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CVT > Module 9: Anesthetic Management of Patients with Respiratory Disease > Flashcards

Module 9: Anesthetic Management of Patients with Respiratory Disease Flashcards

1
Q

Respiratory diseases

  • Patients with respiratory diseases are at increased risk of perioperative respiratory complications
  • Pulmonary complications occurs in up to ________% of patients and leads to increased morbidity and mortality and increased hospital length of stay
  • Postoperative pulmonary complications are very costly and can average increased healthcare costs of $52,466 per patient
A

25%

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2
Q

Risk factors for pulmonary complications

A
  • Chronic obstructive pulmonary disease
  • Asthma
  • Interstitial lung disease
  • Pulmonary HTN
  • Heart failure
  • Functional status
  • Hypoalbuminemia
  • Smoking
  • Age
  • OSA
  • Obesity
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3
Q

Risk factors for pulmonary complications

The site of surgery is an important risk factor for developing postoperative pulmonary complications

  • Pulmonary complications increase the closer the incision is to the _________.
  • Upper abdominal surgery (13-33%) vs. lower abdominal surgery (0-16%)

Surgeries lasting longer than _________ hours are associated with increased risk of pulmonary complications

A
  • diaphragm
  • 3
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4
Q

Risk factors for pulmonary complications

Surgical procedures that may also increase the risk of pulmonary complications

Preoperative Evaluation

A
  • Neurosurgery
  • Head and neck surgery
  • Trauma surgery
  • Cardiac surgery with CPB
  • Esophagectomy
  • Lung resection

History and Physical
Pulmonary Function Testing
Arterial Blood Gas (ABG) Analysis
Chest X-ray

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5
Q

Pulmonary Function Tests

_____________:
* It’s the volume of gas exhaled in 1 second by forced expiration from full inspiration

____________.
* It’s the total volume of gas that can be exhaled after a full inspiration

A
  • Forced Expiratory Volume (FEV)
  • Vital Capacity
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6
Q
A

Normal

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7
Q
A

Obstructive

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8
Q
A

Restrictive

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9
Q

Pulmonary Function Test

The lungs and thorax can be regarded as a simple air pump

The output of the pump depends on the stroke volume, the resistance of the airways, and the force applied to the piston

The ____________is a measure of the stroke volume

A

forced vital capacity (FVC)

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10
Q

Pulmonary Function Test

Causes of stroke volume (FVC) reduction

  1. Diseases of the thoracic cage such as _________
  2. ____________ injuries
  3. Diseases that affect the nerve supply to the respiratory muscles such as __________
  4. Abnormalities of the pleural cavity such _______
  5. Diseases of the lungs such as ________
  6. ____________ lesions
  7. Increased pulmonary blood volume such as ___________
A
  1. scoliosis
  2. Acute lung
  3. muscular dystrophy
  4. pneumothorax
  5. fibrosis
  6. Space occupying
  7. left heart failure
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11
Q

Pulmonary Function Test

The forced expiratory volume (FEV) is affected by airway _________ during forced expiration

Any increase in resistance reduces the ventilatory capacity
* Bronchoconstriction such as with ___________
* Structural changes in the airway such as with ______________
* Obstruction of the airways
* Destructive process in the ____________

A
  • resistance

  • asthma
  • chronic bronchitis
  • lung parenchyma
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12
Q

FEV1:

FVC:

Ratio FEV1 to FVC

A
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13
Q

Pulmonary Function Test

Expiratory Flow-Volume Curve

Recorded from a __________
It records ________ and _______
It measures _________ and __________

A
  • maximal forced expiration
  • flow rate, volume
  • inspiration; expiration
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14
Q

Blood Gases

Arterial PaO2
* Partial pressure of oxygen in arterial blood
* Normal value ____-_____ mmHg

A

85-100

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15
Q

Causes of Hypoxemia

Hypoventilation
* The volume of ________ going to the alveoli per unit time is reduced

Two cardinal features of hypoxemia:
* It ALWAYS causes a rise in _________
* It can be abolished by increasing the ______ by delivering oxygen to the patient

A
  • fresh gas

  • PaCO2
  • PaO2
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16
Q

Causes of Hypoxemia

Causes of hypoventilation:
* Depression of the ______________
* Diseases of the _______________
* Abnormalities of the ___________
* ______________ disease (_________)

A
  • respiratory center (narcotics)
  • medulla (encephalitis, hemorrhage)
  • spinal cord (high dissection)
  • Anterior horn cell (poliomyelitis)
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17
Q

Causes of Hypoxemia

Causes of hypoventilation
* Diseases of the nerves to the respiratory center ________
* Diseases of the ___________ (myasthenia gravis)
* Diseases of the respiratory muscles ___________
* Thoracic cage abnormalities (crushed chest)
* Upper airway obstruction (_________)

A
  • (Guillain-Barre syndrome)
  • myoneural junction
  • (muscular dystrophy)
  • tracheal compression by neoplasm)
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18
Q

Causes of Hypoxemia

__________ Impairment
Equilibration does not occur between the PaO2 in the pulmonary capillary blood and the alveolar gas

