Obstructive Lung Disease Flashcards
(104 cards)
1
Q
A
2
Q
What is diagnosis of an URI usually based on?
A
Clinical symptoms because viral cultures and lab tests are time consuming and expensive
3
Q
What are the four groups of obstructive respiratory diseases based on anesthetic management?
A
- Acute upper respiratory tract infection (URI)
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Miscellaneous respiratory disorders
These groups help guide anesthesia management strategies for patients with obstructive lung diseases.
4
Q
What accounts for approximately 95% of acute upper respiratory infections (URIs)?
A
Infectious nasopharyngitis
Commonly caused by viral pathogens.
5
Q
What are the most common viral pathogens associated with URIs?
A
- Rhinovirus
- Coronavirus
- Influenza
- Parainfluenza
- Respiratory syncytial virus (RSV)
These viruses are frequently implicated in upper respiratory infections.
6
Q
What is a key consideration for scheduling patients with URIs for surgery?
A
If surgery is cancelled due to acute URI, it should not be rescheduled within 6 weeks
Airway hyperreactivity may persist for up to 6 weeks.
7
Q
Children with URI have higher risks for?
A
Hypoxemia
Laryngospasm
Breath holding
Coughing
8
Q
What are anesthetic considerations for acute URI?
A
Adequate hydration
Limit secretions
LA on the vocal cords may reduce sensitivity
LMA instead of ETT may reduce risk of laryngospasm
Deep extubation=smoother emergence
9
Q
What are common adverse respiratory events in patients with URIs?
A
- Bronchospasm
- Laryngospasm
- Airway obstruction
- Postintubation croup
- Desaturation
- Atelectasis
These events can occur during anesthesia and require careful monitoring.
10
Q
How do you treat perioperative hypoxemia of Acute URI?
A
Supplemental O2
11
Q
What is asthma characterized by?
A
Chronic inflammation of the mucosa of the lower airways
This inflammation leads to airway edema and remodeling.
12
Q
What are asthma provoking stimulators?
A
Allergens
Pharmacological Agents
Infections
Exercise
Emotional stress (endorphins and vagal mediation)
13
Q
What pharmacological agents are asthma provoking?
A
Aspirin
B antagonists
Sulfiting agents
some NSAIDs
14
Q
What are the main inflammatory mediators implicated in asthma?
A
- Histamine
- Prostaglandin D2
- Leukotrienes
These mediators contribute to the inflammatory process in asthma.
15
Q
What is status asthmaticus?
A
Dangerous, life-threatening bronchospasm that persists despite treatment
Requires immediate medical intervention.
16
Q
Asthma Symptoms
A
Wheezing
Coughing
Dyspnea
Chest tightness
Eosinophilia
17
Q
FEV1
A
The volume of air that can be forcefully exhaled in 1 second
Normal: 80-120%
18
Q
Forced Vital Capacity (FVC)
A
The volume of air that can be exhaled with maximum effort after a deep inhalation
Women: 3.7 L Men: 4.8L
19
Q
Normal FeV1/FVC Ratio
A
75-80%
20
Q
Diffusing Capacity (DLCO)
A
The volume of a substance transferred across the alveoli into blood per minute per unit of alveolar partial pressure
21
Q
What are the common ABG findings during an asthma attack?
A
- Hypocarbia
- Respiratory alkalosis
These findings are typically due to neural reflexes of the lungs.
22
Q
What drives tachypnea and hyperventilation during an asthma attack?
A
neural reflexes
23
Q
As expiratory obstruction increases, V/Q mismatching ________ resulting in low _______
A
Increases
PaO2
24
Q
When does PaCO2 increase?
A
when the FEV1 is <25%
25
What is the first-line treatment for mild asthma?
Short-acting inhaled β2 agonist
(only recommended if <2 exacerbations/month)
## Footnote
Recommended if the patient has fewer than 2 exacerbations per month.
