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PathoPhysiology Respiratory - CP > Obstructive Lung Disease > Flashcards

Obstructive Lung Disease Flashcards

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1
Q 
Preoperative pulmonary testing is indicated for which of the following patients?
A. baseline NaHCO3 35 mEq/L
B. planned pneumonectomy
C. suspected pulmonary hypertension
D. hypoxemia on room air (PaO2 <60 mmHg)
E. all of the above
A

E. all of the above should have preoperative pulmonary testing.

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2
Q

What is obstructive lung disease?

A

pulmonary conditions characterized by airflow limitation (inside the lumen, bronchial wall, and peri-bronchial region) can be reversible (asthma) or irreversible (COPD)

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3
Q

What is OSA?

A

Obstructive Sleep Apnea
it is a mechanical obstruction of breathing that occurs during sleep when pharyngeal muscles relax that is more common in males and obese patients being the most precipitating factor

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4
Q

Obstructed airways lead to ___

A

chronic hypoxemia and hypercarbia

low FRC

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5
Q

Clinical features and hallmark signs of OSA

A

habitual snoring, fragmented sleep and daytime somnolence

present with comorbidities related to obesity and hypoxemia (systemic and pulmonary HTN, ischemic heart disease, CHF)

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6
Q

How is OSA diagnosed? and significance of AHI value

A

Polysomnography which records the number of abnormal respiratory events (apnea) per hour
AHI - hypo apnea index
>5 associated with sleep related symptoms
>15 moderate OSA
>30 severe OSA
Berlin or STOP BANG questionnaires

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7
Q

STOP BANG

A

Snore loudly, daytime Tiredness, Observed stop breathing, high blood Pressure, BMI > 35 kg/m2, Age >50, Neck circumference >40 cm, Gender - male

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8
Q

How would a flow volume loop look for a restrictive airway disease?

A

smaller volumes, same ratio, looks normal (just smaller)

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9
Q

How would a flow volume loop look for an obstructive airway disease?

A

“scooping” on exhalation, flow taking longer to get out, normal inspiration

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10
Q

Spirometry testing includes

A

Forced expiratory volume in 1 second (FEV1), Forced vital capacity (FVC), FEV1 to FVC ratio, FEV25-75%, MVV, DLCO

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11
Q

Normal FEV1 to FVC ratio

A

75-80%

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12
Q

Forced vital capacity (FVC)

A

volume of air forcefully exhaled after a deep inhalation

3.7 L in females, 4.8 L in males

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13
Q

Forced expiratory volume in 1 second (FEV1)

A

volume of air forcefully exhaled in one second (80-120% of predicted value)
obstructive disease usually <50% usually

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14
Q

FEV 25-75%

A

measurement of air flow at midpoint of a forced exhalation

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15
Q

Maximum voluntary ventilation (MVV)

A

max amount of air that can be inhaled and exhaled in 1 minute
males: 140-180, females: 80-120 L/min

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16
Q

Diffusing capacity (DLCO)

A

volume of carbon monoxide transferred across the alveoli into the blood per minute per unit of alveolar partial pressure
single breath of 0.3% CO and 10% helium held for 20 seconds
normal value 17-25 mL/min/mmHg

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17
Q

Acute upper respiratory infection

A

common cold

diagnosed based on S/S (nonproductive cough, sneezing, rhinorrhea)

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18
Q

bacterial URIs

A

more serious and include fever, purulent nasal discharge, productive cough, malaise, tachypneic, wheezing

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19
Q

Anesthetic considerations for acute URIs (pediatrics)

A

pediatric patients higher risk for complications (higher parasympathetic tone and more reactive airways), they are usually actively sick, have reactive airway disease, having their airway manipulated from ETT intubation and airway surgery

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20
Q

If surgery is cancelled when should surgery be rescheduled?

