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Anesthesia II > Pulmonary > Flashcards

Flashcards in Pulmonary Deck (68):
1

If a patient has ongoing pulmonary disease, then they should really be cleared by

their pulmonologist or medical doctor prior to surgery

2

A person usually (underestimates/overestimates) how much they smoke per day?

Underestimates

3

During auscultation, patients should take ____ breaths first, and then ___ breaths

quiet, then deep

4

Describe bronchial breath sounds

Normal breath sounds of the tracheobronchial tree (large airways).

Heard best at: Trachea, sternoclaviular joint, and the right posterior interscapular space

Sounds like: High pitch and rapid/loud air movement

5

With bronchial breath sounds there is a ____ between inspiration and expiration

Pause

6

Describe vesicular breath sounds

Normal sounds you should hear over lung tissue
Softer and lower pitched than bronchial
No pause between inspiration and expiration.
Expiration is shorter (meaning we will hear more during inspiration)

7

When are bronchial breath sounds abnormal

Whenever they are heard somewhere they shouldn't be (in the periphery)

8

What is lung consolidation?

Lung tissue that has been filled with liquid

9

What type of breath sounds should you hear in consolidation?

Low pitched-bronchial (more bronchial because the tissue that should be making vesicular sounds are not opening)

10

What is cavitary disease?

Disease where normal lung tissue is replaced by a cavity

11

What type of breath sounds should you hear in cavitary disease?

High pitched bronchial, because the lung tissue that should be making vesicular sounds is replaced by a cavity (essentially a large-airway).

12

When are crackles insignificant?

If they clear with deep breathing

13

What is wheezing?

Musical noise as air passes through constricted bronchioles. Usually heard on expiration (when the airways constrict), but can be heard on inspiration as well.

14

What is stridor?

High pitched sound on inhalation due to narrowing of the larynx. Think about how hard you would be truing to breathe in if your larynx was constricted!

15

Can PFTs be used alone to make a diagnosis?

No, they must be taken into consideration with other factors

16

What are PFTs used for?

Diagnosis
Evaluate disease progression and treatment
Assessing risk of pulm compliations

17

Who are good candidates for PFTs?

COPD
Smokers with persistent cough
Wheezing or dyspnea on exertion
Morbid obesity (once they have pulm HTN or OHS)
Thoracic surgery patients (lung surgery)
Open upper abdominal procedures
Those > 70

Remember that PFTs are NOT routinely recommended. Just for those you questions how well they will do from a pulm standpoint post-op

18

Tests that assess abnormalities of gas exchange

ABG
Pulse-ox
Capnography

19

Spirometry

Tells you:
1) Volume (Normal is 80-120% of predicted value)

2) Flow (normal is 80-100% of predicted value)

20

Predicted values for spirometry are based on

Age
Height/weight
Gender
Race

21

Asthma is a disease of

inflammation

22

What happens to lung volumes in restrictive disease?

A proportional decrease in ALL lung volumes

23

What is the most commonly measured parameter in spirometry

Vital capacity

24

What is normal VC?

60-70mL/kg

Normal is >80% of predicted value

25

What is FVC?

Forced vital capacity (max inspiration followed by a FORCED expiration--meaning the patient has to cooperate with the test).

It graphs volume vs. time (meaning that it measures FLOW).

Test measures resistance to flow:
80-120% is normal
70-79% = mild
50-69% = moderate
<50% = severe

26

In COPD, FVC will be

Reduced (even if their VC is normal)
This is because the small airways close early and cause gas trapping

27

What is FEV1?

The amount of air you can forcefully expire in 1 second.

28

FEV1/FVC values

70-80% = normal
60-75% = mild obstruction
50-59% = moderate obstruction
<50% = severe obstruction

29

What is FEF25-75%?

Forced expiratory flow during the middle portion of FVC.
May reflect effort independent expiration and small airway status.
Sensitive in early stages of obstructive disease

30

What is more reliable in early disease, FEF25-75% or FEV1/FVC?

FEF25-75%
- Remember that this is the effort independent portion and is sensitive to the status of small airways, especially early in disease

31

Interpretation of FEF25-75% values

>60% of predicted value = normal
40-60% = mild
20-40% = moderate
<10% = severe obstruction

32

What is maximum voluntary ventilation (MVV)?

The largest volume of air a person is able to inhale and exhale in one minute (although test is only performed over 10, 12, or 15 seconds)

33

MVV is ____ in obstructive disease

decreased

34

MVV is ____ in restrictive disease

Normal (although someone with restrictive disease d/t to paralysis will have a decreased MVV)

35

What information does FRC tell you?

Tells you about compliance and how well someone can tolerate apnea.

Someone with a low FRC will have a harder time maintaining their sats during apnea.

36

How is FRC measured?

Nitrogen wash-out
Basically, someone breathes 100% O2 until the nitrogen analyzer attached to the spirometer detects a nitrogen concentration < 7%. Then all the nitrogen the person breathed out is added together to calculate FRC.

