Obstructive Lung Dx Flashcards
(122 cards)
1
Q
Majority (95%) of URI are due to:
A
Infectious nasopharyngitis pharyngitis
2
Q
Dx of URI is based on:
A
Clinical symptoms (because viral cultures and lab tests lack sensitivity and are expensive)
3
Q
Children w/ URI have a high risk of periop respiratory events with symptoms:
A
-Hypoxemia
-Laryngospasm
-Breath Holding
-Coughing
4
Q
If your patient had an URI for 3 weeks, but is stable and improving, can you continue surgery?
A
Yes, continue with surgery
5
Q
If Sx is cancelled due to acute URI, you should reschedule after _____ weeks due to ______
A
Schedule after 6 weeks due to airway hyper-reactivity
6
Q
Anesthetic management of URI patients
A
- Adequate hydration
- Reduce secretions
- Limit airway manipulation
7
Q
What can you put on the vocal cords to reduce upper airway sensitivity?
A
Nebulized or Topical LA
8
Q
What type of airway can reduce risk of laryngospasm?
A
LMA better than ETT
9
Q
How do you want to extubate your URI patients
A
Deep extubation might allow for smoother emergence
10
Q
What are adverse events in pts with URI?
A
- Bronchospasm
- Laryngospasm
- Airway obstruction
- Postintubation croup
- Desat
- Atelectasis
11
Q
Chronic inflammation of the mucosa of the lower airways;
Episodic disease with acute exacerbations and asymptomatic periods
A
Asthma
12
Q
Airway remodeling in asthma leads to
A
Thickening of the basement membrane and smooth muscle mass, bronchi edema
13
Q
What are the main inflammatory mediators implicated in asthma? (3)
A
- Histamine
- Prostaglandin D2
- Leukotrienes
14
Q
What are pharmacologic agents that provoke asthma?
Emotional stress agents?
A
Aspirin, Beta Antagonists, NSAIDS, Sulfiting agents
Endorphins, Vagal mediation
15
Q
Asthma attacks typically happen during or after exercise?
A
After
16
Q
Symptoms of asthma
A
Wheezing, coughing, dyspnea, chest tightness, eosinophilia
17
Q
Dangerous, life threatening bronchospasm that persists despite treatment
A
Status asthmaticus
18
Q
Status asthmaticus is diagnosed based on:
A
Symptoms
PFT showing airflow obstruction that persists despite treatment with bronchodilators
19
Q
Normal values for FEV1 test
What does this measure?
Values for Asthmatic?
A
Values between 80-120% of the predicted value
Severity of expiratory obstruction
Asthmatic: FEV1 < 35%
20
Q
Normal FVC for females and males
A
Female: 3.7L
Male: 4.8 L
21
Q
FEV1/FVC ratio normal
A
75-80%
22
Q
Forced expiratory at 25-75% of the vital capacity measures the airflow through _____
A
the midpoint of a forced exhalation
23
Q
During moderate/severe attacks, what do FRC and TLC show?
A
FRC may increase
TLC remains normal
DLCO unchanged
24
Q
After an asthma attack, how long do abnormal PFT persist?
A
Several days
25
Since asthma is an ______ illness, its diagnosis may be suspected, even with _______ PFT results
Episodic; normal PFT results
26
During asthma attack, tachypnea and hyperventilation is caused by ________ reflexes of the lungs, not _______
neural reflexes; not hypoxemia
27
What are the most common ABG findings of symptomatic asthma?