A

at least 6 weeks

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21
Q

Anesthetic management for acute URIs

A

hydration, reduce secretions, limit airway maniupulation, decision between LMA vs ETT

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22
Q

adverse respiratory events with acute URIs include

A

bronchospasm, laryngospasm, airway obstruction, postop croup, desaturation

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23
Q

Asthma

A

reversible airway obstruction characterized by bronchial hyperreactivity, bronchoconstriction, chronic inflammation of the lower airways

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24
Q

Pathophysiology of asthma

A

activation of the inflammatory pathway leads to infiltration of airway mucosa with eosinophils, neutrophils, mast cells, T and B cells and inflammatory mediators including histamine, prostaglandin and leukotrienes leading to airway edema and thickening of the basement membrane

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25
Signs and Symptoms of asthma
episodic disease wheezing, productive and nonproductive cough, dyspnea and chest discomfort, eosinophilia status asthmaticus = persists despite treatment
26
Pulmonary function testing in asthma
``` FEV1 <35% of normal downward scooping of expiratory limb on loop FRC increases TLC remains normal DLCO unchanged (not a diffusion disease) ```
27
ABGs in asthma
mild - normal ABG can see hypocarbia and respiratory alkalosis but once accessory muscle use fatigues = acidosis severe - PaO2 <60 mmHg, rise in PaCO2 (shunt conditions)
28
Chest X-Ray and EKG for asthmatics
cxray - may be normal in mild cases but will have hyperinflation and hilar congestion d/t mucus plugging and pulmonary HTN in severe cases ekg - RV strain d/t increase pulmonary pressures = inferior changes (II, III, aVF) ST depression
29
Treatment for asthma
treat inflammation and bronchospasm corticosteroids, long acting bronchodilators, leukotriene modifiers, anti-IgE monoclonal antibody, methylxanthines, mast cell stabilizers get PFT after treatment to see how responsive they are!
30
Status Asthmaticus
EMERGENCY | administer B2 agonist, IV corticosteroids, supplemental oxygen, IV Mag, oral leukotriene inhibitor
31
if resistant to treatment for bronchospasm what are your next thoughts?
airway edema and secretions
32
Anesthetic considerations for asthma
get thorough history and determine severity of disease eosinophil counts (indication of inflammation) PFT results (FVC <70% or FEV1/FVC ratio <65% = increased periop risk!) use regional whenever possible/safest use lidocaine! use Sevoflurane avoid histamine releasing drugs! (atracurium and succinylcholine) deep extubation hydrate avoid anticholinesterase drugs
33
What is one ventilator strategy for asthmatics?
increase PEEP and increase expiration (ratio 1:2-3)
34
COPD
nonreversible loss of alveolar tissue and progressive airway obstruction
35
risk factors of COPD
cigarette smoking, occupational exposure, pollution, recurrent respiratory infections, low birth weight, a1-antitrypsin deficiency
36
Emphysema
characterized by enlargement of air spaces distal to the terminal bronchiole with destruction of walls, loss of alveoli and damage to capillaries, small airways are thin, tortuous and atrophied
37
Centriacinar emphysema
more in apex of lungs
38
panacinar emphysema
no regional preference, but usually more distally and deals with the a1-antitrypsin deficiency
39
Chronic bronchitis
disease characterized by excessive sputum production
40
hallmark findings of chronic bronchitis
hypertrophy of mucus glands of large bronchi, inflammatory changes in small airways, granulation of tissue, smooth muscle increases, peri bronchial fibrosis
41
COPD PFTs
decrease in FEV1/FVC ratio (<70% and not reversible with bronchodilators) decrease in FEV25-75% increase in FRC, RV, and TLC Severity is determined by GOLD spirometric criteria
42
COPD treatment goals
relieve symptoms and slow progression smoking cessation oxygen administration (2 LPM NC) especially if PaO2 <55, Hct >55%, cor pulmonale
43
COPD drug treatment
long acting B2 agonists inhaled corticosteroids long acting anticholinergic drugs
44
Severe cases of COPD
may need to have lung volume reduction surgery increases elastic recoil, decreases amount of hyperinflation, improved diaphragmatic and chest wall movement, decrease in abnormal V/Q
45
anesthetic considerations for a lung volume reduction surgery
double lumen tube avoid nitrous oxide avoid excessive positive pressure ventilation
46
Examples of who needs PFT
hypoxemia or need for home o2 with no known cause NaHCO3 > 33 mEq/L PaCO2 > 50 mmHg Hx of respiratory failure d/t persistent problem Severe SOB Planned pneumonectomy Difficulty assessing pulmonary status Differential diagnosis needed Need to determine response to bronchodilators If they have pulmonary hypertension
