Lung Diseases And Anesthetic Concerns Flashcards Preview

Physio: Respiratory > Lung Diseases And Anesthetic Concerns > Flashcards

Flashcards in Lung Diseases And Anesthetic Concerns Deck (32):
1

What is COPD caused by?

- smoking
- occupational or environmental exposure
- recurrent infections
- genetic factors

2

What are the 3 most common symptoms with COPD?

- cough
- dyspnea
- wheezing

3

What do you need to obtain as part of your pre-op hx for COPD patients?

-Smoking history: always ask 2 questions
- do you smoke? PPD and duration
- have you ever smoked/when did you quit?
* dyspnea: presence, severity, exercise tolerance, home O2 requirement, baseline SpO2 on room air *****
- productive cough—> how often? Fever?
- wheezing—> how often, reversible?
- admissions to hospital: incubated? Length of stay? Prolonged ventilation? Infection
- PSHx
- can the climb a flight of stairs

4

What are some pre-op studies to obtain for a patient with COPD?

- SpO2 on room air
- ABG: elevated CO2 and HCO3 (30s)- you know pt is a big CO2 retainer
- CXR: hyperinflation, bless or bullseye, flattened diaphragm, infiltrates, effusions CA, atelactasis, PTX
- CBC: WBC, elevated Hct
- PFTs: degree of obstruction and bronchodilator response
- electrolytes: elevated bicarbonate to compensate for resp acidosis

5

What are high risk PFT results?

- FEV1 <2L
- FEV1/FVC < 0.5
- VC < 15cc/Kg in adult or <10cc/Kg in peds
- VC<40-50% than predicted
- normal is 80%

6

If FEV1 is in the 40-50% range what should you warn your patient?

They may remain of the vent for a few days after surgery

7

What are they most common symptoms present in chronic bronchitis?

* COUGH
* SPUTUM PRODUCTION
* RECURRENT INFECTION
- airway obstruction
- mucus gland hyperplasia, mucus plugging, inflammation, edema, peribronchiolar fibrosis, bronchoconstriction
*BLUE BLOATERS *

8

What causes chronic bronchitis?

SMOKING
- occupational exposure (radon, coal, asbestosis)

9

What are characteristics of blue bloaters (chronic bronchitis or asthmatic bronchitis)?

- chronic productive cough
- CYANOTIC (blue)
- obese, OSA, pickwickian syndrome (obesity, decreased pulm function, polycythemia)
- short, fat neck
- frequent wheeze
- relatively young

10

What happens with emphysema?

‘*Progressive dyspnea*
- variable cough
- enlarged airspaces from destruction of elastic and collagen network or alveolar walls (without fibrosis)
- loss of pulmonary elastic recoil
- loss of airway support leads to narrowing and collapse during exhalation—> AIR TRAPPING

11

Why are people with emphysema referred to as pink puffers?

Healing through pursed lips, puffing from dyspnea
Enough O2 (pink) but difficulty with exhalation

12

What causes emphysema?

- smoking
- coal miners
****alpha 1 antitrypsin deficiency—> autodigestion of pulmonary tissues by proteases ****

13

What are common characteristics of pink puffers (emphysema)?

- think
- older
- minimal cough
- pink color
- dyspnea, hyperinflation and distant breath sounds
- pursed lips= auto Peep, air trapping

14

What is seen with asthmatic bronchitis?

- chronic productive cough
- episodic bronchospasm
- airway obstruction

Only partially reversible- some degree of obstruction will always remain
- can be a progression of asthma

15

What is true about smoking?

- Doubles the risk of CAD
- 6Xs the risk of post- op complications
- COHb (carboxy hemoglobin can be elevated up to 15%
- 25 pack-year increases physiologic age by 8 years
* NICOTINE STIMULATES SYMPATHETIC GANGLIA—> catecholamines released from adrenal medulla —> increasing HR, BP, and SVR
* persists for 30 minutes after last cigarette



16

Smoking is an irritant to the airway. What does this cause as a result?