Hypocarbia and respiratory alkalosis
28
As expiratory obstruction _________, VQ mismatching ________ , resulting in ______ PaO2
increases; increases; Low
29
PaCO2 increases when the FEV1 is < _____% of predicted
FEV1 < 25 of predicted
30
First line treatment for mild asthma
This is only recommended if you have < ____ exacerbations/month
Short-acting inhaled B2 agonist
< 2
31
What in addition to B2 agonists improve symptoms, reduce exacerbations and decrease hospitalization
Daily inhaled corticosteroids
32
If symptoms remain uncontrolled, you can add daily
inhaled B2 agonists
33
Other treatments for asthma:
1. Inhaled muscarinic antagonists
2. Leukotriene inhibitors
3. Mast cell stabilizers
34
This medication is reserved for severe asthma that is uncontrolled with inhalational medications
Systemic corticosteroids
35
This decreases the use of long-term medications for asthma
SQ immunotherapy
36
A Bronchoscopy used to deliver radiofrequency ablation of airway smooth muscles to all lung fields except the right middle lobe
-Thought to reduce airway smooth muscle to decrease constriction
-Uses intense heat (airway fire risk)
______ used to monitor response to treatment
When the _____ improves to _____ of normal, patients have little to no symptoms
*The only nonpharmacologic treatment for refractory asthma
Bronchial thermoplasty
Serial PFT's monitor response to treatment
FEV1 improves to 50% of normal
37
Fore acute severe asthma, the emergency treatment is:
Other drugs used in severe cases are:
High dose, short acting B2 agonists (q 15-20 minutes)
Systemic corticosteroids (Hydrocortisone & Methylprednisone)
Magnesium and Oral leukotriene inhibitors, Anticholinergics (Ipratropium), broad spectrum ABX, IV fluids, Sedation and paralysis
38
IV corticosteroids should be administered early, because onset takes ________
several hours
39
SaO2 goal during acute severe asthma is
> 90%
40
Vent settings for asthma:
____ Gas flow
_____ Inspiration time
_____ Expiration time
____ RR
High; short inspiration; long expiration; low RR
41
Risk of bronchospasm (0.2-4.2%) is correlated with 2 things
1. Type of surgery (increased with upper abdominal and oncologic surgery)
2. How recent the last asthma attack occurred
42
Some GA mechanisms that increase airway resistance:
Depression of cough reflex
Impairment of mucociliary function
Reduction of palatopharyngeal muscle tone
Depressed diaphragmatic function
Increased Fluid in the airway wall
Airway stimulation on intubation
PNS activation
Release of inflammatory mediators (Sub. P and Neuorkinins)
43
These counts (labs) often mirror the degree of airway inflammation?
Eosinophil counts
44
PFTs (especially _____) before and after a bronchodilator may be indicated
FEV1
45
Reduction in FEV1 or FVC to < ____% and/or FEV1:FVC ratio < ____% of predicted is a risk for periop respiratory complications
FEV1 or FVC < 70%
FEV1:FVC < 65%
46
What can improve reversible components of asthma?
1. Pre-op chest physiotherapy
2. ABX
3. Bronchodilators
47
These 2 drug classes should be continued until induction
Anti-inflammatories
Bronchodilators
48
When is a stress-dose hydrocortisone or methylprednisone indicated?
If the patient had been on systemic corticosteroids within the past 6 months
49
Patients should have a PEFR > ____% of predicted or their personal best before surgery
> 80%
50
Asthma characteristics to be evaluated pre-operatively
Age at onset
Triggers
Any Hospitalizations/intubations
Allergies
Cough
Sputum characteristics
Current medications
Anesthetic Hx
51
Disease of chronic airflow obstruction characterized by lung parenchymal destruction, chronic bronchitis, dyspnea, productive cough, and sputum production
COPD
52
In COPD, cough is ____, breath sounds are ____ and ______ are common
productive; decreased; expiratory wheezes
53
What is lost due to bronchio-alveolar destruction?
Pulmonary elastic recoil
54
Worldwide, COPD has a prevalence of ____% and is the ___ leading cause of death
10%; 3rd leading cause
55
Risk factors for COPD
Smoking, exposure to dust & chemicals, asbestos, gold mining, biomass fuel, genetic, age, female gender, poor lung development, low birth weight, recurrent childhood respiratory infections, low socioeconomic class, asthma
56
COPD leads to:
-Deterioration of the _______ of the lung parenchyma (which normally keeps airways open)
-Decreased bronchiolar wall structure, allowing collapse during _____
-Increased velocity thru the narrowed broncheoli, _____ intrabronchial pressure and favoring collapse
-_____ pulmonary secretions, leading to bronchospasm and obstruction
-______ destruction, _____ air sacs, emphysema
Elastic recoil; exhalation; lowering; increased; parenchymal; enlarged
57
Definitive Dx of COPD is made w/ _______
PFT show:
______ FEV1:FVC ratio
FEF _______ % of vital capacity
Spirometry
Decreased FEV1:FVC ratio
FEF 25-75% of VC
58
Common findings of COPD
FEV:FVC ratio < ____%
_____ FRC and TLC
_____ DLCO
_____ RV
_____ VC
_____ RV: TLC ratio
FEV:FVC ratio < 70%
Increased FRC and TLC
Reduced DLCO
Increased RV
Decreased VC
Increased RV: TLC ratio
59
Increase in _____ and ____ leads to enlarged airway diameter
FRC and RV
60
Stage 1 (mild COPD)
FEV1 ≥ 80% predicted
61
Stage 2 (moderate COPD)
50% ≤ FEV1 ≤ 80% predicted
62
Stage 3 (Severe COPD)
30% ≤ FEV1 ≤ 50% predicted
63
Stage 4 (Very severe COPD)
FEV1 < 30% predicted
64
What CXR finding suggests emphysema
What CXR finding CONFIRMS emphysema
What test is more sensitive at diagnosing COPD over CXR?
