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Flashcards in Pulmonary Deck (36)
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Characteristics COPD and asthma:

Chronic Obstructive diseases characterized by:

  • Chronic airway inflammation
  • Airway wall thickening (epithelial, submucosa and smooth muscle) → impairs gas exchange
  • Expiratory airflow obstruction
    • ​Asthma = reversible
    • COPD = not reversible or incompletely reversible​​
  • Airway hyperreactivity


Causes of asthma exacerbations:

  1. Allergens
  2. Exercise
  3. Nightime/sleep
  4. Chemicals (ASA/NSAIDs, VAs, irritants)
  5. Cold
  6. Infection


S/s of asthma:

  1. Wheezing
  2. Breathlessness/Air Hunger
  3. Chest tightness
  4. Early AM or nighttime cough
  5. Reversible airflow obstruction
  6. Tachypnea
  7. Prolonged expiratory phase
  8. Fatigue


Pre-op assessment of asthma:

  1. Triggers
  2. Severity (med requirements)
  3. Degree of reversibility w/ tx
  4. Current status, symptoms
  5. Prior anesthesia history
  6. Breath sounds
  7. general appearance, etc


Pre-op labs for asthma:

  1. PFTs
  2. ABG
  3. ECG (RH failure)
  4. CBC (eosinophils)
  5. CXR (hyperinflation of lungs)


Pre-op meds for asthmatics:

  1. Benzos
    1. anxiety can precipitate bronchospasm bronchospasm)
  2. Opioids
    • be sure to titrate carfully
  3. H2 antagonists
    • unopposed H1 antagonism may cause bronchoconstriction- Use Caution!
  4. Bronchodilators
    • albuterol) - 15-30 min before 
  5. Pre-op steroids - prohylaxis
    • Hydrocortizone 100 mg q8h if FEV1 predicted 


Overall goal for induction of anesthesia in asthmatics

GOAL= Blunt airway reflexes and avoid bronchoconstriction during airway instrumentation

  1. Consider Regional (good choice)
  2. Whenever possible, use LMA for smoother emergence/extubation
  3. GA should:
    1. ​depress airway reflexes 
      • Lidocaine 1-1.5 mg/kg IV (consider LTA)
      • Opioids -judiciously (fentanyl and analogues)
    2. Avoid hyperreactivity 
      • Use High MAC >1.5 for bronchodilation and bronchial reflex inhibition (Sevo and halothane are the least irritating)
      • AVOID desfluane/isoflurane - airway irritant
      • Propofol and ketamine is best for induction
        • avoid Sodium metabisulfite prep 
        • Higher end of induction doses
      • Ketamine will increase secretions which may irritate the airway, but does bronchodilate - maybe give some glyco?
      • Maybe AVOID ketoralac/NSAIDS - increased leukotrienes via lipooxygenase pathway
    3. Treat bronchoconstriction 
      • ​albuterol
      • sevoflurane
    4. AVOID histamine realease
      • ​​Sux, atricurium, mivicurium, D-tubo, morphine, demerol, thopental
    5. ​​​Neostigmine is ok for reversal, but MUST be given with anticholinergic - glycopyrolate


Maintenance of anesthesthesia in asthmatics:

  1. High concentration VA
    1. Sevo/halo are least pungent/irritating
  2. Avoid histamine releasers (sux, atra, miva)
  3. Avoid bronchospasm


Ventilation goals for asthmatics:


  1. Avoid PEEP !! →prone to air trapping
    • these pts may have intrinsic peep r/t air trapping
    • during an acute attack, may see “breath stacking”
  2. Decrease RR (8-10 bpm) - allows for adequate exhalation 
  3. Longer I:E ratio
  4. Increase TV - to maintain Normal PaCO2
    1. TV and inspiritory flow rates are limited by excessive peak airway pressures
    2. Upper Limit - 40 cm H2O
  5. If you can choose a mode – consider using PCV over  volume controlled ventilation

  6. Liberal hydration of pt and circuit
    • Place a humidifier in the breathing circuit


Treatment of intra-op bronchospasm:

  1. FiO2 to 100%
  2. Deepen anesthesia with VA or drugs
  3. Give a ß-agonist
  4. If no air movement:
    1. Epinephrine IV: 2-8 mcg/min (SQ 0.3-0.5mg q20-30min)
    2. Terbutaline (SQ)
    3. Corticosteroids: 1-2 mg of cortisol
  5. Other IV broncholilators
    1. Ketamine
    2. Propofol
    3. Lidocaine  


Emergence/post-op care for asthma:

  1. Smooth emergence - ETT promotes bronchoconstriction and airway resistence
  2. Pre-emptive albuterol, IV lido 10-15 minutes prior to wake up
  3. Deep extubation if possible
  4. If not, try to get patient to SV as early as possible


