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Fluids, Respiratory, Muscles > Pulmonary Pathophysiology > Flashcards

Pulmonary Pathophysiology Flashcards

1
Q

What is the flow of bulk gases to the alveolar sacs

A

trachea
bronchi
bronchioles
terminal bronchioles
respiratroy bronchioles
alveolar ducts
alveolar sacs

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2
Q

the bulk flow of blood depends on

A

relies on the cardiovascular system
blood delivers oxygen throughout systemic circulation
lung -> peripheral tissues -> lung

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3
Q

What increases the oxygen carrying capacity of blood by 70x

A

Hemoglobin

1 gram Hb can carry 1.34 mL of O2

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4
Q

the percent of hemoglobin that has oxygen bound to it

A

Hemoglobin saturation (%)
measured via pulse ox (SpO2) or Arterial blood gas

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5
Q

What might cause the oxyhemoglobin dissociation curve to shift to the right

A

if it shifts to the right that means there is a decreased hemoglobin affinity for oxygen

1) Increased PCO2
2) Increased H+ (decreased pH)
3) Increased temperature
4) Increased 2,3 DPG

*Harder to load, easier to unload O2

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6
Q

What does it mean when the oxyhemoglobin dissociation curve shifts to the right

A

if it shifts to the right that means there is a decreased hemoglobin affinity for oxygen

1) Increased PCO2
2) Increased H+ (decreased pH)
3) Increased temperature
4) Increased 2,3 DPG

*Harder to load, easier to unload O2

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7
Q

What is the Bohr effect

A

hemoglobin’s lower affinity for oxygen secondary to increases in the partial pressure of carbon dioxide and/or decreased blood pH

if it shifts to the right that means there is a decreased hemoglobin affinity for oxygen

1) Increased PCO2
2) Increased H+ (decreased pH)
3) Increased temperature
4) Increased 2,3 DPG

*Harder to load, easier to unload O2

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8
Q

What 4 factors decrease hemoglobins lower affinity for oxygen

A

1) Increased PCO2
2) Increased H+ (decreased pH)
3) Increased temperature
4) Increased 2,3 DPG

*Harder to load, easier to unload O2

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9
Q

What might cause the oxyhemoglobin dissociation curve to shift to the left

A

Increased Hb affinity for Hb
1) Decreased PCO2
2) Decreased H+ (increased pH)
3) Decreased temperature
4) Decreased 2,3 DPG

*Easier to load, harder to unload O2

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10
Q

What factors increase Hb affinity for Hb

A

1) Decreased PCO2
2) Decreased H+ (increased pH)
3) Decreased temperature
4) Decreased 2,3 DPG

*Easier to load, harder to unload O2

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11
Q

Trace the oxygen molecule to the mitochondria

A

Room air (21%)
Trachea
Primary bronchus
terminal bronchioles
respiratory brionchioles
alveolar sacs
Alveolus (gas exchange- passive diffusion)
Pulmonary capillaries- dissolved in plasma and bound to Hb
Tissues
Cells
Mitochondria

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12
Q

What drives simple diffusion of O2 (from the alveolus to blood and then tissues) and Co2 (From tissues to blood and then alveolus)

A

pressure gradients

Partial pressure = concentration x total pressure

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13
Q

Partial pressure =

A

Concentration x Total pressure

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14
Q

partial pressure of alveolar oxygen

A

PAO2

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15
Q

partial pressure of arterial oxygen (dissolved oxygen)

A

PaO2

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16
Q

Oxygen saturation (oxyhemoglobin)

A

SaO2

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17
Q

low arterial partial pressure of oxygen (PaO2)