- mucus production
- decreased ciliary activity
- decreased pulmonary macrophage activity
- increased inflammatory response
- proteolytic enzyme release
- reduced surfactant integrity

17

Before induction of a smoker, what should you make sure you do?

Pre-oxygentate well (ET O2 80-90)
Avoid instrumentation of airway until deep level of anesthesia

18

What affects does smoking cessation have on the body at different times?

* advise pt to stop smoking at least 12 hours prior to surgery *
- 12-24 h: reduces COHb and nicotine levels to that of non-smokers
- after 2 days: airway reactivity is near the level of a non-smoker
- >8 weeks: will reduce post-op complications
- >2 years: will reduce risk of MI to that of nonsmoking population

19

What do you need to do with the ventilator in a pt with COPD intraoperatively?

- vent adjustments:
- 1:3 —> require longer exhalation times
- closely monitor peal insp. Pressures—> avoid rupturing Blebs
CO2 retainers: keep ETCO2 near pts baseline to avoid alkalosis
- large gradient between ETCO2 and PaO2–> compare Et value to ABG to know what norms are

20

What else should be done with a COPD pt intraoperatively?

- N2O may expand bullae
- airway stimulation with light anesthesia- des, iso
- ALINE to monitor ABGs, since ETCO2 less accurate
- laryngospasm d/t secretions—> suction frequently
- mucocilliary clearance worsened after inhalation agents
- bronchospasm: Avoid *histamine releasing drugs*
- morphine, neostigmine, Pentothal
- treat with nebulized albuterol, especially before extubation

21

Regional anesthesia with COPD is a good choice for which types of surgery?

Extremities
Perineum
Lower abdomen

22

A neuraxial block above _____ will diminish ability to cough and begin motor and sensory loss of external intercostals.

T10 (right at the umbulicus)

23

_____ is at the nipple line.

T4

24

An interscalene block will frequently block the ipsilateral __________ nerve, which can cause_______________________.

Phrenic nerve (C3,4,5)
Loss of 1/2 of the diaphragm, along with loss of intercostal muscle movement—> severe anxiety in COPD person
(Also may see hoarseness and droopy eye ipsalaterally)

25

T/F Continuous regional can be used in post-op period for pain control and improved pulmonary mechanics.

True

* remember, regional may turn into general at any time *

26

What is the classic triad of symptoms in Asthma?

Wheeze
Cough
Dyspnea

27

What triggers an attack?

- infection
- smoke
- occupational or environmental exposures
- ETT stimulation—> right after intubation may have SEVERE BRONCHOSPASM!! (Epi is drug of choice here)
- histamine

28

What is asthma?

** smooth muscle hypertrophy, bronchospasm, mucosal edema, mucus plugging **
-more than just Airway hyperreactivity
- bronchial wall inflammation.
- variable degrees of reversible airflow obstruction

29

What should be done for a person with Asthma pre-op?

- assess severity—> hx of intubation
- 3 admits/year
- > 3 ER visits/year
- last ER visit < 1 month ago
- hx of ICU admits
- recent steroid use
- recent URI
- how often they use their inhaler
- Check PEFP to assess current status
—> severe is <40%
- moderate is 40-60% predicted

30

If decreased wheezing is noticed in a pt with asthma is this a good or a bad thing?

Bad—> may indicate worsening of disease and decreased air exchange
*coughing and no wheezing may be crashing and very little air exchange

31

How do you treat asthma?

O2
Nebulized albuterol. *
Deepen level of anesthesia—> all inhaled agents cause bronchodilation
Epinephrine: IV or racemic
Terbutaline-preferred in pregnant pts
Corticosteroids
Atrovent
Theophylline
Heliox
Cromolyn

32

What is textbook induction drug of choice with asthma?

Ketamine—> powerful bronchodilation ,BUT it will increase secretions—> pre treat with atropine, but watch for tachycardia