In a disease state, if the blood-gas barrier is thickened and diffusion is slowed, the equilibration may be incomplete

Fick’s Law of Diffusion correlates the diffusion capacity
- _________ of the membrane (e.g. fibrosis)
- _________ for diffusion (e.g. emphysema)

A
  • Diffusion

  • Thickness
  • Surface area
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19
Q

Causes of Hypoxemia

Diseases that cause diffusion impairment

A

Sarcoidosis
Asbestosis
Lupus

Rheumatoid lung
Interstitial fibrosis
Scleroderma
Alveolar cell carcinoma

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20
Q

Causes of Hypoxemia: Shunt

  • A shunt allows some blood to reach the arterial system without passing through _________ regions of the lung
  • If a patient with a shunt is given pure oxygen to breath, the arterial PO2 fails to __________ compared to normal patients
A
  • ventilated
  • rise
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21
Q

Causes of Hypoxemia

Ventilation-Perfusion Inequality

Ventilation and blood flow are mismatched in various regions of the lung, it results in inefficient gas transfer

It occurs in most patients with ________, _________, and vascular disorders such as __________

A
  • COPD, interstitial lung disease, PE
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22
Q

Arterial PaCO2
The normal PaCO2 is __-__ mmHg
Causes of increased arterial PaCO2:

A
  • 37 - 43

Hypoventilation
Ventilation-perfusion inequality

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23
Q

Arterial pH

Respiratory acidosis
* Caused by ________ retention
* Depresses pH
* Acute vs chronic respiratory acidosis

Respiratory alkalosis
Seen in ______________.

A
  • CO2

  • acute hyperventilation
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24
Q

Metabolic acidosis
* Caused by a fall in ________
* Acidosis stimulates peripheral chemoreceptors to increase ventilation

Metabolic alkalosis
* Seen in disorders such as ____________
* Usually no ________ compensation

A
  • HCO3

  • severe vomiting
  • respiratory
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25
Q
A
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26
Q

Obstructive Diseases

Very common disease in the US, second only to heart disease as a cause of disability benefits from Social Security Administration

It’s difficult to distinguish among the various types of obstructive disease

One common theme is that they are characterized by _____________.

A
  1. Airway Obstruction
  2. Chronic Obstructive Pulmonary Disease
    * Emphysema
    * Chronic Bronchitis
    * COPD, Types A & B
  3. Asthma
  4. Localized Airway Obstruction
    * Tracheal obstruction

Airway obstruction

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27
Q

Airway Obstruction

Increased airway resistance can be caused by conditions:
Inside the _______
In the _______ of the airway
In the _______

A
  • lumen
  • wall
  • peribronchial region
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28
Q

Chronic Obstructive Pulmonary Disease (COPD)

  1. COPD is a common condition often related to _______ or _________.
  2. It’s projected that by 2020, COPD will rank 5th among diseases world wide
  3. COPD can lead to increased length of hospital stay and mortality
  4. The care of these patients poses a challenge to the anesthesia provider
  5. COPD is a term that is applied to patients with either _______, __________, or a combination of both
A
  1. smoking or industrial toxins

  1. emphysema, chronic bronchitis
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29
Q

COPD is characterized by the progressive development of airflow limitation that is not fully ___________:

  1. Causes loss of _______, which normally maintains the airways open
  2. There is decreased ________ of the of the bronchial that leads to collapse during exhalation
  3. An increase in the _______ in narrowed bronchioles, lowers the pressure in the bronchiole that leads to airway collapse
  4. Active bronchospasm and obstruction results from increased __________
  • The patient has a destruction of __________, enlarged __________, and development of __________.
A
  • reversible
    1. elastic recoil
    2. rigidity
    3. air velocity
    4. air velocity
    5. lung parenchyma, air sacs, emphysema
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30
Q

COPD

Risk Factors

A

Cigarette smoking
Respiratory infection
Occupational exposure to dust
Genetic factors such alpha1-antitrypsin deficiency

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31
Q

COPD

Signs and Symptoms

  • Varies with the severity of COPD
  • As expiratory airway obstruction worsens the patient will have ___________ and have a prolonged ____________
  • Breath sounds are decreased with ____________
A
  • tachypnea; expiratory phase
  • expiratory wheezing
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32
Q

Emphysema:

Characterized by enlargement of the air spaces distal to the _____________, with destruction of their walls

Types

A

terminal bronchiole

Centriacinar
Panacinar

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33
Q

Chronic Bronchitis

  1. Characterized by excessive ___________ in the bronchial tree, sufficient to cause excessive expectoration of sputum
  2. Hallmark is _____________ in the large bronchi and ____________ in the small airways
A
  1. mucus production
  2. enlarged mucous glands; chronic inflammation
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34
Q

COPD

  1. A chronic productive cough, progressive exercise limitation, and ___________ airflow obstruction
  2. Symptoms may be non-specific but a diagnoses is likely in a _________
    Emphysema vs bronchitis

  1. Pulmonary function test
    Decrease in ___________
    Lung volumes are _________
  2. Chest X-ray
    Abnormalities may be minimal
    ____________
    ________ may be present
A
  1. Expiratory
  2. Smoker