26
Asthma Treatments
SAB(2)A
Daily inhaled corticosteroids
Inhaled muscarinic antagonists
Leukotriene inhibitors
Mast Cell stabilizers
Systemic corticosteroids reserved for severe uncontrolled asthma
27
What are the characteristics of COPD?
* Chronic airflow obstruction
* Emphysema
*Lung parenchymal destruction
* Chronic bronchitis
* Dyspnea
* Productive cough
* Sputum production
## Footnote
COPD is a progressive disease that leads to significant morbidity.
28
Risks for COPD
Smoking
Dust & chemicals
Asbestos
Gold mining
Biomass Fuel
Age
Female
Low birth weight
Recurrent childhood infections
Asthma
Low socioeconomic Class
29
Lung Volume/Capacity changes of COPD
Increased FRC &TLC
Reduced DLCO
Increased RV
Increased RV: TLC ratio
Decreased FEV1:FVC ratio (25-75%)
30
Stages of COPD based on FEV1
I: Mild- FEV1>80%
II:Moderate-50%
31
Greater work of breathing at ______ lung volumes in COPD
higher
32
This compensated increase in RV and FRC in COPD leads to an _______ airway diameter
enlarged
33
What is the definitive method for diagnosing COPD?
Spirometry
## Footnote
PFTs show characteristic reductions in FEV1 and FEV1:FVC ratio.
34
What is the significance of α1-antitrypsin deficiency in COPD?
It is an inherited disorder associated with COPD requiring lifelong replacement therapy
## Footnote
Patients with this deficiency are at higher risk for developing COPD.
35
Eosinophils and COPD
High eosinophils indicate the need for inhaled glucocorticoids
Low levels are assoc w/ increased risk of pneumonia
36
ABGs and COPD
ABGs often remain normal until COPD is severe
*Pa02 doesn't usually decrease until the FEV1 is <50% of predicted
*PaC02 may not increase until the FEV1 is even lower
37
What is the first step in treating COPD?
Reducing exposure to smoke and pollutants
## Footnote
Smoking cessation is crucial for slowing disease progression.
38
Treatment of COPD
LAMA
LABA
Inhaled glucocorticoids effective with asthma, rhinitis, elevated eosinophils, and history of exacerbations
PNA and Flu Vaccines
39
When is O2 recommended in COPD?
long-term home 02 is recommended when the Pa02 is <55mmHg, the HCT >55%, or if evidence of cor-pulmonale
Goal: PaO2>60mmHg
Supplemental O2 is more beneficial than drug therapy in decreasing pulmonary vascular resistance and pulmonary htn, and in preventing erythrocytosis
40
Lung volume Reduction Surgery
*May be necessary in COPD patients w/severe refractory COPD & overdistended lung tissue...removal allows normal tissue to expand
*Normally performed sternotomy or VATS
*DLT, avoid N2O, minimize high airway pressures
*CVP unreliable in these
41
What is most predictive of pulmonary complications in COPD patients?
Clinical symptoms
-Smoking
-Wheezing
-Productive cough
42
When in doubt, ______ can be sufficient to assess lung disease
spirometry with FEV1
43
Risk Factors for development of Postop Pulm Complications
Age>60
ASA >II
CHF
Preexisting Pulm disease
Smoker
Emergency Sx
Abd,thorax, Head/neck, neuro, aneursym sx
Anesthesia >2.5 Hr
GA
Albumin<3.5
44
What is bronchial thermoplasty?
The only nonpharmacologic treatment for refractory asthma in which bronchoscopy is is used to deliver ablation of airway smooth muscle to all lung fields except RML
## Footnote
It involves delivering radiofrequency ablation of airway smooth muscles.
45
Risk of bronchial thermoplasty
uses intense heat which carries risk of airway fire
46
Emergency treatment of acute severe asthma
High-dose SABA inhaled every 15-20 min x several doses
IV corticosteroids (hydrocortisone and methylprednisone)
47
Mechanical Vent Parameters for Asthma
Prolonged expiration times to avoid air trapping and auto peep
Permissive hypercarbia
High gas flows
48
What is a common recommendation for patients with severe COPD?
