14

Question 36

Due to mucous plugging and pulm HTN, pt w/ severe asthma demonstrate what 2 symptoms?

Answer 36

hyperinflation and hiliar vascular congestion ## Footnote 15

Question 37

During an asthma attack, what might the EKG show?

Answer 37

RV strain or ventricular irritability ## Footnote 15

Question 38

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?

Answer 38

* short-acting inhaled β2 agonist * daily inhaled corticosteroids *This is only recommended in those w/ < 2 exacerbations/month * ## Footnote 16

Question 39

True or false: if asthma symptoms remain uncontrolled, daily inhaled β2 agonist

Answer 39

True ## Footnote 16

Question 40

What medication can be use to decrease the use of long -term medications for asthma ? *base of a study*

Answer 40

SQ immunotherapy ## Footnote 16

Question 41

What other therapies that can be use as treatment for asthmas?

Answer 41

* inhaled muscarinic antagonists * leukotriene modifiers * mast cell stabilizers ## Footnote 16

Question 42

What medication is reserved for severe asthma that is uncontrolled with inhalational medications?

Answer 42

Systemic corticosteroids ## Footnote 16

Question 43

What is the name of the only nonpharmacologic treatment for refractory asthma?

Answer 43

Bronchial thermoplasty (BT) ## Footnote 17

Question 44

How is Bronchial thermoplasty (BT) utilize to treat refractory asthma?

Answer 44

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

Question 45

Loss of airway smooth muscle mass can reduce what ?

Answer 45

bronchoconstriction ## Footnote 17

Question 46

What is useful in monitoring the reponse to bronchial thermoplasty?

Answer 46

Serial PFTs *FEV1 improves to about 50% of normal, pts usually have minimal or no symptoms* ## Footnote 17

Question 47

What is the emergency treatment for acute severe asthma?

Answer 47

* consists of high-dose * short-acting β2 agonists * systemic corticosteroids ## Footnote 18

Question 48

What is the difference in asthma vs acute severe asthma ?

Answer 48

* bronchospasm doesn’t resolve despite usual treatment * considered life threatening ## Footnote 18

Question 49

How often can INH β2 agonists be adminstered?

Answer 49

every 15-20 min for several doses without adverse hemodynamic effects *although pts may experience unpleasant sensations resulting from adrenergic overstimulation* ## Footnote 18

Question 50

Why is IV corticosteroides adminstered early for treatment of acute severe asthma? What are the 2 corticosteroids most commomly used

Answer 50

onset takes several hours Hydrocortione and methlprednisone ## Footnote 18

Question 51

What other drugs can be administered to patietnts that are experiencing acute severe asthma?

Answer 51

* magnesium * oral leukotriene inhibitors ## Footnote 18

Question 52

# 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

Answer 52

## Footnote 19

Question 53

What are the risk factors that would contribute to bronchospasms during surgery?

Answer 53

* type of surgery (higher with upper abdominal and oncologic surgery) * how recent the last attack occurred ## Footnote 20

Question 54

How does General Anesthesia effects a patient with asthma?

Answer 54

* 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

Question 55

What other factors can affect an asthmatic receiving anesthesia

Answer 55

airway stimulation by intubation, PNS activation, and/or release of  neurotransmitters *such as substance P and neurokinins also play a role* ## Footnote 20

Question 56

What are some pre-op assessment that need to be done for a patient that that has Asthma ?

Answer 56

* 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

Question 57

During a pre-op Assessment for a patient that as asthma, what type of test and mediation should be taken in consideration?

Answer 57

* 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

Question 58

* symptoms = emphysema characterized by lung _____ damage ,, chronic ____ ,, productive _______ ,, small airway dz * _____ leading cause of death ## Footnote COPD

Answer 58

* parenchymal ,, bronchitis ,, cough * 3rd ## Footnote 24

Question 59

COPD risks (long list)

Answer 59

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

Question 60

COPD leads to ?? (5)

Answer 60

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

Question 61

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

Answer 61

* severity * dyspnea ,, cough ,, sputum * tachypnea ,, expiratory * decreased ,, expiratory * frequent ,, bacterial ## Footnote 26