    • FEV1/FVC ratio
    • Increased (RV, FRC, and TLC)

CXR:
Hyperlucency
Bullae

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35
Q

Chronic Bronchitis/Emphysema

A
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36
Q
A
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37
Q

COPD

The treatment of COPD is aimed at relieving the symptoms and halting the progression of the disease
* Smoking cessation
* Oxygen supplementation is recommended if the PaO2 is less than _________ mmHg, the hematocrit is greater than ________%, or there is evidence of cor pulmonale with the goal to maintain the PaO2 between ____-____ mmHg

Drug therapy
* ___________ are the mainstay
* Anticholinergic drugs
* Inhaled corticosteroids
* Broad-spectrum antibiotics
* Annual flu and pneumococcal vaccination
* Diuretic therapy

_____________ reduction therapy

A
  • 55, 55, 60-80

  • Bronchodilators
  • Lung volume
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38
Q

COPD

Management of Anesthesia – Preoperative
* Pulmonary Function Test
* Clinical findings are more predictive of pulmonary complications than _______ results
* Smoking history
* Nutritional status
Poor nutritional status with serum ________ <________mg/dL is powerful predictor of postoperative pulmonary complications

A
  • spirometric
  • albumin, 3.5
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39
Q
A
40
Q

COPD

Management of Anesthesia – Intraoperative
________ is suitable for surgeries that do not involve the peritoneum
* Great choice if large amounts of sedatives and anxiolytics are not needed
* Regional anesthesia that produces sensory anesthesia above _______ is not recommended

General anesthesia
* Inhaled agents are a good choice as they are eliminated rapidly and minimize residual ventilator depression post-op
* Volatile agents cause ____________ (Sevoflurane)
* Avoid _________ as it causes airway irritation and increased airway resistance
* Emergence may be prolonged with inhaled agents due to ___________ of the inhaled agents
* Limit the use of ______________
* Be careful with opioids as they can lead to prolonged ventilator depression
* Make sure you humidify the inspired gases

A

Regional, T6

  • bronchodilation
  • Desflurane
  • air trapping
  • nitrous oxide
41
Q

COPD

Mechanical ventilation
* ________ tidal volumes and ________ rates
* Tidal volumes of __-___ mL/kg
* Respiratory rates of :

Ventilator settings should allow sufficient _______ time to avoid air trapping

Air trapping can be detected by the following methods
* The ETCO2 waveform does not ________ and its still upsloping at the time of the next breath
* When the _________ on the ventilator does not reach baseline or zero
* Direct measure of _________ (done by advanced ventilators)
* When you disconnect the ventilator and notice that the ________ increases from the release of PEEP

Avoid barotrauma by preventing high positive airway pressures

A
  • larger, smaller
  • 6 - 8
  • 6 - 8
    Expiratory

  • plateau
  • expiratory flow
  • PEEP
  • BP
42
Q

COPD

Management of Anesthesia – Postoperative
Prophylaxis against postop pulmonary complications is important especially maintaining the ________
* Lung expansion maneuvers
* Incentive spirometry
* Deep breathing exercises
* Chest physiotherapy
* Positive pressure breathing techniques
* Early ambulation

A

FRC

43
Q

In patients with severe COPD, postop mechanical ventilation may be necessary:

  • Patients with a FEV1/FVC ratio of less than _______with a preoperative PaCO2 greater than ______ mmHg may need postoperative mechanical ventilation
  • Remember if the patients “lives” with a high PaCO2, do not try to correct it back to normal
A
  • 0.5, 50
44
Q

Asthma

Disease characterized by increased _________ of the airways to various stimuli and manifested by inflammation and widespread narrowing of the airways that changes in severity, either spontaneously or as a result of treatment

Signs and Symptoms
* It’s an ________ disease
* Most attacks are short lived
* It can be life-threatening if not treated
* Clinical manifestations include ______, productive or nonproductive cough, dyspnea, chest discomfort or tightness that leads to _________.

A

responsiveness

  • episodic
  • wheezing
  • air hunger
45
Q

Asthma

Pathology
* The smooth muscle of the airways contract during an attack, causing __________
* There is also hypertrophy of ___________, edema of the _________, and extensive infiltration by ________ and ________.
* The __________ is increased in the airways and slow moving

A
  • bronchoconstriction
  • mucous glands
  • bronchial wall
  • eosinophils and lymphocytes
  • mucous
46
Q

Asthma

Pathogenesis
* It’s a _____________, and genetic and environmental factors such as viruses, occupational exposure, and allergens contribute to its initiation and continuance

  • Epidemiologic studies indicate that asthma begins in ________ in a majority of cases
  • ________ factors has led to an increase in asthma over the last 20 years
A
  • heterogeneous disease
  • childhood
  • Environmental
47
Q

Asthma

Hypothesis

  • Children not exposed to typical childhood infectious agents have a greater incidence of developing an ________ or _________
  • Obesity, poor physical fitness, and exposure to pollutants can predispose you to asthma

