Final: 29 Apr Obstructive Lung Disease '24

Question 1

What is the main role of obstructive respiratory diseases in the perioperative setting?

Answer 1

They contribute to the risk of perioperative pulmonary complications

Pulmonary complications play a major role in long-term postoperative mortality.

Question 2

What can significantly decrease the incidence of pulmonary complications prior to surgery?

Answer 2

Patient optimization

This includes addressing any existing respiratory diseases.

Question 3

How many groups can obstructive respiratory diseases be divided into regarding their influence on anesthetic management?

Answer 3

Four groups:
* Acute upper respiratory tract infection (URI)
* Asthma
* Chronic obstructive pulmonary disease (COPD)
* Miscellaneous respiratory disorders

Question 4

What is the annual rate of the ‘common cold’ for ages 25-44?

Answer 4

19% per year

Question 5

What is the most common associated viral pathogen for infectious nasopharyngitis?

Answer 5

Rhinovirus

Other pathogens include coronavirus, influenza, parainfluenza, and respiratory syncytial virus (RSV).

Question 6

What is the COLDS scoring system used for?

Answer 6

To determine the risk of proceeding with surgery in patients with acute URI

It considers current symptoms, onset of symptoms, presence of lung disease, airway device used, and type of surgery.

Question 7

What are some adverse respiratory events in patients with URIs?

Answer 7

Adverse respiratory events include:
* Bronchospasm
* Laryngospasm
* Airway obstruction
* Postintubation croup
* Desaturation
* Atelectasis

Question 8

What is asthma characterized by?

Answer 8

Chronic inflammation of the mucosa of the lower airways

This includes infiltration of eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes.

Question 9

What are the main inflammatory mediators implicated in asthma?

Answer 9

Histamine, prostaglandin D2, and leukotrienes

Question 10

What is status asthmaticus?

Answer 10

Dangerous, life-threatening bronchospasm that persists despite treatment

Question 11

How is asthma diagnosed?

Answer 11

Through clinical history, symptoms, and objective measurements of airway obstruction

Asthma is diagnosed when wheezing, chest tightness, or shortness of breath is reported along with reversible airflow obstruction.

Question 12

What is a common ABG finding during an asthma attack?

Answer 12

Hypocarbia and respiratory alkalosis

Question 13

What are the first-line treatments for mild asthma?

Answer 13

Short-acting inhaled β2 agonists

This is recommended only for those with fewer than 2 exacerbations per month.

Question 14

What is bronchial thermoplasty (BT)?

Answer 14

A nonpharmacologic treatment for refractory asthma using bronchoscopy to deliver radiofrequency ablation of airway smooth muscles

Question 15

What is the BODE index used for?

Answer 15

To assess prognosis in COPD patients

It considers BMI, degree of obstruction, level of dyspnea, and exercise tolerance.

Question 16

What are common symptoms of COPD?

Answer 16

Symptoms include:
* Dyspnea at rest or exertion
* Chronic cough
* Chronic sputum production

Question 17

What is the prevalence of COPD worldwide?

Answer 17

10%

COPD is the 3rd leading cause of death.

Question 18

What can trigger COPD exacerbations?

Answer 18

Bacterial respiratory infections

Question 19

What defines the diagnosis of COPD?

Answer 19

A decrease in the FEV1:FVC ratio and an even greater decrease in the FEF between 25% and 75% of vital capacity

Question 20

What abnormalities might be seen on a chest X-ray in severe COPD?

Answer 20

Hyperlucency in the lung periphery suggests emphysema

Bullae confirms emphysema, but only a small percentage of patients with emphysema have bullae.

Question 21

What is α1-antitrypsin deficiency?

Answer 21

An inherited disorder associated with COPD

Low α1-antitrypsin requires lifelong replacement therapy.

Question 22

What should be monitored in patients with uncontrolled COPD?

Answer 22

Eosinophil levels

High eosinophils indicate the need for inhaled glucocorticoids.

Question 23

What is α1-antitrypsin deficiency?

Answer 23

An inherited disorder associated with COPD

Question 24

What is required for low α1-antitrypsin levels?

Answer 24

Lifelong replacement therapy

Question 25

Why should eosinophils be measured in patients with uncontrolled disease?

Answer 25

High eosinophils indicate the need for inhaled glucocorticoids

Question 26

What is the association of low eosinophil levels?

Answer 26

Increased risk of pneumonia

Question 27

When do ABGs often remain normal in COPD?

Answer 27

Until COPD is severe

Question 28

At what FEV1 percentage does PaO2 usually decrease?

