Flashcards in Pulmonary Diseases & Axis, Hypertropy, Enlargement Deck (70):
Pulmonary embolism is a blockage of the ________ and is most likely caused by blood clots that travel to the ______ from another part of the body (most commonly the legs). In short, a PE is a complication of a _________.
pulmonary artery lungs DVT
What are the risk factors(3) for PE?
Venous stasis (immobility, reduced flow) Abnormal vessels/wall injury (trauma, phlebitis) Hypercoagulability (polycythemia, sickle cell, smoking, pregnancy)
What are the 9 clinical manifestations of Pulmonary Embolism?
* Acute dyspnea
* Tachypnea (>20 RR)
* Pleuritic chest pain
* Nonproductive cough
* Accentuation of pulmonic valve (S2)
* Tachycardia (>100 bpm)
* Fever (38-39 deg C)
What 4 diagnostic tools/test used to detect a PE?
* Perfusion lung scanning (V/Q scan)
* Venous ultrasonography
* Pulmonary angiography
* Spiral CT scan
Perfusion lung scanning (V/Q scan):
Medical imaging using scintagraphy and medical isotopes to evaluate the circulation of air and blood within a pt. lungs, to determine the ventilation/perfusion ratio.
Sonogram of the lower extremeties to evaluate DVT (normal results don't exclude PE)
Injection of radiocontrast into circulation with fluoroscopy of the lungs.
Spiral CT scan:
CT slices in a helical pattern for increase resolution
What 5 things should be considered for treating PE?
* anticoagulant (heparin, coumadin)
* Inotropes for hypotension (dopamine, dobutamine)
* Airway management (intubate, MV w/ PEEP)
* Pulmonary artery embolectomy w/ CPB (massive PE unresponsive to medical management)
Chronic obstructive pulmonary disease (COPD) encompasses__________ and ___________.
Obstructive bronchitis and emphysema
Chronic bronchitis is:
* Cough due to hypersecretion of mucus not necessarily accompanied with airfflow limitation.
* productive cough >3months in duration for >2 successive yrs.
Emphysema is characterized by:
* loss of elastic recoil in the lungs
* airway collapse occurs during exhalation, leading to increased airway resistance
* severe dyspnea with use of accessory muscles
What 4 diagnostic tools can be used to detect COPD?
* Physical exam: tachypnea, prolonged expiration w/ wheezing
* Pulmonary Function tests
* Chest Radiography
What are the preoperative, intraoperative, and postoperative anesthetic considerations for COPD patients?
Preoperative: cessation of smoking and eradicate bacterial infections Intraoperative: REGIONAL Anesth for procedures on the extremeties or don't invade the peritoneum. GENERAL Anesth for upper abdominal & thoracic proc Postoperative:analgesia and lung vol expansion techniques
List 5 other causes for airflow obstruction:
* Csystic fibrosis (common genetic dz in caucasions)
* Primary ciliary dyskinesia
* Bronchiolitis Obliterans
* Tracheal stenosis
Asthma is characterized by:
Chronic airway inflammation Reversible expiratory airflow obstruction Ariway (bronchial) hyperreactivity
T of F: Asthma is usually reversible.
What are the clinical manifestations of asthma?
Wheezing, cough, dyspnea
How do you treat Asthma?
Antiinflammatory drugs: corticosteroids, cromolyn, leukotriene inhibitors Bronchodilator drugs: B-Adrenergic agonists, anticholinergic drugs
What are the preoperative meds for asthma pts?
Bronchodilators: B-adrenergic agonists, anticholinergic drugs Avoid NSAIDs
What anesthetic considerations should you consider for ASTHMA pts during induction and maintenance?
Regional - when operative site is superficial or on extremeties General - adequate depth before DL (fentanyl, lidocaine, propofol-bronchodilating effects)
How do you treat intraoperative bronchospasm?
Increase depth and administer bronchodilator via ETT
What is Restrictive Lung Disease?
A decrease in total lung capacity usually caused by an intrinsic disease that alters the elastic properties of the lungs, causing the lungs to stiffen.
List 4 causes for acute restrictive lung disease (pulmonary edema):
Acute respiratory distress syndrome (ARDS), aspiration, upper airway obstruction, CHF
List 4 causes for Chronic intrinsic restrictive lung disease:
Sarcoidosis, hypersensitivity pneumonitis, drug-induced pulumonay fibrosis
List common causes for Chronic EXTRINSIC restrictive lung disease:
Obesity/ascites/pregnancy, deformities of skeletal structures/sternum, NM disorders (Guillan-Barre syndrome, Myasthenia gravis)
List 3 common causes of restrictive lung disease due to disorders of the pleura and mediastinum:
Pleural effusion, pneumothorax, mediastinal mass
What are the clinical manifestations of Restrictive lung disease?
Decreased VC Dyspnea Hypercarbia / arterial hypoxemia Weakness of expiratory muscles from NM dz
What diagnostic measurements are indicative of Restrictive Lung Dz?
* FEV1/FVC > 80%
* TLC is 80% or less than expected value
What other procedures can be performed to diagnose Restrictive Lung Dz?
Fiberoptic bronchoscopy, percutaneous needle biopsy, pleuroscopy, mediastinoscopy
How do you treat Restrictive Lung Disease?
Corticosteroid, immunosuppressive agents, and cytotoxic agents are the mainstay of therapy for many of the interstitial lung diseases. Lung transplantation to those who are refractory to medical management.