Characteristics of COPD:

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


COPD staging:

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


"Blue bloaters":

  1. Chronic bronchitis
  2. Copious secretions cause obstruction
  3. Cough
  4. Diminshed breath sounds
  5. PaO2 →cyanosis and dusky appearance
  6. PaCO2 > 45
  7. Pulmonary hypertension d/t HPV
  8. Marked cor pulmonale/righ sided heart failure
  9. Overweight 
  10. CXR: increased bronchovascular markings


"Pink puffers":

  1. Emphysema
  2. Obstruction due to loss of recoil
  3. Severe dyspnea
  4. PaO2 > 60
  5. Normal PaCO2 
  6. Very diminished breath sounds
  7. Tend to be thin
  8. anxious, pursed lips
  9. CXR: hyperinflation with a low diaphragm


Smoking cessation timeline:

  1. 12-24 hours:
    • decreased carboxyhemoglobin levels to normal
  2. 2-3 weeks:
    • ciliary function improves, increased airway secretions, hyperreactivity
  3. 4 weeks: PFTs improve
  4. 8 weeks:
    •  decreased rate of postoperative complications
    • immune, metabolic function normalizes

​(if patient cannot quit for four weeks before surgery, it is better to only have them quit for 24 hours before)


Induction in COPD patients:

GOAL= minimize risk of post op respiritory failure

  1. Caution with pre-medication
    • They don’t tolerate respiratory depressant effects of drugs (medulla is “reset” d/t chronic hypercarbia, so these pts are less sensitive to ↑ levels of CO2)
    • Hold opioids until the pt is hooked to monitors and with oxygen on
  2. Ketamine is good for pts who tolerate the CV effects, otherwise propofol
  3. Regional is a good choice: Avoid levels > T6
  4. Depress airway reflexes/reactivity
    • Lidocaine 1-1.5 mg/kg IV (consider LTA)
    • Opioids -judiciously (fentanyl and analogues)
    • Consiter comorbitities for other agents (Heart failure??)
    • Sevo may be best for bronchodilation (least irritating)​
    • AVOID desfluane/isoflurane - airway irritant​
    • albuterol
  5. AVOID histamine realeasers
    • ​Sux, atricurium, mivicurium, D-tubo, morphine, demerol, thopental
  6. Use Short acting NMB-
    1. monitor with TOF so you know you are able to reverse
  7. ​Neostigmine is ok for reversal, but MUST be given with anticholinergic - glycopyrolate


Maintenance in COPD patients:

  1. Cautious with N2O;
    1. Given in high concentration→limits the amount of oxygen delivery 
    2. can cause rupture of bullae from emphysema→ pneumothorax
  2. VAs bronchodilate but also attentuate Hypoxic Pulmonary Vasoconstriction reflex
  3. Increased gradient between PaCO2 and ETCO2
    • ​ this is r/t air-trapping & ↑deadspace ventilation
  4. Opioids - less useful than VA’s for maintenance phase b/c can be associated w/prolonged depression of ventilation & delayed emergence

  5. ​​Humidification


Ventilation goals in COPD patients:

  1. No PEEP
  2. Large TVs (10-15ml/kg
    • Large TV’s = ↓ likelihood of turbulent airflow and help maintain optimal VQ matching

  3. low RR (6-10 bpm)
    • sufficient time for venous return; 
  4. Humidifier in circuit
  5. Consider patient's baseline CO2 and tolerate hypercarbia based on it
    • are they a blue bloater or pink puffer?
  6. Monitor for air trapping
    • monitor for intrinsic PEEP or dynamic hyperinflation r/t air-trapping (expiratory volume never reaches baseline again, so next breath starts out at a higher baseline volume)


Emergence and post-op management in COPD patients:

Postoperative ventalitory status is the Priority issue

  1. May need to stay intubated/ventilated for prolonged period (they are susceptible to acute respiratory failure during post-op pd (d/t atelectasis, hypercapnia, hypoxemia, retention of secretions, bronchospasm​)
    • esp. after abdominal/thoracic surgeries →but the goal is to get them extubated as soon as possible, they wil do better!
    • Education →Post op ventilation is NOT a complication, but rather an expected result
  2. Adjust vent based on blood gasses
  3. Adequate pain control 
    • allows for pain free breathing and improved coughing & to avoid splinting → reduced atelectasis risk 


Causes of reduced lung compliance:

Normal compliance = 100-200ml/cmH​2O

  1. Increased fibrous tissue
    • long-standing COPD, sarcoidosis, bleomycin toxicity

  2. Alveolar edema
    • sepsis, re-expansion pulm edema, negative pressure pulm edema
  3. Low lung volumes
    • atalectasis
  4. Increased pulm venous pressure
    • pulm HTN secondary to chronic Hypoxic Pulmonary Vasoconstriction