Answer 28

When FEV1 is <50% of predicted

Question 29

What is the first step in COPD treatment?

Answer 29

Reducing exposure to smoke and environmental pollutants

Question 30

How can smoking cessation affect COPD progression?

Answer 30

It can decrease disease progression and lower mortality by up to 18%

Question 31

What is the first-line treatment for COPD?

Answer 31

Long-acting inhaled muscarinic antagonists

Question 32

What should be added if dyspnea persists in COPD treatment?

Answer 32

Long-acting β2 agonist

Question 33

Inhaled glucocorticoids are most effective for patients with which conditions?

Answer 33

* Associated asthma * Rhinitis * Elevated eosinophils * History of exacerbations

Question 34

What are other treatments for COPD apart from inhaled medications?

Answer 34

* Flu & pneumonia vaccines * Diuretics if RHF or CHF developed * Antibiotics, corticosteroids, and theophylline during exacerbations * Pulmonary rehab programs

Question 35

What is recommended for patients with PaO2 <55 mmHg in COPD?

Answer 35

Long-term home oxygen therapy

Question 36

What is the goal of supplemental oxygen in COPD treatment?

Answer 36

To achieve a PaO2 >60 mmHg

Question 37

What is a common surgical intervention for severe refractory COPD?

Answer 37

Lung volume reduction surgery

Question 38

What is the mechanism of improvement in lung function after lung volume reduction surgery?

Answer 38

* Increased elastic recoil * Decreased hyperinflation * Decreased ventilation/perfusion mismatch

Question 39

What anesthesia management is recommended for lung volume reduction surgery?

Answer 39

* Double-lumen ETT * Avoidance of nitrous oxide * Minimizing excessive airway pressure

Question 40

What should be assessed in patients with COPD before surgery?

Answer 40

* Causes, course, and severity of COPD * Smoking history * Current medications * Exercise tolerance * Exacerbation frequency

Question 41

What are indications for preoperative pulmonary evaluation?

Answer 41

* Hypoxemia on room air * Bicarbonate >33 mEq/L or PaCO2 >50 mmHg * History of respiratory failure * Severe shortness of breath * Planned pneumonectomy * Difficulty assessing pulmonary function * Need to distinguish causes of respiratory compromise * Need to determine response to bronchodilators * Suspected pulmonary hypertension

Question 42

What is the significance of spirometry with FEV1 in COPD?

Answer 42

It can be sufficient to assess lung disease

Question 43

What characterizes the expiratory curve in COPD?

Answer 43

It is concave due to uniform emptying of the airways

Question 44

What is the optimal timing for smoking cessation before surgery?

Answer 44

6-8 weeks

Question 45

What are the adverse effects of smoking cessation in the immediate preoperative period?

Answer 45

* Increased sputum production * Inability to handle stress * Nicotine withdrawal * Irritability * Restlessness * Sleep disturbances * Depression

Question 46

What is bronchiectasis?

Answer 46

Irreversible airway dilation, inflammation, and chronic bacterial infection

Question 47

What are the common symptoms of bronchiectasis?

Answer 47

* Chronic productive cough with purulent sputum * Hemoptysis * Clubbing

Question 48

What is the gold standard for diagnosing bronchiectasis?

Answer 48

CT scan showing dilated bronchi

Question 49

What are key treatments for bronchiectasis?

Answer 49

* Antibiotics * Chest physiotherapy * Yearly flu vaccine * Bronchodilators * Systemic corticosteroids * Oxygen therapy

Question 50

What is cystic fibrosis?

Answer 50

An autosomal recessive disorder of chloride channels leading to abnormal secretion production and clearance

Question 51

What is the primary cause of morbidity and mortality in cystic fibrosis?

Answer 51

Chronic pulmonary infection

Question 52

What diagnostic criteria indicate cystic fibrosis?

Answer 52

* Sweat chloride concentration >60 mEq/L * Clinical symptoms or family history

Question 53

What is the main nonpharmacologic approach to enhancing clearance of secretions in cystic fibrosis?

Answer 53

Chest physiotherapy with postural drainage

Question 54

What are the anesthesia implications for cystic fibrosis patients?

Answer 54

* Delay elective surgery until optimal pulmonary function is ensured * Humidification of inspired gases * Frequent tracheal suctioning may be necessary

Question 55

What is primary ciliary dyskinesia?

Answer 55

Congenital impairment of ciliary activity leading to respiratory issues and infertility

Question 56

What is Kartagener syndrome?

Answer 56

Triad of chronic sinusitis, bronchiectasis, and situs inversus

Question 57

What is the management for bronchiolitis obliterans?