Long-term home oxygen therapy when PaO2 is <55 mmHg
## Footnote
This therapy can significantly improve outcomes.
49
What are key components of preoperative assessment for asthmatic patients?
* Frequency of exacerbations
* Need for hospitalization/intubation
* Previous anesthesia tolerance
* Physical appearance
* Accessory muscle use
* Auscultation for wheezing or crackles
*Eosinophil counts often mirror the degree of airway inflammation
*FEV1or FVC <70% or FEV1/FVC ratio <65% risk for complications
*ABG
## Footnote
A thorough assessment helps mitigate perioperative risks.
50
What is the risk associated with bronchospasm during general anesthesia?
Reported in 0.2-4.2% of asthmatics undergoing GA
Correlated with type of surgery and how recent last attack was
**higher risk with upper abdominal and oncologic sx
## Footnote
Higher risk is correlated with type of surgery and recency of last attack.
51
What is the significance of the FEV1 measurement in asthma?
Measure the severity of the asthma
## Footnote
This measurement is crucial for assessing asthma severity.
52
The typical symptomatic asthmatic has an FEV1 of _____
<35%
53
How are lung volumes changed with moderate/severe asthma attacks?
FRC may increase substantially
TLC remains normal
DLCO is unchanged
54
True or False: Abnormal PFTs do not persist after an attack and can't be normal with an asthma attack
False. Abnormal PFTs may persist days after the attack and diagnosis may be made even with normal PFTs
55
Best imaging to diagnose COPD?
CT
56
True or False: Bullae on CXR confirms emphysema
True. Only a small percentage of patients have them
57
Multiorgan loss of tissue (MOLT)
phenotype of COPD, is associated with airspace enlargement, alveolar destruction, loss of bone, muscle, and fat tissues, and carries higher rates of lung cancer
58
Bronchitic COPD
phenotype is associated w/ bronchiolar narrowing and wall thickening and is usually accompanied by metabolic syndrome and cardiac disease
59
What is the impact of smoking cessation on perioperative outcomes?
Max benefit of smoking cessation is not seen until 8 weeks
## Footnote
Short-term abstinence does not eliminate the adverse effects of smoking.
60
True or False: some components of smoking stimulate liver enzymes and may take 6 weeks or longer for hepatic enzyme activity to return to normal
True
61
What is the elimination half-life of carbon monoxide?
4-6 hours
62
What happens to the PaO2 at which HGB is 50% saturated with oxygen (P50) 12 hours after smoking cessation?
Increases from 22.9 to 26.4 mmHg
63
What is the percentage decrease in plasma levels of carboxyhemoglobin 12 hours after stopping smoking?
Decreases from 6.5% to 1%
64
True or False: Short-term abstinence from cigarettes has been proven to decrease postoperative pulmonary complications.
False
65
How long does it take for normal immune function to return after smoking cessation?
At least 6 weeks
66
What is the optimal timing of smoking cessation before surgery to reduce postoperative pulmonary complications?
6-8 weeks (maximum benefit at 8 weeks)
67
Fill in the blank: Nicotine replacement therapies include patches, inhalers, nasal sprays, lozenges, and _______.
gum
68
What medication can help with smoking cessation?
SR Buproprion started 1-2 weeks before cessation
69
What are some disadvantages of smoking cessation in the immediate preoperative period?
Increase in sputum production, anxiety, irritability, nicotine withdrawal
70
What characterizes bronchiectasis?
Irreversible airway dilation, inflammation, and chronic bacterial infection
71
What is the prevalence of bronchiectasis highest in?
Patients over 60 with chronic lung disease such as COPD and asthma
72
What are common symptoms of bronchiectasis?
* Chronic productive cough with purulent sputum
* Hemoptysis
* Clubbing
73
What diagnostic imaging is the gold standard for bronchiectasis?
CT scan
74
What is the main treatment for bronchiectasis?
Antibiotics based on sputum cultures and chest physiotherapy
75
What are other treatments for bronchiectasis?