Question 62

# COPD Diagnosis: * Definitive diagnosis is made with ______________ * PFTS = decrease in ______ and ________ * increase in _______ volume d/t gas trapping which causes a _______ airway diameter

Answer 62

* spirometry * FEV1/FVC ratio + FEF25-75 * residual * enlarged ## Footnote 27

Question 63

Common findings of COPD include * FEV1:FVC <_____% * increased _____ and _____ * reduced ______

Answer 63

* <70% * FRC + TLC * DLCO ## Footnote 27

Question 64

# COPD Diagnosis: * CXR findings = may be ______ even with severe COPD * ________ suggests emphysema * ______ confirms emphysema

Answer 64

* minimal * hyperlucency * bullae ## Footnote 30

Question 65

# COPD Diagnosis: Most Sensitive to diagnose COPD

Answer 65

CT ## Footnote 30

Question 66

# COPD Diagnosis: * Multi Organ Loss of Tissue (MOLT) is a ____ of COPD * high rates of _____ cancer * Sx = ______ enlargement , ______ destruction , loss of _______, muscle, fat tissues

Answer 66

* phenotype * lung * airspace , alveolar , bone ## Footnote 30

Question 67

# COPD Diagnosis: Bronchitic Phenotype = _________ narrowing and _______ thickening * accompanied by _______ syndrome and ______ disease

Answer 67

* bronchiolar + wall * metabolic + cardiac ## Footnote 30

Question 68

____________ eosinophil levels indicate the need for inhaled ____________. ____________ eosinophil levels are associated with poor response and increased risk of ___________.

Answer 68

**high** eosinophil indicate the need for inhaled **glucocorticoids** **low** levels are associated with poor response and increased risk of **pneumonia** ## Footnote 31

Question 69

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 _________.

Answer 69

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

Question 70

________________deficiency is an inherited disorder associated with premature development of COPD This deficiency indicates genetic disease and need for lifelong ____________therapy

Answer 70

**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

Question 71

____________should be measured in pts with uncontrolled disease despite adequate bronchodilator treatment

Answer 71

**Eosinophils** should be measured in pts with uncontrolled disease despite adequate bronchodilator treatment ## Footnote 31

Question 72

T/F COPD treatment is designed to alleviate symptoms and slow progression

Answer 72

TRUE COPD treatment is designed to alleviate symptoms and slow progression ## Footnote 32

Question 73

The 1st step in treating COPD is reducing exposure to ____________and ________________pollutants

Answer 73

The 1st step in treating COPD is reducing exposure to **smoking** and **environmental** pollutants ## Footnote 32

Question 74

Smoking cessation can decrease COPD disease progression and lower mortality by up to: a. 20% b. 8% c. 18% d. 32%

Answer 74

C. 18% * Chronic bronchitis and lung degeneration may also diminish or disappear* ## Footnote 32

Question 75

The first medical treatment for COPD begins with inhalers, specifically long-acting: a. muscarinic antagonist b. muscarinic agonist

Answer 75

A. Muscarinic antagonists ## Footnote 32

Question 76

If dyspnea persists with COPD, the second treatment that can be added is a long-acting: a. β2 agonist b. β2 antagonist

Answer 76

a. β2 agonist ## Footnote 32

Question 77

The third treatment for COPD, inhaled ________________, is most effective with associated ____________, rhinitis, elevated eosinophils, and history of _______________

Answer 77

The third treatment, inhaled **glucocorticoids**, is most effective with associated **asthma**, rhinitis, elevated eosinophils, and history of **exacerbations ** ## Footnote 32

Question 78

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)

Answer 78

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

Question 79

During exacerbations, antibiotics, corticosteroids, and ____________ may be necessary Pulmonary rehab programs are beneficial as they can increase ____________ capacity

Answer 79

During exacerbations, antibiotics, corticosteroids, and **theophylline** may be necessary Pulmonary rehab programs are beneficial as they can increase **exercise** capacity ## Footnote 33

Question 80

T/F COPD Exacerbations may be due to URI’s and antibiotics are always warranted

Answer 80

FALSE Exacerbations may be due to URI’s or may be *noninfective * * so antibiotics **are not** always warranted ## Footnote 33

Question 81

The goal of supplemental 02 is to achieve a Pa02 >________mmHg, which can usually be accomplished w/ NC @ ____L/min

Answer 81

The goal of supplemental 02 is to achieve a Pa02 >**60 **mmHg, which can usually be accomplished w/ NC @ **2** L/min ## Footnote 34

Question 82

To decrease the risk of death, long-term home 02 is recommended when the Pa02 is <_______mmHg, the HCT >______%, or if evidence of ___________.

