Pulmonary Pathophysiology Flashcards
(131 cards)
1
Q
Primary purpose is NOT _________ but supplying necessary O2 to the tissues and excreting ____
A
arterial saturation of 100%
CO2
2
Q
“the respiratory system delivers gas and the circulatory system delivers liquid. However, both systems deliver the same molecules, namely ____ and ____ from the body”
A
oxygen
carbon dioxide
3
Q
Obstructive Disease Characteristics
A
- more common than restrictive dz
- airway resistance increased
- air trapping & obstruction impedes airflow out - extended expiration times
- lung volumes increase (RV and TLC)
- turbulent airflow leads to expiratory wheezing
- impaired gas exchange (VQ imbalance)
4
Q
Restrictive disease characteristics: decreased _____ ______, reduced _____ _____, and ______ resistance is not increased
A
- decreased lung compliance - lung expansion restricted impedes airflow in
- lung volumes reduced
- air resistance is not increased
5
Q
post op morbidity/mortality is _______ with restrictive and obstructive pulm disease
A
increased
6
Q
increased airway resistance leading to obstructed air flow is caused by 3 mechanisms:
A
- excessive secretions in bronchial lumen
- airway thickening, edema, hypertrophy of mucous glands, bronchitis, asthma
- destruction of lung parenchyma which leads to loss of airway radial traction
7
Q
Chronic airway inflammation with acute exacerbations
A
asthma
8
Q
bronchial airways are hyper reactive to stimuli with asthma causing ____________________
A
airway narrowing at all levels and varying severity of narrowing
9
Q
with asthma, ______ becomes obstructed therefore categorizing it as an _____________
A
expiratory airflow
obstructive disease
10
Q
asthma is reversible with
A
bronchodilators
11
Q
asthma category - extrinsic
A
allergic category
- family history of allergic/immunologic dz
- allergic related (allergen identified)
- immune system activation
- elevated IgE levels
- elevated serum eosinophils
12
Q
asthma category - intrinsic
A
non allergic
- idiosyncratic (specific to individual)
- exacerbations with triggers
- non-immune related, no allergen identified
- normal IgE levels
13
Q
Asthma periodic acute exacerbations
A
- mild to severe attacks
- bronchospasm
- mucosal edema/secretions
14
Q
asthma patients live with ______________ lasting for weeks
A
mild airway obstruction
15
Q
with asthma, increased airway resistance to gas flow leads to a common symptom:
A
wheezing
16
Q
asthma patients have
A
productive cough, dyspnea
17
Q
with asthma, hypertrophied airway smooth muscle contracts during an attack causing _________
A
bronchoconstriction
18
Q
asthma mucous gland hypertrophy leads to:
A
- increased secretions, usually white and scant (bc of absence of infection)
- thick, slow moving
- mucous plugs leading to obstruction
19
Q
asthma pathology
A
- hypertrophied airway smooth muscles
- mucous gland hypertrophy
- bronchial wall edema
- infiltration of eosinophils and lymphocytes
- remodeling/scar tissue leading to subepithelial fibrosis
20
Q
etiology of asthma
A
- allergy induced (atopy is greatest risk factor)
- respiratory viruses
- occupational/environmental irritants
- drugs - aspirin, beta2 blockers, NSAIDS, and drugs that release histamine
- exertional exercise (turbulent air causing tracheal inflammation)
- stress: emotional and psychological
21
Q
asthma inflammatory mediators
A
- cytokines associated with Th-2, helper T cells, IL-4, IL-5, IL-9, IL-13
- arachidonic acid metabolites - leukotrienes, prostaglandins
- platelet-activating factor (PAF)
- neuropeptides
- reactive oxygen species
- kinins
- histamine
- adenosine
- serotonin
- chemotactic factors
22
Q
allergen binds to _____ on _____ causing degranulation
A
IgE
mast cell
23
Q
following degranulation, there is a release of __________
A
inflammatory mediators
24
Q
bronchoconstriction happens via __________ cAMP, __________ cGMP, ___________ PNS activity, and ________ cholinergic sensitivity
A
decreased cAMP
increased cGMP
increased PNS
increased cholinergic sensitivity
25
balance between _____ and ______ regulates ________ ____
PNS
SNS
bronchial tone
26
_____ stimulation via vagal activation causes activation of the muscarinic receptors in bronchial smooth muscle
PNS
27
__________ receptors cause an increase in intracellular levels of cGMP
muscarinic
28