Hyperlucency in lung periphery
Bullae confirm (only small % have it)
Chest CT
65
A phenotype of COPD, associated with airspace enlargement, alveolar destruction, loss of bone, muscle, tissues, carries higher rate of lung CA
Multiorgan loss of tissue (MOLT)
66
Phenotype associated with bronchiolar narrowing and wall thickening, accompanied by metabolic syndrome & cardiac dx
Bronchitic
67
Inherited disorder associated with COPD
-Requires lifelong replacement therapy
a1-antitrypsin deficiency
68
This lab should be measured in patients with uncontrolled COPD
-High levels indicate the need for inhaled glucocorticoids
-Low levels associated with increased risk of pneumonia
Eosinophils
69
This lab remains normal until COPD is severe
_____ does not decrease until FEV1< ____%
_____ does not increase until the FEV1 is even lower
ABG
PaO2; < 50%
PaCO2
70
1st step in COPD treatment is:
reducing exposure to smoke and pollutants
71
Smoking cessation can decrease disease progression & mortality by up to ____%
18%
72
First line treatment for COPD
If dyspnea persists, add this
Long-acting inhaled muscarinic antagonists
Long-acting B2 agonists
73
This drug for COPD is effective in pts with associated asthma, rhinitis, elevated eosinophils, and hx of exacerbations
Inhaled glucocorticoids
74
Other treatments for COPD:
Flu & Pneumonia vaccines
Diuretics if RHF/CHF developed
ABX, Corticosteroids, Theophylline during exacerbations
Pulmonary rehab (increase exercise capacity)
75
In order to decrease risk of death, long-term O2 is recommended in COPD when the PaO2 < ____ mmHg, Hct > ___%, or evidence of cor-pulmonale
PaO2 < 55
HCT > 55%
76
Supplemental O2 goal in COPD is PaO2 > ___ mmHg
> 60 mmHg
77
What is more effective than drug therapy in decreasing PVR and Pulmonary HTN, & preventing erythrocytosis
Supplemental O2
78
Surgical treatment for COPD to decrease overdistended lung tissue
performed via ________ or VATS
Anesthesia management:
Lung-volume reduction surgery
Median sternotomy
Anesthesia: DLT, Avoid Nitrous, minimize high airway pressure
79
If a patient has pulmonary disease, ______ function should be assesed by clinical exam with Echo
RV function
80
Inhalation therapy for COPD patients should be continued until
Morning of surgery
81
What is more predictive of pulmonary complications vs spirometer tests?
Smoking, wheezing, productive cough
82
Indications for pre-op pulmonary evaluation
1. Hypoxemia on RA or Home O2 without cause
2. Bicarb >___ meQ or PaCO2 > ___ mmHg without diagnosis
Others
Bicarb > 33 meq or PaCo2 > 50 mmHg
83
When in doubt, spirometry with ____ can be sufficient to assess lung dx
FEV1
84
Max benefit of smoking cessation is not seen until
8 weeks after cessation
85
CO and nicotine adverse effects on the O2 carrying capacity is
Elimination 1/2 life of CO is
short-lived
4-6 hours
86
12 hours after smoking cessation, the P50 value increases from ____ to ____ mmHg, and plasma carboxyhemoglobin decreases form____ to ___%
P50 inc. from 22.9 mmHg to 26.4 mmHg
Plasma levels of carboxyHb decrease from 6.5% to 1%
87
Return of normal immune function requires at least ____ wks of abstinence from smoking
Some components of smoke stimulates ____ enzymes and might take ___ weeks or longer for return of normal activity
6 weeks
Liver
6 weeks or longer for return of normal hepatic enzyme activity
88
What is the optimal timing of smoking cessation before surgery to reduce post-op lung complications?
6-8 weeks (max benefit at 8 weeks)
89
What drug can help with smoking cessation?
Sustained release Bupropion (start 1-2 weeks before stop smoking)
90
Disadvantages of smoking cessation in the immediate pre-op period?