Answer 82

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

Question 83

T/F - Supplemental 02 is ________ effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing _______________

Answer 83

Supplemental 02 is **more** effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing **erythrocytosis** ## Footnote 34

Question 84

Pts should be advised to do deep breathing exercises or ________________ ________________, which may improve respiratory function postoperatively

Answer 84

Pts should be advised to do deep breathing exercises or **incentive spirometry**, which may improve respiratory function postoperatively ## Footnote 34

Question 85

All of the COPD treatments in a chart!

Answer 85

## Footnote 35

Question 86

All of the COPD exacerbation treatments in a chart!

Answer 86

## Footnote 35

Question 87

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?

Answer 87

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

Question 88

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

Answer 88

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

Question 89

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

Answer 89

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

Question 90

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

Answer 90

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

Question 91

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..)

Answer 91

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

Question 92

If pt has pulmonary disease, ________ ventricular function should be assessed by clinical exam, along with echocardiogram

Answer 92

If pt has pulmonary disease, **right** ventricular function should be assessed by clinical exam, along with echocardiogram ## Footnote 37

Question 93

Should inhalation therapies be continued until the morning of surgery?

Answer 93

YES - continue inhalation therapies ## Footnote 37

Question 94

What can be done pre-operatively to help reduce pulmonary complications post-operatively?

Answer 94

Preoperative chest physiotherapy such as deep breathing, coughing, incentive spirometry, and pulmonary physical therapy can reduce postop pulmonary complications ## Footnote 37

Question 95

T/F Clinical findings such as smoking, wheezing, and productive cough are less predictive of pulmonary complications than spirometric tests

Answer 95

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

Question 96

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 ____

Answer 96

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

Question 97

What respiratory test is sufficient to assess COPD lung disease?

Answer 97

spirometry with FEV1 ## Footnote 38

Question 98

What are expected to show in the flow volume loop of a COPD pt?

Answer 98

* decreased expiratory flow rate at any given lung volume * expiratory curve is concave * RV is increased because of air trapping ## Footnote 39

Question 99

How are flow-volume loops obtained with COPD?

Answer 99

* 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

Question 100

What test predictor show risk factors for development of postoperative pulmonary complications?

Answer 100

Albumin level < 3.5 g/dL ## Footnote 40

Question 101

What are patient related risk factors for development of postoperative pulmonary complications?

Answer 101

* Age > 60 yr * ASA > 2 * CHF * Pre-existing pulmonary disease * Cigarette smoking ## Footnote 40 - table

Question 102

What are procedure related risk factors for development of postoperative pulmonary complications?

Answer 102

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

Question 103

What pre-op strategies to do to reduce post-op complications?

Answer 103

* **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

Question 104

What intraop strategies to do to reduce post-op complications?

Answer 104

* use **minimally invasive sx techniques** (if possible) * consider **Regional Anesthesia** * **avoid sx procedure > 3 hours** ## Footnote 41 - table

Question 105

What post-op strategies to do to reduce post-op complications?

Answer 105

* institute lung volume expansion maneuvers * maximize analgesia ## Footnote 41 - table

Question 106

How long does it take for benefit of smoking cessation to be seen?

Answer 106

**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

Question 107

What is the single-most important risk factor for developing COPD and death caused by lung disease?

Answer 107

smoking ## Footnote 42

Question 108

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?

Answer 108

**it is short lived** Nicotine on heart: **20-30 mins** E1/2 of Carbon Monoxide: **4-6 hours** ## Footnote 43

Question 109

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 ____

Answer 109

**26.4 mmHg** **1%** ## Footnote 43

Question 110

Despite of favorable effects, does **short-term abstinence from cigarettes** has been proven to decrease the incidence of postoperative pulmonary complications?

Answer 110

NO! ## Footnote 43

Question 111

What does cigarette smoking cause?