Four types of restrictive lung disorders with examples:

  1. Acute intrinsic (pulm edema, ARDS, aspiration pneumonitis)
  2. Chronic intrinsic (pulm fibrosis, sarcoidosis)
  3. Chronic extrinsic (chest wall/ab/neuromusc diseases, obesity, kyphosis)
  4. Disorders of pleura/mediastinum (tumors, pneumothorax, pleural effusions)


Describe re-expansion pulm edema:

Acute Intrinsic restrictive disorder

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

  1. Treament:
    1. O2
    2. PEEP
    3. no diuretics unless volume overload is primary issue


Describe negative pressure pulmonary edema:

Acute Intrinsic restrictive disorder 

Occurs minutes to 2-3 hours after acute upper airway obstruction (in a spontaneously breating patient)

  1. Highly negative intrapleural pressure causes: 
    • decreased interstitial hydrostatic pressure
    • increased venous return
    • increased LV afterload
    • incerased SNS outflow→HTN and displacement of blood volume
    • Acute pulmonary edema
  2. Most often caused by:
    • post-extubation laryngospasm
    • attempting to breath against closed airway- muscle guys
    • Obstructve sleep apnea, hiccups, epiglotitis, tumors
  3. self-limiting to 12-24 hour duration
  4. Treatment:  
    • O2
    • airway monitoring/maintinence (C-Pap if needed)
    • mechanical ventilation + PEEP if needed


Aspiration Pneumonitis s/s and treatment: 

Acute Intrinsic restrictive disorder

Gastric Acid aspirate is rapidly distributed through the lungs it destroys surfactant producing cells and injures lung epithelium

  1. Results in capilary permability/atelectesis
  2. s/s:
    • arterial hypoxemia (decreased sats)
    • Tachypnea
    • Bronchospasm
    • Pulmonary vascular constriction can causel pulmonary HTN
    • X-ray shows changes 6-12 hours later 
  3. Treatment: 
    • Increase FiO2
    • PEEP
    • B2 agonists (albuterol) bronchodilation
    • Bronchoscopy if suspect solid material
    • generally abx and steroid use is not used



  • what is it?
  • how do these patients present?  
  • what are the anesthetic considerations?

Chronic Intrinsic restrictive disorder

Systemic granulomas disorder that leads to pulmonary fibrosis leading to cor pulmonale and pulmonary hypertension

  • Laryngeal sarcoid = Decrease diameter of airway (smaller tube and difficult  airway/intubation)
  • Myocardial sarcoid = heartblocks, dysrhythmias, restrictive cardiomyopathy → cardiac involvement
  • Liver, spleen, unilateral optic and facial nerves palsey
  1. Often present w/ dyspnea, cough & rapid shallow breathing
  2. Cor pulmonale and pulm HTN are likely
  3. Decreased alveolar diffusion capacity
  4. Often haveng a mediasinoscopy →lymph node biopsy
  5. Often times on corticosteroids→STRESS DOSE!
  6. Check electrolytes; check for hyperclacemia r/t metabolism of granulomas


Consiterations with chronic extrinsic lung disease:

  1. Chest wall disorders
    • decreased lung voume corespond with increased airway resistence
  2. Neuromuscular disorders -
    • Inefective cough/clearance of secretions
    • prone to infection/pneumonia  
    • high risk for aspiration d/t ineffective swallowing.
  3. Mediastinal tumors
    • ​​can compress the pumonary artery, myocardium or SVC
    • can occulde airway if given a muscle relaxant


S/s of pneumothorax:

  1. Acute dyspnea
  2. Ipsilateral chest pain
  3. Decreased PaO2
  4. increased PaCO2
  5. Hypotension
  6. Tachycardia
  7. Uneven/decreased chest wall movement
  8. Hyperresonant percussion
  9. Decreased or absent breath sounds


Regional anesthesia in restrictive lung disease:

  1. AVOID > T10 level =  loss of accessory muscles
    • vital esp in spont breathing patients
  2. Good to note they don't tolerate sedation well so regional may be benificial for post op pain control 


Induction in restrictive lung disease:

  1. Pre-meds: Titrate pre-meds carefully to avoid respiratory depression (lose accessory muscle function easily)
    • they need high minute vent to compensate for low volumes
  2. Pre-oxygenation critical d/t reduced FRC & decreased safe apnea time
  3. Will have a shorter apnea time - work efficiently
  4. Use nitrous with caution - risk for barotrauma!!
  5. May need etomidate if CV comorbidities
  6. Use short actinng NMB