A

Hypoxemia

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18
Q

What constitutes hypoxemia vs severe hypoxemia

A

Hypoxemia= PaO2 <80mmHg
Severe Hypoxemia= PaO2 <60mmHg

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19
Q

What is the difference between hypoxemia and hypoxia

A

Hypoxemia = low PaO2
Hypoxia = low tissue oxygen levels

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20
Q

What is the fraction of inspired oxygen

A

FiO2
21% on room air, 100% if under anesthesia

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21
Q

What is the barometric pressure

A

Pb
760mmHg at sea level
640mmHg at Fort Collins

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22
Q

What is the partial pressure of inspired oxygen

A

PiO2 = FiO2 (Pb- PH20)
at room air at sea level
0.21 (760-47) =150mmHg

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23
Q

partial pressure of alveolar CO2

A

PACO2

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24
Q

partial pressure of arterial CO2 (dissolved)

A

PaCO2

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25
Q

Why is PACO2 and PaCO2 about the same

A

because CO2 is really good at dissolving so it is about the same

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26
Q

is PvCO2 or PaCO2 higher

A

the partial pressure of venous CO2 (PvCO2) is about 5mmHg higher than PaCO2

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27
Q

How much higher is PvCO2 from PaCO2

A

about 5mmHg higher than PaCO2

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28
Q

What is hypercarbia

A

high CO2, we see hypoventilation instead

PaCO2>40mmHg

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29
Q

What value tell you that your patient is hypoventilating

A

When there is a PaCO2 > 40mmHg

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30
Q

Whaat value tells you that your patient is hyperventilating

A

When there is a PaCO2 <36mmHg

“Hypocarbia” or low PaCO2

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31
Q

When an animal is panting, are they hyperventilating

A

No. they are only moving the dead space in their longs and they are not hyperventilating

you can also only determine this with a blood gas to look at PaCO2

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32
Q

How do you estimate the alveolar oxygen, the amount of oxygen in the alveolus

A

Must be estimated (PAO2) using the alveolar gas equation

PAO2= FiO2 (Pb-PH20)- (PaCO3/R)

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33
Q

What is the partial pressure of water vapor

A

PH20; Always 47mmHg

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34
Q

What is the respiratory quotient in the alveolar gas equation

A

R = 0.8

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35
Q

You have a patient at sea level with a PaCO2 of 40mmHg, breathing room air. What is the PAO2

A

PAO2= FiO2 (Pb-PH20)- (PaCO2/R)

PAO2= 0.21(760mmHg-47mmHg)- (40/0.8)
PAO2= 150-50
PAO2=100mmHg

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36
Q

You have a patient in Fort Collins with a PaCO@2 of 35mmHg, breathing room air. What is the PAO2

A

PAO2= FiO2 (Pb-PH20)- (PaCO2/R)

PAO2= 0.21(640mmHg-47mmHg)- (35/0.8)
PAO2= 125-44
PAO2=81mmHg

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37
Q

What is a normal A-a gradient

A

<10mmHg

Pa)2 is typically 5-10mmHg less than PAO@

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38
Q

What does it mean if the A-a gradient is >10mmHg

A

there is gas exchange impairment

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39
Q

T/F: A-a gradient can be calculated on a patient receiving oxygen supplementation

A

False- and you cannot perform this with oxygen supplementation

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40
Q

What are the 5 causes of hypoxemia *

A

1) Decreased PiO2 (= FiO2(Pb-PH20))
2) Hypoventilation (Increased PaCO2)
3) Ventilation- perfusion mismatch (V/Q)
4) Diffusion impairment
5) Shunt

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41
Q

What are the 5 causes of hypoxemia *

A

1) Decreased PiO2 (= FiO2(Pb-PH20))
2) Hypoventilation (Increased PaCO2)
3) Ventilation- perfusion mismatch (V/Q)
4) Diffusion impairment
5) Shunt

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42
Q

Which of the following values on an arterial blood gas (sea level, FiO2 21%) is consistent with a patient with severe hypoxemia
a. PaO2= 76mmHg
b. PaCO2= 52mmHg
c. PaO2= 53mmHg
d. PaCO2= 38mmHg

A

c. PaO2= 53mmHg

Severe hypoxemia= PaO2 <60mmHg

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43
Q

Which of the following values on an arterial blood gas (sea level, FiO2 21%) is consistent with a patient that is hypoventilating
a. PaO2= 76mmHg
b. PaCO2= 52mmHg
c. PaO2= 53mmHg
d. PaCO2= 38mmHg

A

b. PaCO2= 52mmHg

Hypoventilation= PaCO2>40 mmHg

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44
Q

You have a dog under surgery with PaCO2: 23mmHg and PaO2: 40mmHg. What is the most likely cause of hypoxemia?

