Oral Review: Pulm

Question 1

Characteristics of asthma:

Answer 1

Chronic airway inflammation
Airway wall thickening (severe cases)
Reversible expiratory airflow obstruction

Question 2

Causes of asthma exacerbations:

Answer 2

Allergens
Exercise
Nighttime/sleep
Chemicals (ASA/NSAIDs, VAs, irritants)
Cold
Infection

Question 3

S/s of asthma:

Answer 3

Wheezing
Middle-sized airways narrowed by bronchospasm & further narrowed by forced exhalation
Cough - can be mucoid
Dyspnea/air hunger

Question 4

Pre-op assessment of asthma:

Answer 4

Triggers
Severity (med requirements)
Degree of reversibility w/ tx
Current status, symptoms
Prior anesthesia history
Breath sounds, general appearance, etc

Question 5

Pre-op labs for asthma:

Answer 5

PFTs
ABG
ECG (RH failure)
CBC (eosinophils)
CXR (hyperinflation of lungs)

Question 6

Pre-op meds for asthmatics:

Answer 6

Benzos (anxiety –> bronchospasm)
H2 antagonists (unopposed H1 antagonism –> bronchospasm)
Bronchodilators (albuterol)
Pre-op steroids (if FEV1 is

Question 7

Overall goal for induction in asthmatics:

Answer 7

Blunt airway reflexes and bronchoconstriction response during airway instrumentation

Question 8

Induction in asthmatics:

Answer 8

EDTA-preserved propofol + ketamine (+/- glyco for secretions)
Opioids (non-histamine)
Lidocaine
VA w/ mask prior to laryngoscopy
LMA if possible

Question 9

Maintenance in asthmatics:

Answer 9

High concentration VA
Sevo/halo are least pungent/irritating
Avoid histamine releasers (sux, atra, miva)

Question 10

Ventilation goals for asthmatics:

Answer 10

Avoid PEEP - they are prone to air trapping
Low RR, high TV, long I:E ratio
Keep peak airway pressure volume control
Liberal hydration of pt and circuit

Question 11

Tx of intra-op bronchospasm:

Answer 11

FiO2 to 100%
Deepen VA
If no air movement: ketamine, propofol, lido
B2 agonists
IV epi in severe cases or SQ terbutaline
IV corticosteroids

Question 12

Emergence/post-op care for asthma:

Answer 12

Pre-emptive albuterol, IV lido
Deep extubation if possible
If not, try to get patient to SV as early as possible

Question 13

Characteristics of COPD:

Answer 13

Progressive airway obstruction
Chronic bronchitis and/or emphysema
Smoking #1 risk factor

Question 14

COPD staging:

Answer 14

Stage 1: FEV1 > 50% predicted
Stage 2: FEV1 35-49%
Stage 3: FEV 1

Question 15

“Blue bloaters”:

Answer 15

Chronic bronchitis
Mucus/inflammation obstruction
Moderate dyspnea
PaO2  45
Pulmonary hypertension d/t HPV
Cough and diminished breath sounds
Marked cor pulmonale
Tend to be obese
Poor prognosis
CXR: increased bronchovascular markings

Question 16

“Pink puffers”:

Answer 16

Emphysema
Obstruction due to loss of recoil
Severe dyspnea
PaO2 > 60, normal PaCO2
Very diminished breath sounds
Better prognosis
Tend to be thin
CXR: hyperinflation with a low diaphragm

Question 17

Smoking cessation timeline:

Answer 17

12-24 hours: decreased carbon monoxide and nicotine levels
48-72 hours: decreased carboxyhemoglobin, ciliary function improves, increased airway secretions, hyperreactivity
1-2 weeks: decreased secretions/sputum
4-6 weeks: PFTs improve
6-8 weeks: immune, metabolic function normalizes
8-12 weeks: decreased overall postop M&M

Question 18

Induction in COPD patients:

Answer 18

Caution with pre-medication
Hold opioids under monitored and with oxygen on
Ketamine is good for pts who tolerate the CV effects, otherwise propofol
Short-acting NMB
Stay away from histamine releasers

Question 19

Maintenance in COPD patients:

Answer 19

Cautious with N2O; can cause rupture of bullae from emphysema
VAs bronchodilate but also attentuate HPV reflex
Increased gradient between PaCO2 and ETCO2

Question 20

Ventilation goals in COPD patients:

Answer 20

No PEEP
Large TVs (10-15ml/kg) and low RR (6-10 bpm)
Humidifier in circuit
Consider patient’s baseline CO2 and tolerate hypercarbia based on it
Monitor for air trapping

Question 21

Emergence and post-op management in COPD patients:

Answer 21

May need to stay intubated/ventilated for prolonged period, esp. after abdominal/thoracic surgeries
Good pain control to avoid splinting

Question 22

Causes of reduced lung compliance:

Answer 22

Normal compliance = 100-200ml/cmH2O
Increased fibrous tissue
Alveolar edema
Low lung volumes/atalectasis
Increased pulm venous pressure

Question 23

Four types of restrictive lung disorders with examples:

Answer 23

Acute intrinsic (pulm edema, ARDS, aspiration pneumonitis)
Chronic intrinsic (pulm fibrosis, sarcoidosis)
Chronic extrinsic (chest wall/ab/neuromusc diseases, obesity, kyphosis)
D/o of pleura/mediastinum (tumors, pneumothorax, pleural effusions)

Question 24

Describe re-expansion pulm edema:

Answer 24

After rapid evacuation of > 1L from pneumothorax/effusion that’s > 24 hours old, due to enhanced capillary membrane permeability

O2, PEEP, no diuretics unless volume overload is primary issue

Question 25

Describe negative pressure pulmonary edema:

Answer 25

Minutes to 2-3 hours after acute upper airway obstruction, due to highly negative intrapleural pressure caused by attempting to breath against closed airway Most often post-extubation laryngospasm; self-limiting in 12-24 hours; tx with O2, airway monitoring, mechanical ventilation + PEEP if needed

Question 26

Tx for aspiration pneumonitis:

Answer 26

Increase FiO2 PEEP B2 agonists for bronchodilation Bronchoscopy for suspected solid material

Question 27

Describe sarcoidosis:

Answer 27

Systemic granulomas Can be in airway (difficult intubation) and myocardium (CV effects) Liver, spleen, optic and facial nerves too Pulm HTN and RH failure Often on chronic steroids Prone to hypercalcemia

Question 28

Describe chronic extrinsic lung disease effects:

Answer 28

RH dysfunction d/t chronic compression of pulm vasculature | Impaired cough --> chronic infections and obstructive component

Question 29

S/s of pneumothorax:

Answer 29

``` Acute dyspnea Decreased PaO2, increased PaCO2 Hypotension Tachycardia Uneven/decreased chest wall movement Hyperresonant percussion ```

Question 30

Regional anesthesia in restrictive lung disease:

Answer 30

> T10 level means loss of accessory muscles which may put patients at risk, plus they don't tolerate sedation well; not a bad idea for post-op pain though

Question 31

Induction in restrictive lung disease:

Answer 31

Titrated pre-meds carefully d/t respiratory depression Pre-oxygenation critical d/t reduced FRC May need etomidate if CV comorbidities

Question 32

Maintenance in restrictive lung disease:

Answer 32

VA uptake will be faster d/t reduced FRC Need ETT, not LMA; will need higher pressures Low TV (4-8ml/kg) and high RR (14-18 bpm) Avoid excessive FiO2