What are anesthetic considerations for pts with Restrictive Lung Disease?
* Minimize ventilation depression
* Regional for peripheal operations and sensory levels T10 and below
* Post-operative mechanical ventilaion may be needed
Define Acute Respiratory Failure:
Inability of the patient's lung to provide adequate arterial oxygenation with or without acceptable elimination of CO2. Fatigue of the breathing muscles usually a factor.
What is the criteria for Acute Respiratory Failure?
* PaO2 < 60 mmHg (despite supplemental O2 in the absence of R-L intracardiac shunt)
* PaCO2> 50mmHg (in the absence of respiratory compensation)
How is Acute distinguished from Chronic Respiratory Failure?
By pH: 7.35-7.45 (normal) despite increased PaCO2 (I interpret the slide to mean ARF has normal pH range but this doesn't seem right; so do more research to confirm)
I think this is right Marlon because ARF doesn't have time to compensate, thus the pH would be in a normal range.
List treatments for Acute Respiratory Failure (12):
Supplemental O2, Traheal intubation, Mech. Ventilation, PEEP, Optimize IV fluid volume, drug-induced diuresis, inotropic support, removal of secretions, control of infection, nutritional support, glucocoricoids?, and inhaled B-adrenergic agonists?
Define Hypertrophy of the heart:
* Refers to an increase in muscle mass
* The wall of a hypertrophied ventricle is thick and poweful Caused by a pressure overload in which the ventricle pumps against increased resistance (HTN & aortic stenosis)
Define Enlargement of the heart:
* Refers to dilation of a particular chamber Typically caused by volume overload in which the chamber dilates to accomodate an increased amount of blood as a result of valvular insufficiency (AR and MR)
Which EKG wave do we use to assess atrial enlargement?
Which EKG signal can be used to assess ventricular hypertrophy?
List 3 ways an EKG can change when a chamber enlarges or hypertrophies:
* The chamber can take longer to depolarize so the EKG may increase in duration
* The chamber can generate more current and thus a larger voltage so the the wave may increase in amplitude
* A large % of the total electrical current can move through the expanded chamber so the mean electrical vector (axis) may shift
How can you quickly determine if the QRS axis is normal?
If the QRS is positive in leads I and AVF, then the QRS axis is normal.
A normal QRS axis lies between ____ and ____ degrees.
0 and +90 deg
Define the term axis.
Refers to the direction of mean electrical vector, representing the average direction of flow. Defined in the frontal plane only.
Describe the 3 steps to determine the QRS axis.
* Find the lead where the QRS complex is most nearly biphasic.
* The axis must then be oriented approximately perpendicular to that axis.
* A quick estimate can be made by looking at leads I and AVF (normal if both are positive)
Normal QRS axis =
0 to +90 deg (Leads I + and AVF +)
Right Axis Deviation (RAD) =
90 to 180 deg (Leads I- and AVF +)
Left Axis Deviation (LAD) =
0 to -90 deg (Leads I+ and AVF -)
Extreme Rigt Axis Deviation =
-90 to 180 deg (Leads I- and AVF -)
A normal p-wave is ___ sec in duration and the largest deflection (+ or -) should not exceed ___mm
The first half of the p wave represents _______ and the second half represents __________.
right atrial depolarization left atrial depolarization
Atrial enlargement is assessed in which two leads?
Leads II and V1
Define Lead II:
Lead II is oriented parallel to the flow of current through the atria (parallel to the mean p wave vector/largest positive deflection)
Define Lead V1:
Lead V1 is oriented perpendicular to the flow of current (biphasic-easy separation fo the right and left atrial components)
Right Atrial Enlargement is also called ____.
P pulmonale b/c it is often caused by severe lung disease.
Right atrial enlargement (RAE) can quickly be diagnosed by the presence fo tall P waves in which leads?
Leads II, III, and AVF
Left atrial enlargement indicated by what changes in the EKG?
2nd portion of p wave may increase in amplitude
The diagnosis of left atrial enlargement requires that the terminal (LA portion) of the p wave should do what in V1?
drop at least 1 mm below the isoelectric line in V1
There is a more prominent increase in duration in the p wave (because this can be demonstrated in LA which is last to depolarize). True or false?
Left atrial enlargement is also known as:
P mitrale because mitral disease is a common cause of LAE
In RAE, there is no change in p wave duration. True or false?
In RAE, there is a possible right axis deviation of the p wave. True or false?
To diagnose LAE, there are 3 changes to observe. Name them.
1) the amplitude of the terminal component of the p wave may by increased and must descend at least 1 mm below the isoelectric line in V1.
2) duration of p wave is increased
3) no significant axis deviation is seen b/c the LA is normally electrically dominant.
In right ventricular hypertrophy, the most common feature is what?
is right axis deviation (nl axis between 0-90 veers to between 90-180
What will you also notice will change in EKG for right ventricular hypertrophy?
QRS complex in lead I (0 degrees) must be slightly more negative than positive
What will you notice change on EKG in precordial leads for left ventricular hypertrophy?
*R wave amplitude in lead V5 or V6 plus the S wave amplitude in lead V1 or V2
exceeds 35 mm.
What will you notice change on EKG in limb lead for left ventricular hypertrophy?
*The R wave amplitude in lead AVL exceeds 13 mm
The R wave is larger than the S wave in V1, whereas the S wave is larger than the R wave in V6 indicates what heart condition?
right ventricular hypertrophy
The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35 mm
left ventricular hypertrophy