Answer 57

Treat pulmonary infection and assess for organ inversion

Question 58

What are risk factors for developing bronchiolitis obliterans?

Answer 58

* Viral respiratory infections * Environmental exposures * Lung transplant * Stem cell transplant

Question 59

What is Bronchiolitis Obliterans?

Answer 59

Results from epithelial and subepithelial inflammation leading to bronchiolar destruction and narrowing ## Footnote Risk factors include viral respiratory infections, environmental exposures, lung transplant, and stem cell transplant.

Question 60

What are the symptoms of Bronchiolitis Obliterans?

Answer 60

Nonspecific symptoms including dyspnea and nonproductive cough

Question 61

What do pulmonary function tests (PFTs) show in Bronchiolitis Obliterans?

Answer 61

Obstructive disease with a reduced FEV1 and FEV1:FVC ratio that is unresponsive to bronchodilators

Question 62

What does high-resolution CT show in severe cases of Bronchiolitis Obliterans?

Answer 62

Air trapping and bronchiectasis

Question 63

What constitutes Central Airway Obstruction?

Answer 63

Obstruction of airflow in the tracheal and mainstem bronchi

Question 64

What percentage of lung cancer patients can be affected by airflow obstruction?

Answer 64

20-30%

Question 65

What can cause obstruction in Central Airway Obstruction?

Answer 65

Tumors, granulation from chronic infection, and airway thinning from cartilage destruction

Question 66

What can tracheal stenosis develop from?

Answer 66

Prolonged intubation either with an ETT or a tracheostomy tube

Question 67

What can tracheal mucosal ischemia progress to?

Answer 67

Destruction of cartilaginous rings and subsequent circumferential scar formation

Question 68

How can tracheal stenosis be minimized during intubation?

Answer 68

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

Question 69

When does tracheal stenosis become symptomatic?

Answer 69

When the lumen is decreased to <5mm in diameter

Question 70

What are the prominent symptoms of tracheal stenosis?

Answer 70

Dyspnea, stridor, and use of accessory muscles throughout all phases of the breathing cycle

Question 71

What do flow-volume loops typically display in fixed airway obstruction?

Answer 71

Flattened inspiratory & expiratory curves

Question 72

What does CT illustrate in cases of tracheal stenosis?

Answer 72

Tracheal narrowing

Question 73

What is a temporizing measure for treating tracheal stenosis?

Answer 73

Tracheal dilation

Question 74

What techniques can be used for tracheal dilation?

Answer 74

Bronchoscopically using balloon dilators, surgical dilators, or laser resection

Question 75

What is the most successful treatment for tracheal stenosis?

Answer 75

Surgical resection & reconstruction with primary re-anastomosis

Question 76

What type of intubation is necessary for surgical resection of tracheal stenosis?

Answer 76

Translaryngeal intubation

Question 77

What is a useful maintenance method for anesthesia during tracheal resection?

Answer 77

Use of volatile anesthetics for ensuring maximal FiO2

Question 78

How can high-frequency ventilation assist in tracheal stenosis anesthesia?

Answer 78

It may improve flow through the area of tracheal narrowing

Question 79

What can improve the anesthetic management of a patient with a recent URI?

Answer 79

Focusing on reducing secretions and limiting manipulation of a potentially hyperresponsive airway

Question 80

What is the immediate therapy for bronchospasm in asthma treatment?

Answer 80

Short-acting β-agonists

Question 81

What may long-term relief in asthma treatment include?

Answer 81

* Inhaled corticosteroids * Long-acting bronchodilators * Leukotriene inhibitors * Monoclonal antibodies * Bronchial thermoplasty

Question 82

What is the goal during induction and maintenance in asthmatic patients?

Answer 82

To depress airway reflexes and avoid bronchoconstriction

Question 83

What interventions may slow the progression of COPD?

Answer 83

* Smoking cessation * Long-term O2 therapy

Question 84

What is the goal of drug therapies in COPD management?

Answer 84

To decrease exacerbations

Question 85

Why is regional anesthesia preferred over general anesthesia in COPD patients?

Answer 85

To decrease the incidence of bronchospasm, barotrauma, and the need for positive pressure ventilation

Question 86

How should COPD patients receiving general anesthesia be ventilated?

Answer 86

At slow respiratory rates to allow sufficient time for exhalation

Question 87

What is a key point in preventing postoperative pulmonary complications?

Answer 87

Restoring lung volumes, especially FRC, and facilitating effective coughing

Question 88

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

Answer 88

By deepening the anesthetic, administering bronchodilators, and suctioning secretions as needed