The trigger to asthma _______ always be identified

A
  • allergic diathesis or asthma
  • allergic diathesis or asthma
48
Q

Asthma

Diagnosis utilizing spirometry
* The typical asthmatic patient has an FEV1 that is less than __________%
* Flow-volume loops show characteristic __________ scooping of the expiratory limb of the loop
* Flow-volume loops in which the inhaled or exhaled portion of the loop is ____________ helps distinguish wheezing caused by airway obstruction from asthma or another cause

A
  • 35
  • downward
  • flat
49
Q

Asthma

Diagnosis
ABG
* Mild asthma is accompanied by a normal ____ and ______
* _________ and ________ during an asthma attack usually results in in hypocarbia and respiratory alkalosis
* __________ can occur with muscle fatigue

Chest X-ray
* __________ of the lungs

A
  • PaO2 and PaCO2
  • Tachypnea and hyperventilation
  • Hypercarbia

Hyperinflation

50
Q

Asthma

Treatment
1. Emphasis of treatment is preventing and controlling _______________
1. Asthma treatment has 2 components
* Controller treatments modify the airway so that acute airway narrowing occurs less frequently
Inhaled and systemic ______, ________, and _____________.
* Reliever or rescue treatments treat acute bronchospasm
B-adrenergic agonists and anticholinergic drugs
_________ is the B2-agonist most commonly used

A
  1. bronchial inflammation
      • corticosteroids, theophylline, and antileukotrienes
  • Albuterol
51
Q

Asthma

Bronchoactive drugs
B-adrenergic agonist
B1- receptors in the heart (increase HR and force of contraction)
B2 – receptors relax smooth muscle in the bronchi, blood vessels, and uterus
_____________ are used to treat asthma

  1. _____,______,____ and _________ (intermediate duration)
  2. _______ and _________(long-acting agents used in combination with a corticosteroid)

Drugs are delivered by aerosol

Inhaled corticosteroid
* They inhibit the inflammatory/immune response, and they enhance ___________ expression or function
* Patients who use __________ more than twice a week are placed on corticosteroids

A
  • B2 selective adrenergic agonist
    1. Metaproteranol, albuterol, terbulatine, and pirbuterol
    2. Formoterol and salmeterol

  • B receptor
  • B2 agonist
52
Q

Asthma

Bronchoactive drugs
Other treatments
__________________
* Theophylline and aminophylline
* Mechanism of action is unknown but they have modest anti-inflammatory properties

__________________
* Useful in reversible bronchoconstriction in patients with COPD

__________ and ____________
Mast cell stabilizers
Block airway inflammation

A
  • Methyxanthines
  • Anticholinergics
  • Cromolym and Nedocromil
53
Q

Asthma

Status asthmaticus
_____________ that does not resolve despite treatment
It is life-threatening
Emergency treatment
* ___________ by inhalation
* ___________

A

Bronchospasm
* B2 - agonist
* Corticosteroids

54
Q

Asthma

Management of Anesthesia – Preoperative
Assess disease severity, the effectiveness of the current treatment, and the potential need for additional treatment before surgery
Goal is to come with an anesthetic plan that prevents or blunts ____________

Pre-op evaluation
Ask the patient about the severity and characteristics of the asthma
Age of onset
Triggering events
Hospitalizations for asthma
Allergies
Cough
Sputum characteristics
Current medications
Anesthetic history

A

expiratory airflow obstruction

55
Q

Asthma

Management of Anesthesia – Preoperative
* Listen to the patients breath sounds
* Assess labs, blood ____________ often parallels the degree of airway inflammation and airway hyperactivity

  • PFT before and after bronchodilator treatment:
    A reduction of FEV1 or FVC of less than __________% as well as FEV1/FVC less than ________% of predictive values, is considered a risk factor for preoperative complications

Assess if the patients needs any treatments prior to anesthesia
Antibiotics
Bronchodilator therapy
Supplementation with stress-dose corticosteroids, if the patient is on chronic steroids

The patients should be free from prior to surgery

A
  • eosinophils count
  • 70; 65
  • wheezing
56
Q

Asthma

Management of Anesthesia – Intraoperative

  • During induction and maintenance, airway reflexes must be suppressed to avoid bronchoconstriction
  • Regional anesthesia should be considered in ______________
  • General anesthesia should be accomplished with an intravenous induction
  • Propofol’s bronchodilating effects is unknown
  • Ketamine has bronchodilating effects but increases ____________
  • Lidocaine 1-1.5mg/kg 1-3 minutes prior to intubation suppresses airway reflexes
  • Narcotics prevent increased airway resistance
  • The depth of anesthesia during maintenance should depress hyperactive airway reflexes
  • __________ is a bronchodilator
  • Consider an LMA as it is less irritating to the airway
A
  • brittle asthmatic
  • airway secretions
  • Sevoflurane
57
Q
A
57
Q

Management of Anesthesia – Intraoperative
Ventilation
* A __________ inspiratory flow rate produces optimal distribution of ventilation and perfusion
* Allow sufficient time for ________ to avoid air trapping
* Humidify the airway in patients with exercise induced asthma
* Liberal administration of fluids to keep the secretions in the airway less viscous

Avoid muscle relaxants that cause histamine release

Attempt to extubate the patient while airway reflexes are suppressed “________”