Flu vx
Bronchodilators
Corticosteroids
O2 therapy
Surgery reserved for severe or recurrent
76
What is cystic fibrosis caused by?
A mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene which normally produces a protein to aid in salt and water movement in and out cells. Without it, it leads to thick mucus
77
What are common symptoms of cystic fibrosis?
* Dehydrated viscous secretions
* Luminal obstruction
* Destruction and scarring of glands and tissues
*can lead to severe organ damage
78
What is the primary cause of morbidity and mortality in cystic fibrosis?
Chronic pulmonary infection
79
What sweat chloride concentration indicates cystic fibrosis?
>60 mEq/L
80
True or False: COPD is present in virtually all adult CF pts
True
81
What is a sign of airway inflammation?
High percentage of neutrophils in bronchoalveolar lavage
82
What is the common treatment for pancreatic exocrine insufficiency associated with cystic fibrosis?
Pancreatic enzyme replacement
83
What is primary ciliary dyskinesia?
Congenital impairment of ciliary activity in the respiratory tract, epithelial cells and sperm tails and ciliated ovary ducts leading to chronic sinusitis, recurrent respiratory infections, bronchiectasis and infertility
84
What triad is associated with Kartagener syndrome?
* Chronic sinusitis
* Bronchiectasis
* Situs inversus
85
What is situs inversus and how is it related to ciliary dyskinesia?
Chest organ position is inversed
Approx 50% pts with congenitally nonfunctioning cilia have situs inversus
86
What is dextrocardia?
Where the heart is pointed towards the R side of the chest and is almost always associated with congenital heart disease
87
Anesthesia considerations for Primary Ciliary Dyskinesia (especially with situs inversus)
*Reverse EKG position if dextrocardia
*Left IJ >R IL for CVC
*Uterine displacement R >L
*DLT-may indicate R DLT placement rather than L
*Avoid nasal airways
***Pretty much everything is backwards
88
What minimizes tracheal ischemia in central airway obstruction?
high-volume, low-pressure cuffs on ETTs
89
Central Airway obstruction
obstruction of airflow in the tracheal and mainstem bronchi
90
True or False: In primary ciliary dyskinesia, RA is preferable to GA to decrease postoperative pulmonary complications.
True
91
What is bronchiolitis obliterans?
Epithelial inflammation leading to bronchiolar destruction and narrowing
92
What are the risks associated with bronchiolitis obliterans?
* Viral lung infections
* Toxin exposures
* Lung transplant
* Stem cell transplant
93
What is the characteristic finding in PFTs for bronchiolitis obliterans?
Obstructive disease with reduced FEV1 and FEV1:FVC ratio unresponsive to bronchodilators
94
What can cause central airway obstruction?
* Tumors
* Granulations
* Airway thinning
95
What is the critical lumen size for tracheal stenosis to become symptomatic?
<5mm
96
What are the symptoms of tracheal stenosis?
* Dyspnea, even at rest
* Stridor (normally audible)
*accessory muscles utilized in all phases
**may not develop until weeks after extubation
97
How does helium help anesthesia of inspired gases?
decreases the density of the gas mixture and may improve flow through the area of tracheal narrowing
98
What is the most successful treatment for tracheal stenosis?
Surgical resection and reconstruction
99
What is the role of high-frequency ventilation in tracheal stenosis management?
It can be helpful during anesthesia
100
What is the goal of asthma treatment?
Depress airway reflexes and avoid bronchoconstriction
101
What can slow the progression of COPD?
* Smoking cessation
* Long-term oxygen therapy
102
What should be done for intraoperative bronchospasm?
Deepen the anesthetic, administer bronchodilators, and suction secretions
103
What is the importance of prophylaxis against postoperative pulmonary complications?
Restoring lung volumes, especially FRC, and facilitating effective coughing
104
COPD Anesthesia
RA>GA
GA pts should be ventilated at slow respiratory rates to allow sufficient time for exhalation, minimizing the risk of air trapping and auto-PEEP