A

PaCO2: nx= 36-40mmHg
PaO2: nx= 90-100mmHg
Decreased FiO2 -> Decreased PiO2 -> hypoxemia

oxygen flow is not on

No oxygen is entering the alveolus so none will diffuse into the blood

increase the oxygen supplementation (Normal A-a gradient so its oxygen responsive)

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45
Q

Frenchie presents in repsiratory distress after playing ball outside.
PaCO2: 65mmHg
PaO2: 70mmHg
What is the likely cause of the hypoxemia

A

PaCO2: nx= 36-40mmHg
PaO2: nx= 90-100mmHg

Hypovenitaltion causing the hypoxemia
Alveolus is full of CO2 and oxygen cannot get in

*Yes this cause is responsive to oxygen (normal A-a gradient) . fixes the hypoxemia but does not fix the cause

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46
Q

What is a good sedative to use in a patient with respiratory distress

A

opioid (ie butorphanol) bc it has limited respiratory effects and then you can intubate

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47
Q

For every 1mmHg increase in PaCO2, PaO2 _______- by ________

A

decreases by 1mmHg

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48
Q

8yo MC golden present for 3 days of vomiting. Placed on oxygen but prior to, this arterial blood gas was achieved
PaCO2: 25mmHg
PaO2: 58mmHg
What is likely cause of hypoxemia

A

PaCO2: nx= 36-40mmHg
PaO2: nx= 90-100mmHg

Aspiration pneumonia: V/Q mismatch
normally the lung matches ventilation and perfusion perfectly
but this has compromised ventilation with adequate perfusion (aspiration pneumonia, pulmonary contusions, pulmonary edema)

might be oxygen responsive? because youre increasing gradient but it depends how severe it is

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49
Q

What is the most common cause of hypoxemia in vet med

A

V/Q mismatch

50
Q

What might lead to a low V/Q mismatch

A

compromised ventilation with adequate perfusion
most common cause is something in alveoli impairing gas exchange
-aspiration pneumonia
-pulmonary contusions

51
Q

How does aspiration pneumonia cause V/2 mismatch

A

if alveolus is filled with pus from the infection
then it can fill with oxygen
Low V/Q mismatch from low ventilation

52
Q

Is hypoxemia due to aspiration pneumonia (V/Q mismatch) responsive to oxygen

A

might be oxygen responsive? because youre increasing gradient but it depends how severe it is

53
Q

With a low V/Q mismatch, is there an elevated A-a gradient

A

Yes. Less is about to perfuse due to the low ventilation
(ie aspiration pneumonia- pus or edema in the lungs)

54
Q

How does high V/Q mismatch cause hypoxemia

A

there is adequate ventilation and compromised perfusion (ie. PTE or hypovolemic)
blood cant get to the lungs
elevated A-a gradient

*oxygen supplementation may be effective but it depends on how much of the lung is affected.
+/- mildly responsive

55
Q

Why might there be a high V/Q mismatch

A

-PTE (most common cause)
-Hypovolemic patient
-Anesthesia- compression

56
Q

With high V/Q mismatch is there an elevated A-a gradient

A

Yes, there is adequate ventilation and compromised perfusion (ie. PTE or hypovolemic)
blood cant get to the lungs
elevated A-a gradient

*oxygen supplementation may be effective but it depends on how much of the lung is affected.
+/- mildly responsive