If a deep extubation is not safe, make sure the airway reflexes are suppressed
* Intravenous lidocaine
* Pretreatment with inhaled bronchodilators - albuterol

A
  • slow
  • exhalation
  • deep extubation
58
Q

Asthma

Intraoperative Bronchospasm
* Make sure you have ruled out other causes of bronchospasm
* Mechanical obstruction of the breathing circuit, the airway, or the ETT
* If the bronchospasm is caused by asthma
* Deepen the anesthetic with a volatile agent, ketamine, propofol, lidocaine or a combination
* Administer 100% O2
* Consider B2-agonist treatment (Albuterol)
* In severe cases, administer intravenous or subcutaneous ________ (________)
* Corticosteroid administration – ______________ 2-4 mg/kg
* Consider ___________, if long term postoperative mechanical ventilation is needed

A
  • epinephrine 10 mcg/kg
  • Hydrocortisone
  • aminophylline
59
Q

Tracheal Obstruction

  • Can be caused by a foreign body, _______ after a prolonged intubation, or compressing masses (I.e., an enlarged thyroid or a malignant mass)
  • _______ and ________ stridor is present
  • Abnormal inspiratory and expiratory flow volume curves
  • No response to _________

  • Develops after a ____________
  • The _____________ may progress to destruction of the cartilaginous rings and circumferential constricting scar formation
  • The use of ___________, ____________ ETT cuffs is preferred
  • The patient becomes symptomatic when the lumen of the adult trachea is less than _________ mm in diameter
  • The patient may have audible stridor
  • Flow-volume loops have:
  • The stenosis is relieved with tracheal dilation or tracheal resection of the stenotic trachea
A
  • stenosis
  • Inspiratory and expiratory
  • bronchodilators

  • prolonged intubation
  • tracheal ischemia
  • high-volume; low pressure
  • 5
  • flattened inspiratory and expiratory curves
60
Q

Restrictive diseases

Restrictive diseases are those in which expansion of the lung is restricted by alterations in the _________, ________, ________, or __________.

Restrictive diseases are characterized by a reduction in all _______, decreased ___________, and preservation of __________

A
  • lung parenchyma, diseased pleura, the chest wall, or a neuromuscular disease
  • lung volumes, lung compliance, expiratory flow rates
61
Q

Restrictive Diseases

Diffuse Interstitial Pulmonary Fibrosis
* Principle feature is _________ of the alveolar wall
* Infiltration with _____ - _______> a cellular exudate consisting of ________ and other mononuclear cells is seen within the alveoli > the alveolar architecture is destroyed and scarring occurs which cause multiple air-filled cystic spaces formed by ________ and _________ called “honeycomb lung”
* Cause of the disease is _______

A
  • thickening of the interstitium
  • lymphocytes and plasma cells
  • macrophages
  • dilated terminal and respiratory bronchioles

unknown

62
Q

Restrictive Diseases

Pulmonary Function Test
1. Spirometry reveals a restrictive pattern
1. The FVC is ______, but the gas is exhaled so quickly that even though the FEV1 is also _______, the FEV/FVC% may _______ normal value
1. All lung volumes are reduced, the ______,_____, and ______
1. The fibrous tissue reduces the dispensability of the lung
1. The lung volumes are ______ and _________ are needed to distend the lungs
1. The airway resistance is _______

A
  2. reduced, low, exceed
  3. TLC, FRC, and RV
  4. -
  5. small, large pressures
  6. normal or decreased
63
Q

Gas Exchange

Restrictive diseases

  • The arterial PaO2 and PCO2 are typically ______ and the pH is _______
  • __________ is mild at rest until the disease is advanced
  • In the advanced stages of the disease physiologic _______ and _______ are increased
  • These patients typically have ______ ________ breathing pattern
A
  • reduced; normal
  • hypoxia
  • dead space and shunt
  • shallow rapid
64
Q

Other types of Restrictive diseases

Sarcoidosis
1. Characterized by the presence of __________ _______ and can occur in other organs such as the lymph nodes, heart, lungs, skin, eyes, spleen, and lungs

  1. Cause is unknown but one possibility is that an unknown antigen is recognized by _________ and it results in the activation of ___________ and the production of __________.
  2. There are 4 stages in sarcoidosis
    - The restrictive pattern is seen in stages ______ and _____

  1. All lung volumes are ______
  2. Lung _______ is reduced
  3. The __________ is reduced is low and often falls considerably with exercise
A
  1. Granulomatous tissue
  2. alveolar macrophages; T-lymphocytes, interleukin-2
  3. 2 and 3

  1. small
  2. compliance
  3. resting PaO2
65
Q

Other types of Restrictive diseases

Hypersensitivity pneumonitis
1. Also known as ____________
2. It’s a hypersensitivity reaction affecting the _________ that occurs in response to inhaled organic dust such as _____,______, and ______/______ material.
3. Example “_______ lung”

  1. The alveolar walls are thickened and infiltrated with _______, _________, and occasional _________ that together with collections of ________, which cause the formation of ________.