Answer 111

* mucous hypersecretion * impairment of mucociliary transport * narrowing of small airways ## Footnote 44

Question 112

How long does it take to see improved ciliary and small airway function and decreased sputum production after smoking abstinence?

Answer 112

takes **weeks** of abstinence from smoking ## Footnote 44

Question 113

What does smoking do to normal immune responses? How long does it take to return to normal after smoking abstinence?

Answer 113

**interfere with normal immune responses** (affects responsd to pulmonary infection after sx) requires **at least 6 weeks** of abstinence from smoking ## Footnote 44

Question 114

How does some components of cigarette smoke affect the liver? How long does it take to return to normal after smoking cessation?

Answer 114

**stimulate hepatic enzymes** **may take 6 weeks or longer** for hepatic enzyme activity to return to normal ## Footnote 44

Question 115

In cystic fibrosis, what causes the thick viscosity of secretions?

Answer 115

presence of neutrophils and degradation products that release DNA forming long fibrils that add to viscocity. ## Footnote 52

Question 116

What is given based on identification of bacteria isolated from sputum?

Answer 116

antibiotics ## Footnote 52

Question 117

What is indicated if cultures show no pathogens?

Answer 117

bronchoscopy ## Footnote 52

Question 118

What is given to pts w/ CF long-term to suppress chronic infection?

Answer 118

Antibiotics ## Footnote 52

Question 119

What would be the goal after delaying elective surgery in someone w/ CF?

Answer 119

Optimal pulmonary function is ensured by controlling infection and facilitating removal of airway secretions ## Footnote 53

Question 120

Which vitamin may be necessary if hepatic fx is poor or exocrine pancreatic function is impaired?

Answer 120

Vitamin K ## Footnote 53

Question 121

What are the important steps in maintaining less- viscous secretions?

Answer 121

Humidification of inspired gases, hydration, and avoidance of anticholinergic drugs. Frequent tracheal suctioning may be necessary ## Footnote 53

Question 122

What should pts regain prior to extubation?

Answer 122

full airway reflexes, adequate TV & RR ## Footnote 53

Question 123

What is important to have in control to allow for deep breathing, coughing, and early ambulation?

Answer 123

Postop pain control to minimize pulmonary complications ## Footnote 53

Question 124

What are the consequences of the impaired ciliary activity?

Answer 124

chronic sinusitis, recurrent respiratory infections, bronchiectasis and infertility ## Footnote 54

Question 125

What is Kartagener syndrome?

Answer 125

Triad of chronic sinusitis, bronchiectasis, and situs inversus (chest organ position is inversed) ## Footnote 54

Question 126

How many patients with congenitally nonfunctioning cilia exhibit situs inversus?

Answer 126

Approximately 1/2 of pts ## Footnote 54

Question 127

What is isolated dextrocardia almost always associated with?

Answer 127

congenital heart disease ## Footnote 54

Question 128

What is primary ciliary dyskinesia?

Answer 128

Congenital impairment of ciliary activity in respiratory tract, epithelial cells and sperm tails and ciliated ovary ducts ## Footnote 54

Question 129

What is the preop preparation directed at to determine if significant organ inversion is present?

Answer 129

directed at treating pulmonary infection ## Footnote 55

Question 130

What type of anesthesia is preferred for primary ciliary dyskinesia?

Answer 130

Regional anesthesia ## Footnote 55

Question 131

When would EKG position be reversed for accurate interpretation in case of primary ciliary dyskineasia?

Answer 131

Presence of dextrocardia ## Footnote 55

Question 132

In what case would you select the left IJ vein for CVC?

Answer 132

Inversion of the great vessels *Normally the right IJ is preferred as it leads straight to the SVC* ## Footnote 55

Question 133

To what side would you see uterine displacement in pregnant women?

Answer 133

To the Right Normally LUD is implemented to avoid vena cava syndrome ## Footnote 55

Question 134

What would indicate pulmonary inversion in presence of a double- lumen ETT?

Answer 134

R DLT placement Typically, L DLT is preferred b/c the R mainstem is shorter and RUL more easily obstructed ## Footnote 55

Question 135

What would prompt you to avoid the nasopharyngeal airway?