Increased sputum production, anxiety, irritability, nicotine withdrawal
91
Irreversible airway dilation, inflammation and chronic bacterial infection with high prevalence in > 60 age with chronic lung disease (COPD/Asthma), and women
Symptoms:
Bronchiectasis
S/s: Purulent sputum from productive cough, hemoptysis, clubbing
92
Gold standard for diagnosis of bronchiectasis, shows ____
Main treatment:
surgery reserved for severe symptoms or recurrent complications
CT; dilated bronchi
Tx: ABX & chest physiotherapy
93
______ normally produces a protein, which helps in salt and water movement in and out of cells
mutation of this gene leads to abnormally thick mucus
CFTR Gene (Cystic fibrosis transmembrane conductance regulator)
94
In cystic fibrosis, exocrine pancreatic insufficiency leads to malabsorption of _____ and _____
fats and fat-soluble vitamins
95
The primary cause of morbidity and mortality in cystic fibrosis is
chronic pulmonary infection
96
Dx of CF is
Sweat chloride concentration > 60 mEq/L
DNA analysis can ID CFTR mutation
Response to pancreatic enzyme treatment
97
Bronchiolar lavage in CF shows a high % of _____ which is a sign of airway inflammation
Neutrophils
98
Present in almost all CF patients
COPD
99
Tx for CF
1. ABX
2. Chest physiotherapy
3. Bronchodilators
4. Pancreatic enzyme replacement
5. O2 therapy
100
This increases sputum clearance
recombinant human deoxyribonuclease
101
Congenital impairment of ciliary activity in the respiratory tract, epithelial cells, and sperm cells and ciliiated ovary ducts
-Leads to chronic sinusitis, recurrent resp. infections, bronchiectasis, and infertility
Primary ciliary dyskinesia
102
Kartagener Syndrome is a triad of
1. Chronic sinusitis
2. Bronchiectasis
3. Sinus inversus (chest organ position inverse)
103
____% patients with congenital non-functioning cilia have ________
_____ is always ass. with congenital heart dx
50% situs inversus
Isolated Destrocardia
104
What type of anesthesia for Primary ciliary dyskinesia?
RA over GA
105
Intervention for dextrocardia:
EKG position is reversed for accurate interpretation
106
Which Intervention in PCD is done for CVC placement
Left IJ preferred due to inversion of the great vessels
107
Which Intervention in PCD is done for pregnant pt's
Uterine displacement to the RIGHT (usually left to avoid vena cava syndrome)
108
Which Intervention in PCD is done for double-lumen ETT placement
Right sided DLT placement
109
Avoid which airways due to high incidence of sinusitis
Nasal airway
110
Epithelial inflammation leading to bronchiolar destruction and narrowing
Risk: Viral lung infection, toxin exposure, lung transplant, stem cell transplant
Sx: Non-specific (dyspnea, non-prod. cough)
PFT show:
CT shows:
Bronchiolitis obliterans
PFT: Decreased FEV1:FVC unresponsive to bronchodilators
CT: Air trapping and bronchiectasis
111
Obstruction of airflow in tracheal and mainstem bronchi
Affects 20-30% of Lung CA patients
Caused by: Tumors, granulations, airway thinning
_____ develops after prolonged intubation
Central airway obstruction
Tracheal stenosis
112
How do you minimize tracheal ischemia?
High volume, low-pressure cuffs on ETT
113
Tracheal stenosis is symptomatic when lumen < to ___ mm
Symptoms might not develop until ___ after extubation
<5 mm
Weeks
114
Symptoms of tracheal stenosis
Prominent dyspnea at rest
Accessory muscles constant use
Audible stridor
Flat inspiratory and expiratory curves on flow volume loops (fixed airway obstruction)
115
Treatment for tracheal stenosis that can be done bronchoscopically with dilators or laser resection
Tracheal dilation
116
Most successful treatment of tracheal stenosis
Surgical resection and reconstrucion
117
What type of intubation is necessary for tracheal resection
Translaryngeal intubation via the distal trachea
-High frequency ventilation
118
Anesthesia for tracheal stenosis can be facilitated by addition of _____ to the inspired gas because it (2)
Helium;
decreases the density of the as mixture and improves flow thru the tracheal narrowing area
119
The goal in asthmatic patients:
Depress airway reflexes, avoid bronchoconstriction
120
Only ways to slow COPD dx progression
Smoking cessation and long-term O2 therapy
121
COPD patients which anesthesia is preferred
RA over GA to reduce bronchospasm, trauma, and PPV
122
How to treat intraoperative bronchospasm
1. Deepen anesthetic
2. Bronchodilator administration
3. Suction secretions