Signs and symptoms
* Dyspnea and cough __-___ hours after inhalation of the antigens
* Chest x-ray shows:
* _________ develops after multiple episodes

A
  1. extrinsic allergic alveolitis
  2. lung parenchyma ; fungi, spores, and animal or plant material
  3. farmers
  4. lymphocytes, plasma cells, eosinophils. histiocytes, small granulomas

  • 4-6
  • pulmonary infiltrates
  • Pulmonary fibrosis
66
Q

Restrictive diseases

Management of Anesthesia – Preoperative
* Patients usually present with ______ and ________ cough
* _________ may be present

Chest X-ray
* _______ or _______pattern
* ABG will show hypoxemia with normocarbia
* PFT will show a restrictive pattern
* A vital capacity less than 15mL/kg indicates severe pulmonary function

A
  • dyspnea; nonproductive
  • Cor pulmonale
67
Q

Restrictive disease

Management of Anesthesia – Intraoperative
These patient do not tolerate apneic periods
* Small FRC and low oxygen stores

______, ______, and _______ ventilation all contribute to further decreases in FRC

Uptake of inhaled agents is _________ in these patients because of the decrease in FRC

Inhalation induction is quicker

Keep peak airway pressures as low as possible to prevent barotrauma

A
  • GA, supine position, and controlled
  • faster
68
Q

Restrictive disease

Diseases of the Pleura

Diseases of the Chest Wall

Neuromuscular Disorders

A

Diseases of the Pleura
Pneumothorax
Tension pneumothorax
Pleural effusion

Diseases of the Chest Wall
Scoliosis
Ankylosing Spondylitis

Neuromuscular Disorders
Guillain-Barre syndrome
Amyotrophic lateral Sclerosis
Myasthenia gravis
Muscular dystrophies

69
Q

Diseases of the pleura
Pneumothorax

The pressure in the intrapleural space is subatmospheric as a result of the elastic recoil forces of the lung and chest wall

When air enters the space, the lung ______ and the rib cage _________

___________ pneumothorax usually occurs in young males due to high mechanical stress that occurs in the upper zone of the upright lung

  • Symptoms are:
  • Breath sounds are reduced on the _______ side and its diagnosed by chest x-ray
A
  • collapses, springs out
  • Spontaneous
  • pain on one side accompanied by dyspnea
  • affected
70
Q

Tension pneumothorax
* When air enters the intrapleural space during inspiration but cannot escape during expiration

  • It causes a large pneumothorax in which pressure may _______ atmospheric pressure and it interferes with _________ in the thorax
  • It’s a medical emergency
  • It can cause respiratory distress, tachycardia and signs of mediastinal shift such tracheal deviation

Treatment
* Chest tube

A
  • exceed; venous return
71
Q

Restrictive Diseases

Scoliosis: Refers to lateral curvature of the spine and kyphosis to posterior curvature

Can be caused by ________ or __________

Signs and symptoms
Depends on the severity of the curvature;

A

bony tuberculosis or neuromuscular disease

Dyspnea on exertion
Rapid and shallow breathing
Hypoxemia worsens with increased severity of curvature which leads to CO2 retention and cor pulmonale

72
Q

Restrictive Diseases

PFTs will reveal a reduction in all lung volumes

In advanced disease the patient has a reduced ventilator response to ________, respiratory muscles are ______, the vascular bed is restricted causing a rise in _____________.

A

CO2; inefficient;
pulmonary artery pressures

73
Q

Restrictive diseases

Diseases of the Chest Wall
Ankylosing Spondylitis
* The disease has an unknown etiology
* There is a ________ onset of immobility of the __________ and fixation of the ________
* The movement of the chest wall is ___________.
* There is a reduction in FVC and TLC, but the FEV1/FVC and the airway resistance are normal
* Chest compliance is reduced

A
  • gradual; vertebral joints; ribs
  • reduced
74
Q

Restrictive diseases

Disorders of the Mediastinum
- Mediastinal mass have various causes:

Large mediastinal masses may be associated with:
- airway obstruction,
- loss of lung volumes,
- pulmonary artery or cardiac compression, and
- superior vena cava obstruction

A

-Lymphoma, thymoma, teratoma, and restrosternal goiter

75
Q

Superior vena syndrome

Develops when the mass obstructs venous drainage in the ________.

Leads to:
- dilation of collateral veins in the thorax and neck, edema of the face, neck, and upper chest, edema of the conjunctiva,

  • increased ____________ to include headaches and altered mental status
  • _______ is common
  • Usually caused by a __________
A
  • upper thorax
  • intracranial pressure
  • Dyspnea
  • cancerous mass
    *
76
Q

Management of Anesthesia – Mediastinal Mass

Preoperative evaluation should include a chest x-ray, measurement of a flow-volume loop, chest imaging studies, and clinical evaluation for evidence of _______.

Must assess the size of the mass to predict whether airway difficulties will be expected

A ____________ technique is the best anesthetic choice for a diagnostic tissue biopsy

The patient may be asymptomatic when awake but may develop _________ under anesthesia in the supine position

Symptomatic patients may need to be induced in the _____ position

Topical anesthesia of the airway with/without sedation to facilitate ___________.