Increased intracellular _____ increases protein kinases that cause bronchoconstriction
cGMP
29
someone with significant wheezing pre-op will get an inhaler with _________ agonist which increases ______ causing _______
beta2
cAMP
bronchodilation
30
Mast cell degranulation releases mediators: ________, __________, ___________, and __________, which cause increased capillary permeability and other inflammatory changes
histamine
leukotrienes
chemotactic factors
bradykinin
31
bronchodilation is promoted by ___________
cAMP
32
intracellular levels of cAMP can be increased by beta adrenoceptor agonists which increase the rate of its synthesis by _____ or by _________ which slow the rate of its degredation
adenylyl cyclase
phosphodiesterase inhibitors (such as theophylline)
33
bronchoconstriction can be inhibited by ___________ antagonists and possibly by ___________ antagonists
muscarinic
adenosine
34
goal of asthma treatment is to prevent ________ ________ and maintain patent airways
bronchial inflammation
35
2 types of drugs for asthma treatment
long term control of airway narrowing
rescue acute bronchospasm attacks
36
anti-inflammation drugs for asthma (3)
glucocorticoids
leukotriene blockers
mast cell-stabilizing agents
37
bronchodilation drugs for asthma (3)
beta 2 agonists
methylxanthines
anticholinergics (antimuscarinics)
38
Glucocorticoids are administered _____, decrease bronchial hypersensitivity and inflammatory response, ________- stabilizing, most effective ___________ drugs, and are effective as __________ _______ drugs
IV/inhaler
membrane-stabilizing
anti-inflammatory
prophylactic pre-op
39
glucocorticoid drugs:
IV hydrocortisone, methylprednisone
fluticasone (flovent), salmeterol (advair)
budesonide (pulmicort)
triamicinolone (azmacort)
beclomethasone (beclovent)
40
leukotriene blockers
leukotrienes mediate __________ in asthma. These drugs inhibit the __________ _________ pathway, and reduce the synthesis of ____________. Only 50% of patients have beneficial response and these ARE effective for ________ induced asthma
inflammation
5-lypoxygenase enzymatic pathway (5-LO inhibitors)
leukotrienes
aspirin induced asthma
41
leukotriene blocker drugs:
monotelukast (singulair)
zafirlukast (accolate)
pranlukast (zyflo)
zileuton (ultair)
42
Mast cell stabilizer drug
cromolyn
43
cromolyn - effective only with _________ asthma, blocks airway ___________, inhibits mediator release from ______ ______, and stabilizes ___________.
extrinsic (allergic)
inflammation
mast cells
membranes (inhibits mast cell degranulation)
44
beta adrenergic agonists are the most ______ __________
potent bronchodilators
45
stimulation of beta2 receptors in the lungs cause increased _____ _______, which causes increased intracellular _______, leading to decreased ________
adenylyl cyclase
cAMP
Ca++
46
beta adrenergic agonist drugs: (3) and side effects: (3)
Drugs: albuterol (ventolin), metaproterenol (alupent), terbutaline (brethaire)
Side effects: hypokalemia, tachycardia, vasodilation
47
beta2 agonist activates _________ which activates __________ which activates _________ and __________
adenylate cyclase
cAMP (by ATP)
phosphodiesterase and bronchodilation
48
methylxanthines moa:
inhibits __________________ which
inhibits __________________
catecholamine ____________
__________ blocking actions
phosphodiesterase enzyme (which degrades cAMP) resulting in increased cAMP
inhibits prostaglandins
catecholamine release
histamine blocking actions
49
methylxanthines are for ______ _______ and __________, NOT for _________ bronchospasm attacks
chronic control and management
acute bronchospasm attacks
50
methylxanthine drugs and side effects
theophylline (elixophyllin, theo-24, uniphyl)
seizures, v-ectopy, agitation, N/V
51
anticholinergics/antimuscarinics decrease ______ ______, inhibit production of _______, results in _____________, and inhibits ______________ ____________
vagal tone
cGMP
bronchodilation
tracheobronchial secretions
52
anticholinergic/antimuscarinic drugs: (3)
ipratropium (atrovent)
atropine
glyco (robinul)
53
status asthmaticus is considered ______-_________, can last for _________, attacks are unresponsive to _________
life-threatening
hours to days
bronchodilator Rx
54
status asthmaticus results in ____________, _____________, and _____________. treatment regimen is repeated __________, ___________.