Answer 135

high incidence of sinusitis ## Footnote 55

Question 136

What is bronchiolitis obliterans?

Answer 136

Results from epithelial and subepithelial inflammation leading to bronchiolar destruction and narrowing ## Footnote 56

Question 137

What are the risk factors for Bronchiolitis Obliterans?

Answer 137

viral respiratory infections, environmental exposures, lung transplant, and stem cell transplant ## Footnote 56

Question 138

What are sx of Bronchiolitis Obliterans?

Answer 138

Sx are nonspecific and include dyspnea and nonproductive cough ## Footnote 56

Question 139

What would PFTs and CT show in someone with Bronchiolitis Obliterans?

Answer 139

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

Question 140

What is central airway obstruction?

Answer 140

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

Question 141

How many (%) lung cancer pts can be affected by airflow obstruction?

Answer 141

20-30% ## Footnote 57

Question 142

What is likely to develop after prolonged intubation either with ETT or a tracheostomy tube?

Answer 142

Tracheal stenosis ## Footnote 57

Question 143

What can progress to destruction of cartilaginous rings, and subsequent circumferential scar formation?

Answer 143

Tracheal mucosal ischemia ## Footnote 57

Question 144

How do you minimize Tracheal mucosal ischemia?

Answer 144

By the use of high-volume, low-pressure cuffs on ETTs ## Footnote 57

Question 145

When does tracheal stenosis becomes symptomatic?

Answer 145

when the lumen is decreased to <5mm in diameter ## Footnote 58

Question 146

What symptom of trachea stenosis is prominent even at rest?

Answer 146

Dyspnea ## Footnote 58

Question 147

what muscles are utilized throughout all phases of the breathing cycle?

Answer 147

accessory muscles ## Footnote 58

Question 148

What would you expect to see on flow-volume loops in someone with central airway obstruction? What would CT show?

Answer 148

flattened inspiratory & expiratory curves, which is characteristic of a fixed airway obstruction.  CT will illustrate tracheal narrowing ## Footnote 58

Question 149

What can be used as a temporizing measure to treat tracheal stenosis?

Answer 149

tracheal dilation ## Footnote 59

Question 150

How is tracheal dilation performed?

Answer 150

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

Question 151

What is the most successful tx for tracheal stenosis?

Answer 151

surgical resection & reconstruction with primary re-anastomosis ## Footnote 59

Question 152

What kind of intubation is neccessary prior to surgical resection & reconstruction with primary re-anastomosis?

Answer 152

translaryngeal intubation ## Footnote 59

Question 153

How do you facilitate the anesthesia for tracheal resection?

Answer 153

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

Question 154

What should be the focus of anesthetic management of a pt with a recent URI?

Answer 154

reducing secretions and limiting manipulation of a potentially hyperresponsive airway ## Footnote 61

Question 155

What is all included into immediate and long-term therapy for asthmatic patients?

Answer 155

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

Question 156

What is the goal in asthmatic pts during during induction & maintenance?

Answer 156

depress airway reflexes and avoid bronchoconstriction  ## Footnote 61

Question 157

What are the only two interventions in COPD patients that may slow progression of the disease?

Answer 157

smoking cessation and long-term 02 therapy ## Footnote 61

Question 158

What drug therapies are managed with a goal of decreasing exacerbations?

Answer 158

inhaled β-agonists, inhaled corticosteroids, and anticholinergic drugs. ## Footnote 61

Question 159

What type of anesthesia is preferred in pts w/ COPD to decrease the incidence of bronchospasm, barotrauma, and the need for positive pressure ventilation?

Answer 159

RA ## Footnote 62

Question 160

Why should COPD pts receiving GA be ventilated at slow respiratory rates?

Answer 160

to allow sufficient time for exhalation, minimizing the risk of air trapping and auto-PEEP ## Footnote 62

Question 161

What are two goals of prophylaxis against postop pulmonary complications?

Answer 161

restoring lung volumes, especially FRC, and facilitating effective coughing  ## Footnote 62

Question 162

How should Intraoperative bronchospasm due to obstructive lung disease be treated?

Answer 162

by deepening the anesthetic, administering bronchodilators and suctioning secretions as needed ## Footnote 62