An ________ induction with maintenance of spontaneous ventilation

A
  • tracheobronchial compression
  • local anesthetic
  • airway obstruction
  • sitting; fiberoptic laryngoscopy
  • inhalation
77
Q

Restrictive diseases

Neuromuscular disorders

Neuromuscular disorders that interfere with the transfer of central nervous system input to the skeletal muscles necessary for inspiration and exhalation can result in restrictive disease

All of the diseases below can lead to dyspnea and respiratory failure (4)

The patient’s inability to take a _______ breath leads to reduced FVC, TLC, inspiratory capacity, and FEV1.

These patients usually do not complain of dyspnea until the ________ is involved
These diseases are usually monitored by FVC and blood gases

Management of Anesthesia
Avoid or limit drugs with prolonged respiratory depressant effects

In patients with a pneumothorax, avoid N2O

Regional anesthesia is a good choice for peripheral operations as long as the sensory block is below _____

Mechanical ventilation should facilitate optimal ventilation and oxygenation

Since the lungs have poor compliance, higher __________ may be needed

Postoperative mechanical ventilation should be considered in patients with advanced restrictive lung disease

A

Guillian Barre syndrome
Amyotropic lateral sclerosis (ALS)
Myesthenia gravis
Muscular dystrophies

  • deep
  • diaphragm

  • T10
  • inspiratory pressures
78
Q

Pulmonary edema

  1. An abnormal accumulation of fluid in the ____________ spaces and ________ of the lung
  2. It’s a complication of a variety of _____ and ________ diseases and may be life-threatening
  3. It’s due to leakage of intravascular fluid into the __________ of the lungs and into the _______

  1. It can be caused by:
A
  1. extravascular, tissues
  2. heart and lung
  3. interstitium; alveoli

  • increased capillary pressure (hydrostatic or cardiogenic pulmonary edema) or
  • by increased capillary permeability
79
Q

**

Pulmonary edema
It typically manifest as _____________on X-ray (see next slide).

A _________ distribution (________ pattern) of the lung opacity is common; seen with increased _____________

The presence of ___________ on chest x-ray suggest increased permeability pulmonary edema

A
  • bilateral symmetrical opacities
  • perihilar; butterfly; capillary pressure
  • air bronchograms
79
Q

Various causes of pulmonary edema
Aspiration
___________ problems
Opioid overdose
High-altitude pulmonary edema
____________ of collapsed lung
Upper airway obstruction (negative-pressure)

A
  • Neurogenic
  • Re-expansion
80
Q

Pulmonary edema – Preoperative

  1. Elective surgery should be delayed in patients with _______ pulmonary edema
  2. Large __________ may need to be drained
  3. Persistent hypoxemia may require mechanical and PEEP

Pulmonary edema – Intraoperative

These patients are critically ill
The ICU management should continue into the operating room
Have an intraoperative plan for ventilation

To avoid barotrauma and hemodynamic compromise it is reasonable to ventilate with ________ tidal volumes (_______ mL/kg) with a compensatory ________ in ventilator rate (____-___ mL/kg)
Attempt to maintain the PIP less than _____ cm H2O

In patients with severe ARDS, a more sophisticated ventilator (i.e., HFOV or HFJV) may be needed

A
  1. acute
  2. pleural effusions

  1. low, 6
  2. increase; 14-16
  3. 30
81
Q
A
82
Q

Vascular diseases

PE is a condition that is preventable and potentially life-threatening

Most pulmonary emboli arise from detached portions of venous thrombi that have formed in the deep veins of the lower extremity, right side of the heart, and pelvic area

Non-thrombotic emboli such air, fat, and amniotic fluid can also occur

Factors that lead to venous thrombi formation:

Pulmonary embolus

Diagnosis is difficult; it can mimic other cardiopulmonary illnesses

Clinical manifestations of PE are nonspecific

The most consistent symptom of acute PE is __________.

________-________ are the most common signs of PE but are nonspecific

Other symptoms
Wheezing, fever, ________, pleural rub, a loud pulmonic component of the second heart sound, a ______ ventricular shift, and bulging neck veins

A
  • Stasis of blood
  • Alterations in the blood coagulation system
  • Abnormalities of the vessel wall

  • acute dyspnea
  • Tachypnea and tachycardia
  • rales, right
83
Q

ABG
* Could be normal or demonstrate arterial _________ and __________

In the presence of PFO or ASD
* Severe hypoxemia
* ECG findings are ST-T wave changes and _________ axis deviation
* Peaked ________ waves, _______, and ________ may be present if the PE causes acute cor pulmonale

A
  • hypoxemia, hypocapnia

  • right
  • P, atrial fibrillation, and RBB
84
Q

Pulmonary embolus

Manifestations under general anesthesia may be nonspecific: (4)

The ECG and CVP may indicate onset of pulmonary HTN and RV dysfunction

Capnography will demonstrate a _________ in ETCO2

Lab test
* A _____________ strongly suggest a thromboembolism is present
* _______ levels may be elevated