exhaustion (need to intubate), dehydration, tachycardia.
glucocorticoids, beta2 agonist
55
Step 1 asthma and medications
mild, intermittent
- anti-inflammatory: no daily meds needed
- short acting bronchodilator: inhaled B2-agonist as needed for symptoms
56
Step 2 asthma and meds
mild, persistent asthma
- anti-inflammatory: inhaled steroid (low dose) or cromolyn or nedrocromil
- short-acting bronchodilator: inhaled B2-agonist as needed for symptoms
57
Step 3 asthma and meds
moderate, persistent asthma
- anti-inflammatory: inhaled steroid (medium dose) or inhaled steroid (low to medium dose) and inhaled long acting B2-agonist
- short-acting bronchodilator: inhaled B2 agonist as needed for symptoms
58
Step 4 asthma and meds
severe, persistent asthma
- anti-inflammatory: inhaled steroid (high dose) and long-acting inhaled B2-agonist, possibly systemic steroids
- short-acting bronchodilator: inhaled B2-agonist as needed for symptoms
59
Categorizing obstructive disease
(ABCCE)
asthma
bronchospasm
chronic bronchitis
COPD/emphysema
(all obstructive disease has trouble getting air OUT)
60
bronchospasms are more common in chronic bronchitis and asthmatics with _______ __________ and patients with __________ ________
reactive airways
smoking histories
61
adult bronchospasm triggers
mechanical or noxious chemical irritants
62
pediatric bronchospasm triggers
environmental allergens
recent viral illness
URI
63
bronchospasms can be caused by histamine releasing drugs such as _______ and _______
MSO4
atricurium
64
_________ and ___________ reactions can trigger bronchospasms
anaphylactoid
transfusion
65
bronchospasms are mediated by the _________
PNS
66
causes of acute bronchospasms in anesthetized patients:
- nonspecific bronchial hyperresponsiveness
- allergic or anaphylactic reaction to drugs or blood transfusion
- allergic or anaphylactic reaction to other allergens (latex)
- exacerbation of asthma
- pharm factors: b-blockers, prostaglandin inhibitors (remember AA pathway), anticholinersterases
- stimulation of parasympathetic fibers and M2 and M3 muscarinic receptors
- tracheal irritation from intubation
67
with bronchospasms, avoid ______ ___________, use ______ or _________
airway instrumentation (ETT)
LMA
regional
*tracheal intubation is the most common cause of bronchospasm*
68
with bronchspasms, avoid __________-__________ drugs, ________, and _____ _________.
histamine releasing
NSAIDs
beta2 blockers
(would still give vanco but would pre-treat)
69
Bronchospasm treatment - most important to _____ _______
deepen anesthetic
70
_______ is better than ___________ for bronchospasms and __________ has bronchodilator effects and increases catecholamines
propofol
thiopental/etomidate
ketamine
71
IV ______ and ______ blunt airway reflexes
opioids and lidocaine
72
increase _______ concentration
FiO2 (inspired oxygen)
73
use periop bronchodilators such as __________
albuterol
74
use antimuscarinics such as ______ or _______
robinul or atropine
75
(for bronchospasms) use corticosteroids such as
solumedrol 125 mg IV
76
(for bronchospasms) use epi dose
0.1-1 mg IV
77
COPD management - remove ________, give __________, __________, supplemental _________, and possible diuretics if ___ _________ has developed
remove cause (smoking, polllutants - may be reversible with this)
bronchodilators
steroids
supplemental oxygen
cor pulmonale
78
COPD management - Trelegoy Ellipta 3 different drugs:
inhaled long acting beta2 agonists (LABA)
inhaled long acting muscarinic antagonist (LAMA)
inhaled long acting corticosteroids
79
chronic bronchitis is characterized by excessive mucous production in bronchial tree, _________ of mucous glands in large bronchi, increase in bronchial ______ _______, ___________ and environmental pollutants
hypertrophy
smooth muscle
smoking
80
with chronic bronchitis, outward airflow ___________ results
obstruction
81
chronic bronchitis: chronic hypoxemia leads to erythocytosis and _________ _________, which leads to ____ _____ _______, giving the appearance of a "_____ __________"
chronic
pulmonary HTN
right heart failure
blue bloater
82
emphysema is characterized by enlarged ____ _____ distal to the terminal bronchiole caused by destruction of the _________ ________, which causes destruction and subsequent loss of _________ walls, and destruction of surrounding ________ _______.