47
Risk of postoperative complications for COPD
> 60 y/o, ASA III or IV, current smoker, CV involvement (RV function), low albumin <3.5, active S/S (wheezing, low SpO2, edema, crackles)
48
How long ideally should someone stop smoking before surgery?
at least 6 weeks | benefits are seen in as little as 4 hours
49
Malnutrition increases risk of
pleural leaks after lung surgery
50
What can be a complication with interscalene blocks in COPD patients?
causes ipsilateral phrenic nerve palsy which can be bad for COPD patients because it can put them into respiratory failure
51
Why should nitrous oxide be avoided in COPD patients?
it attenuates HPV which will worsen the V/Q mismatch
52
mechanical ventilation considerations for COPD patients
``` humidification avoid dynamic hyperinflation Vt 6-8 mL/kg PIP < 30 mmHg FiO2 to maintain Spo2 >90% or their baseline ```
53
What can result from positive pressure ventilation without sufficient expiration?
increased intrathoracic pressure (decreases venous return) and increased pulmonary artery pressure = right heart strain!
54
How does air trapping present?
capnography shows sloped carbon dioxide concentration | expiratory flow does not reach baseline before next breath
55
Treatment for bronchospasm
deepen anesthetic, deliver short acting bronchodilator, suction, IV steroids, epinephrine
56
bronchiectasis
irreversible airway dilation and collapse resulting from inflammation d/t chronic infection can have significant hemoptysis
57
Distinguishing factors of bronchiectasis
Finger clubbing!, hemoptysis, history of chronic cough w/ purulent sputum, and pleuritic chest pain
58
General anesthesia with ETT in bronchiectasis considerations
double lumen tube (to prevent cross contamination from one lung to the other) frequent suctioning avoid nasally intubating
59
cystic fibrosis
autosomal recessive disorder from chromosome 7 prevents chloride transport and movement of salt and water in and out of cells = abnormally thick sputum production outside of epithelial cells
60
primary cause of morbidity and mortality in cystic fibrosis is
chronic pulmonary infection
61
diagnosis of cystic fibrosis
sweat chloride concentration >70 mEq/L chronic purulent sputum production malabsorption with response to pancreatic enzyme therapy, bronchoalveolar lavage high in neutrophils
62
presence of normal sinuses is strong evidence that
Cystic fibrosis is NOT present
63
treatment of cystic fibrosis
alleviate symptoms | clearance of secretions, correction of organ dysfunction, nutrition, prevent intestinal obstruction, gene therapy?
64
anesthetic considerations for cystic fibrosis
``` delay until optimized (controlling infection and removing secretions) vitamin K GA with volatile agents avoid anticholinergic meds awake extubation! adequate pain control ```
65
What may you need to do if you use volatile agents in cystic fibrosis?
SUCTION their airway after turning gas on
66
primary ciliary dyskinesia
congenital impairment of ciliary activity in respiratory tract epithelial cells and sperm cells
67
Kartagener's syndrome triad of
chronic sinusitis bronchiectasis situs inversus (organs reversed)
68
anesthetic considerations for primary ciliary dyskinesia
regional anesthesia preferred reverse ECG leads if have organ reversal do a left IJ cannulation for central line insertion if pregnant place in right uterine displacement avoid nasal pharyngeal airways (risk of sinusitis)
69
bronchiolitis obliterans
disease of the small airways and alveoli in children from respiratory syncytial virus (RSV)
70
adults can develop bronchiolitis obliterans from
viral pneumonia, collagen vascular disease (RA), inhalation of nitrogen dioxide (Silo filler's disease), graft vs host disease post-transplant
71
Bronchiolitis obliterans organizing pneumonia (BOOP) shares features of
interstitial lung disease and bronchiolitis obliterans
72
tracheal stenosis
occurs following prolonged intubation or over inflation of ETT cuff = ischemia of tracheal mucosa = scarring
73
symptomatic tracheal stenosis in adults
when tracheal diameter < 5 mm (dyspnea at rest, use of accessory muscles in all phases)
74
what would a flow loop look like for tracheal stenosis?
flattened inspiratory and expiratory curves | "fixed obstruction"
75
treatment for tracheal stenosis
tracheal dilation (temporary measure) with balloon or stent laser scarred tissue tracheal resection with anastomosis (best treatment)
76
anesthetic considerations with tracheal stenosis
``` translaryngeal intubation (below stenosis) volatile anesthetics (ensures max inspired oxygen concentration) helium (decreases density of gas mixture and improves flow through narrowing) ```

PathoPhysiology Respiratory - CP (4 decks)

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