  • Pulmonary arteriography is the gold standard for the diagnosis of PE
A

Unexplained arterial hypoxemia
Hypotension
Tachycardia
Bronchospasm

  • decrease
  • positive D-dimer
  • Troponin
85
Q

Pulmonary embolus
Treatment

Anticoagulation, thrombolytic therapy, inferior vena cava filter placement, and surgical embolectomy

_________ remains the cornerstone of treatment of acute PE

An intravenous bolus of _____ to _______ followed by an intravenous infusion should be administered if patient is considered to have a high likelihood of PE

In patients with significant bleeding after anticoagulation or reoccurrence of PE will have a vena cava filter placed

_________ caused by the PE will require treatment

Inotropes such as dopamine or dobutamine
Vasoconstrictor such as norepinephrine

Pulmonary vasodilator to control pulmonary HTN

Pulmonary artery embolectomy is reserved for patients who are unresponsive to medical therapy or who cannot receive thrombolytic therapy

A
  • Heparin
  • 5,000 to 10,000U

  • Hypotension
86
Q

Pulmonary embolus

When life threatening PE occurs the goal is to support vital function

The patient who comes to the operating room for the treatment of life-threatening PE

  • Patients is usually intubated and mechanically ventilated
  • Monitor cardiac filling pressures
  • Use right atrial pressures to guide fluid administration
  • Cardiac output may need to be supported with inotropic drugs
  • Dopamine, dobutamine, amrinone, milrinone

Induction and maintenance:
Avoid arterial hypoxemia, hypotension, or pulmonary HTN

Maintain anesthesia with any drug that does not cause ___________

Avoid N2O as it may increase _______

Use a muscle relaxant that does not release __________

A

  • myocardial depression
  • PVR
  • histamine
87
Q

Respiratory failure

Acute respiratory failure is the inability to provide adequate arterial oxygenation and/or elimination of CO2

Diagnosis
* PaO2 is less than _______ mmHg despite oxygen supplementation in the absence of a right to left shunt

  • A PaCO2 higher than _______ mmHg in the absence of respiratory compensation for respiratory alkalosis
  • pH is ____________

It is often accompanied by a decrease in
____ and _________

A
  • 60
  • 50
  • decreased

  • FRC and lung compliance
88
Q

Adult Respiratory Distress Syndrome

It is caused by an inflammatory injury to the lung and is manifested clinically by acute hypoxemic respiratory failure

Pathogenesis
* Manifest as rapid onset of __________ accompanied by ____________ refractory to treatment

  • There is an influx of ___________ into the alveoli as a result of increased alveolar capillary membrane permeability
  • ______________ may be produced locally in the lungs
  • In some patients it progresses to ____________ with persistent arterial hypoxemia and decreased lung compliance
A
  • respiratory failure; arterial hypoxemia
  • protein-rich edema fluid
  • Proinflammatory cytokines
  • fibrosing alveolitis
89
Q

ARDS

Signs and Symptoms
* Arterial hypoxemia resistant to treatment with ______ is the first sign
* _________ can lead to right sided heart failure
* Death from ARDS is usually caused by multiple organ failure or sepsis

Diagnosis
* Acute _________ hypoxemia
* _____________ of chest x-ray
* PCWP of less than ________ mmHg

A
  • O2
  • Pulmonary HTN

  • refractory
  • Diffuse infiltrates
  • 18
90
Q

ARDS

Treatment
* Treatment is directed at supporting oxygenation and ventilation

Goals
* Correcting hypoxemia
* Removing excess carbon dioxide
* Securing a patent airway
* Find and treat the cause of ARDS for example an infection
* Adequate nutrition
* Prevent GI bleeding and thromboembolism
* Inhaled b-agonist

Treatment – Tracheal intubation and ______

Initial steps in treatment is to secure the airway
Keep inspired oxygen concentration to maintain the PaO2 between 60-80 mmHg
Avoid barotrauma by maintaining peak airway pressures below 35-40 cm H2O

A

  • PEEP
91
Q

ARDS

Application of PEEP
* Helps prevent alveolar collapse at end expiration and increases lung volumes, especially FRC
* Improves ventilation/perfusion matching
* Decreases the magnitude of right to left intrapulmonary shunting

  • PEEP is indicated when high concentrations of inspired oxygen (FIO2 > _____) are needed to maintain PaO2
  • High levels of PEEP decrease cardiac output and cause barotrauma
  • PEEP is added in increments of 2.5-5 cm H2O until the PaO2 is at least ____ mmHg with an FiO2 of less than 0.5
A
  • 0.5
  • 60
92
Q

ARDS

Treatment – Fluid and hemodynamic management

The rational for restricting fluids in patients with ARDS is to decrease the risk of ____________

Maintain urine output at 0.5-1 mL/kg/hr

Diuresis with furosemide may help with excessive fluid administration

The goal of fluid therapy is to maintain the intravascular fluid volume at the lowest level consistent with adequate organ perfusion as assessed by metabolic acid-base balance and renal function

Treatment

Removal of airway secretions
* Adequate hydration and humidification of inspired gases

Infection
* Antibiotic therapy based on sputum culture and sensitivity testing

Nutritional support
* Its important to prevent muscle weakness
* Hyperalimentation

A
  • pulmonary edema
93
Q
A

CVT (6 decks)

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