air space
alveoli septa
alveolar
capillary bed
83
centriacinar emphysema - destruction of _________ ________ __ _________
central part of lobule
84
panacinar emphysema - destruction of _________ ________
entire lobule
85
bullous emphysema - _______ areas or bullae form
cystic
86
with emphysema, breathing through _______ _____ delays the closure of small airways
pursed lips
87
emphysema - _______ ________ is primary pathologic factor
cigarette smoking
88
emphysema - ___ ___________ deficiency (inhibits elastase) leads to increased elastase, smoking causes a decrease in elastase inhibitors leading to ______ _________.
a1 antitrypsin
increased elastase
*both a1 antitrypsin deficiency and smoking cause increased elastase*
89
elastase destroys _________ inside the lung
elastin
90
elastin is essential as it supports what?
elastic structure of the lungs responsible for elastic recoil
91
elastic recoil supports smaller airways by providing _____ _______
radial traction (this leads to weak, floppy walls)
92
Note that in centriacinar emphysema, the destruction is confined to the ________ and ___________ bronchioles. In panacinar emphysema, the ___________ alveoli are also involved
terminal
respiratory
peripheral
93
___________ pts will have a harder time uptaking our anesthetic/volatile gases bc they have decreased diffusion capacities
pulmonary emphysema
94
restrictive lung disease characteristics - reduced lung ___________ and ___________
reduced lung compliance and volumes result
95
restrictive lung disease - airway resistance is _________________
not increased
- exp flow rates are normal
- reduced FEV1 (bc low lung volumes)
- reduced FVC
- normal FEV1/FVC ratio
96
restrictive lung disease. usually has __________ gas exchange, but breathing is ______ and ________.
normal
rapid and shallow (but it gets it done!)
97
acute intrinsic lung disease
(pulm edema)
- drug/chemical pneumonitis
- aspiration pneumonitis
- pneumonia
- ARDS
- neurogenic pulm edema
- NPPE
- CHF
98
chronic intrinsic disease
- fibrosis (radiation, occupational toxin)
- oxygen toxicity
- sarcoidosis
- scleroderma
99
extrinsic lung disease
- neuromuscular dz
- muscular dystrophy
- spinal cord transection
- Guillain-Barre syndrome
- Eaton-lambert syndrome
- Myasthenia gravis
- morbid obesity, ascites, pregnancy
- pleural effusion
- pleural thickening
- mediastinal mass
- pneumothorax
- neuroskeletal diseases
- scoliosis, kyphosis
100
acute intrinsic restrictive dz is primarily bc of an increase in _________ _______ ________ r/t increased pulm capillary ______ and _______ which results in reduced lung compliance.
intravascular lung water
pressure and permeability
101
acute intrinsic restrictive dz multiple causes: (3 listed)
- cardiogenic pulm edema (increased hydrostatic pressure)
- pulmonary aspiration
- infection
102
In managing edema, delay ______ _______, reduce ________ _______ _______, use ________ _________ ventilation with _________, and adjust __________ to maintain adequate oxygenation
elective surgery
interstitial lung water
positive pressure ventilation with PEEP
FiO2
103
Reduce interstitial lung water with:
- diuretic treatments, limit fluids
- inotropes and vasodilators
104
Use positive pressure ventilation with PEEP and:
lower Vt to ______ with higher _________
reduce ___________ and _____________
keep PiPs less than __________________
- lower Vt (4-6ml/kg) and higher RR (>14)
- reduce volutrauma, barotrauma
- keep PiPs less than 30 cm H2O
105
chronic intrinsic lung dz is also referred to as:
interstitial lung dz
106
changes in intrinsic lung properties (parenchyma) include reduced _______ and _________
compliance and FRC
107
Multiple cause contributing to formation of interstitial lung dz: Chronic inflammation of ________ _______ and _________ ________, most commonly due to pulmonary __________, which all ultimately results in gas exchange abnormalities = altered ______.