37

Appearance of the flow/volume loop in obstructive disease

Scooped out expiration d/t air trapping

38

FV Loop in restrictive disease

Basically a normal loop, but skinnier d/t reduced volumes (volume is on the x axis)

39

Flattened upstroke in a FV loop indicates

Some sort of upper airway obstruction such as tracheal stenosis.
In the anesthetized patient, this could be a mucus plus, kinked ET tube, etc.

40

PA, Pa, and Pv pressures and Lung Zones

Zone 1: PA > Pa > Pv
Zone 2: Pa > PA > Pv
Zone 3: Pa > Pv > PA

41

Does Zone 1 type V:Q normally occur in the awake and spontaneously breathing patient?

NO! Normally, we should have enough BP to force blood into the apices.
However, this type of V:Q may occur if BP drops or alveolar pressure increases (like in PPV!)

42

Does Zone 3 type V:Q normally occur in the awake and spontaneously breathing patient?

NO! Normally a nice deep breath should provide enough PA to overcome the arterial and venous pressures.

43

Zone 3 is an example of a

Shunt. Because there is a lot of blood flow, but little ventilation.

44

In the awake and spontaneously breathing patient, where is ventilation the smallest?

At the highest portion of the lung

45

In the awake and spontaneously breathing patient, where is ventilation the best?

In the more dependent parts of the lung. Here, the alveoli are compressed d/t gravity and the lung tissue has good compliance.

46

Pulmonary risks of PPV

Atelectasis (if not enough TV)
Increased blood flow to the dependent lung
Increased ventilation in the independent lung
(^^ above two cause worsened V:Q mismatch)
Dead space (apparatus)
Potential for barotrauma

47

How to counteract the pulm risks of PPV

Set PAW pressures to 15cm above what their normal PAW is
Deliver an adequate TV (to prevent atelectasis)
Maintain BP to perfuse the lung well
PEEP (prevent atelectasis)
FiO2

48

CV risks of PPV

Decreased preload and BP
(decreased preload will decrease CO, which decreases BP)

Can cause right to left shunt if the person has an atrial-septal defect

Counteract these effects with positioning, fluids, alpha and beta stimulants, and inotropes

49

Who may cancel a case if the patient has been smoking?

Plastics or ortho, because it will interfere with wound healing.

50

How to maximize pulm function before surgery?

Smoking cessation
Mobilize secretions and treat infections
Treat bronchospasm
Improve motivation ad stamina

51

Effects of smoking cessation

12-24 hours = carboxyhemoglobin levels return to normal, and patient is able to oxygenate better
2-3 weeks = mucociliary function returns and the patient has an increase in secretions and airway irritability
4 weeks = secretions reduce
8 weeks = rate of post-op pulmonary complications decrease** ideal amount of time to stop smoking before surgery

52

How can we help mobilize secretions?

Hydrate!!
Vibration/percussion
Aerosol therapy
Mucolytic agents?? (may increase secretions and cause irritable airways)

53

Meds used to treat/prevent bronchospasm

B2 agonists
Anticholinergics (atrovent)
Methylxanthines
Corticosteroids (will probably need a booster dose of this before surgery)

54

Point to note with FRC and restrictive disease

FRC will be reduced, so less safe apnea time. Be careful with your pre-op sedation.

Also, this decrease in FRC accelerates uptake of inhaled agents

55

Restrictive disease and regional anesthesia

Be careful of block > T10. This will cause loss of accessory muscles that they need to breath!!

56

Restrictive disease and PPV

Expect increased PAW pressures
Decrease TV to 4-8 mL/kg
Increase RR to 14-18 (to normalize MV)
Give PEEP (but remember this will decrease preload)

57

Affect of anesthesia on FRC

Normally, there is a 10-15% decrease in supine position
Additional 5-10% with GA
Plateau of FRC occurs after 10 minutes, regardless of ventilation
Can take up to 3-7 days for FRC to recover after upper abdominal surgery

58

VC may have up to a ___% reduction after an upper abdominal procedure, and take up to __ days to return to normal

40%
14 days
And this is for a healthy patient! Will be even worse for someone with pulmonary disease

59

How can we reduce airway reactivity?

Aggressive bronchodilator therapy
High alveolar concentrations of inhaled anesthetics (remember that IAs are bronchodilators!!)
IV opioids/lidocaine prior to AW manipulation
Single-dose corticosteroids

60

Vent management for obstructive disease

Large TV (remember their lung volumes are increased!)
Slow resp rate
Longer exp-time
Keep PIP below 40cmH20

Intrinsic PEEP may occur due to air trapping

61

In obstructive disease, MVV is

reduced

62

In restrictive disease, MVV is

normal
(although it depends on cause, obviously someone with muscle disease will have reduced MVV)

63

What does FRC tell you about?

Safe apnea time and pulmonary compliance

64

Effect of obstructive disease on FEF25-75%

Reduced
Remember that this test tells you about the small airways, and small airways close early in obstructive disease

65

When may zone 1 occur?

PPV or drop in BP

66

In PPV, you get increased ventilation to the ______ lung

Independent

67

Vent settings for restrictive disease

Lower TV (4-8mL/kg)
Increased RR (14-18bpm)
Give PEEP
Expect high peak airway pressures

68

In obstructive disease, we should avoid PIP above

40
Remember that their airways have thinned, and we want to avoid high pressures.