alveolar walls
perialveolar tissue
pulmonary fibrosis (fibrotic elastic tissue)
altered VQ
108
Sarcoidosis is a systematic _____________ disorder
granulomatous
granulomatous tissue is present in several other organ systems - skin, eyes, liver, spleen and is prone to develop in intrathoracic lymph nodes and the lungs
109
with sarcoidosis, fibrotic changes in the lungs occur in _______ ______
alveolar walls
110
____________ sarcoid is common
endobronchial
111
Primary feature of diffuse interstitial pulm fibrosis is:
thickening of interstitum of alveolar wall
112
in diffuse interstitial pulm fibrosis, thickening of the interstitium of alveolar wall is followed by infiltration of _________ and _____ ______, followed by __________ which form thick ________ _________ which ultimately destroys the structure of the alveoli.
lymphocytes and plasma cells
fibroblasts
collagen bundles
113
final scarring occurs and air-filled cystic spaces form referred to as:
honeycomb lung
114
diffuse interstitial pulm fibrosis results in reduced _________ and impaired ____________
compliance
gas exchange
115
management of chronic intrinsic dz:
- decreased _______ causing inability tolerate long periods of apnea
- inhaled anesthetic uptake is ___________
- pneumothorax risks are ____________ (PiPs should be ______)
- more prone to _______ _________
- decreased FRC causing inability tolerate long periods of apnea
- inhaled anesthetic uptake is faster
- pneumothorax risks are increased (PiPs should be <30 cm H2O)
- more prone to oxygen toxicity (oxygenate with lower FiO2 if possible, and consider regional anesthetic if not contraindicated)
116
chronic extrinsic restrictive dz is a disorder of ____________ or _____________
thoracic cage or chest wall (may be mechanical or tumor)
117
chronic extrinsic restrictive dz: lung expansion is ____________, lungs are __________, and volume is _________.
restricted
compressed
reduced
118
increased __________ airway resistance from decrease lung volumes
inspiratory airway resistance
(near end expiration)
119
recurrent __________ ____________ result from ineffective cough dynamics
pulmonary infections
120
_______ _____________ due to low ventilated regions
V/Q mismatches
121
chronic extrinsic dz management:
- avoid drugs with ______ ________ _______ effects
- be cautious with _______
- consider _______ __________
- reduced lung compliance may prompt:
- higher _________ _________ may need to be considered
chronic extrinsic dz management:
- avoid drugs with prolonged respiratory depressant effects
- be cautious with N2O
- consider regional anesthesia
- reduced lung compliance may prompt: need for higher PiPs to maintain oxygenation/ventilation
- higher respiratory rates may need to be considered to maintain oxygenation/ventilation
122
intra-op PE is ______. Embolic material occludes ________ _________ _________.
rare
pulmonary vascular bed
123
Peri-op PE mortality
10%
PEs happen in 1% of surgical patients and 30% of ortho pts (long bones)
124
PEs primarily originate from blood clots in the ______________ and _______________
lower extremities and pelvic veins
>90% of DVTs are from iliofemoral vessels
125
Three primary factors known as Virchow's Triad are:
Virchow's Triad
1. venous stasis
2. hypercoagulability
3. vascular (venous) injury
126
PE clinical signs (5)
- reduced ETCO2 and capnograph wave
- unexplained hypoxemia
- sudden CV collapse
- tachycardia, RBBB
- bronchospams (lots of wheezing)
127
PE intaop goal:
optimize cardiac output and O2 delivery
- increase FiO2 to 100%
- PEEP
- support circulatory system
- Phosphodiesterase inhibitors
- ultimate removal or dissolution of embolic fragments
128
PE - support circ system by (3 things)
- sympathomimetics and inotropes
- IV fluid boluses
- treat ventricular dysrhythmias
129
PE - phosphodiesterase inhibitors increase:
increase contractility and are pulmonary artery dilators
130
shunt
perfusion without ventilation
- atelectasis - collapsed alveoli where gas exchange ventilation is no longer occurring
131
dead space
ventilation without perfusion
- alveoli are adequately ventilated but perfusion is less than adequate