57
Q

With V/Q mismatch, patients are never responsive to oxygen

A

False- there is variable response to oxygen. depends on how much of the lung or blood flow to the lung is affected
Elevated A-a gradient

58
Q

You have a 8yo FS West Highland White Terrier with chronic cough and acute dypsnea after a hike. Short breathing pattern. What is likely cause

A

Diffusion impairment via pulmonary fibrosis

West highland white terriers randomly get thickening on alveolar membranes (Pulmonary fibrosis)

59
Q

What breed of dog commonly get pulmonary fibrosis (thickening of the alveolar membranes) resulting in hypoxemia from diffusion impairement

A

West Highland White Terriers

60
Q

an infrequent cause of hypoxemia in vet med
usually silent until the animal is exercising
-Decreased alveolar surface area (emphyema in people)
-thickening of alveolar membranes (pulmonary fibrosis in West Highland White terriers)
-Interstitial pulmonary edema

A

Diffusion Impairment

61
Q

How might you get diffusion impairment leading to hypoxemia

A

-Pulmonary fibrosis (West Highland White Terriers)
-Interstitial Pulmonary edema
-emphysema

*Anything where there is thickening of alveolar membranes and oxygen cant diffuse across that thicker membrane

62
Q

Fick’s Law

A

Diffusion is proportional to
1) Solubility of gas
2) Surface area
3) Differences in partial pressure between compartments

Inversely proportional to
1) thickness of membrane
2) molecular weight

63
Q

Fick’s law state that diffusion is proportional to
_______
_______
_______
while inversely proportional to
_______
_______
_______

A

Diffusion is proportional to
1) Solubility of gas
2) Surface area
3) Differences in partial pressure between compartments

Inversely proportional to
1) thickness of membrane
2) molecular weight

64
Q

Are diffusion impairments response to oxygen

A

yes
Diffusion is proportional to
1) Solubility of gas
2) Surface area
3) Differences in partial pressure between compartments

*Increasing oxygen partial pressure

65
Q

Do you see an elevated A-a gradient with diffusion impairment

A

Yes
increase differences in O2 partial pressure -> increases in diffusion and elevated A-a gradient

66
Q

What causes the most severe hypoxemia

A

Shunt reversal
not oxygen responsive

67
Q

Is a reversed shunt responsive the oxygen

A

No

68
Q

Is there an A-a gradient with shunts?

A

Yes, increased

69
Q

Which of the 5 causes of hypoxemia is responsible for hypoxemia associated with aspiration pneumonia

A

V/Q mismatch

70
Q

Which of the 5 causes of hypoxia are responsive to 100% oxygen

A

-Decreased PiO2
-Hypoventilation
-Diffusion Impairment

*Variable: V/Q mismatch

71
Q

Which of the 5 causes of hypoxemia are not responsive to 100% oxygen supplementation

A

Diffusion impairment

Variable: V/Q mismatch

72
Q

Which of the 5 causes of hypoxemia have an elevated A-a gradient

A

Diffusion impairment
Shunt
V/Q mismatch

73
Q

Which of the 5 causes of hypoxemia have a normal A-a gradient

A

-Decreased PiO2
-Hypoventilation

74
Q

Respiratory failure can be due to

A

-Oxygenation failure
-Ventilatory failure
-Fatigue

75
Q

What is the gold standard for assessing oxygenation

A

Measuring PaO2

Advantages: reliable/precise, als oget acid-base information

Disadvantages: must get arterial sample, not continuous, maintenance, expensive machine

76
Q

PaO2 is roughly ___________ FiO2

A

4-5x FiO2

21% x 5= 105mmHg
100% x 5= 500mmHg

77
Q

Why might you not see cyanosis

A

You need to have >5g/dL deoxygenated hemoglobin
if anemic (ex: Hb=5 g/dL ) then youll never see cyanosis
if Hb= 15g/dL -> PaO2= 37mmHg and already very low

disadvantages is the cyanosis is unreliable, late indicator and subjective

78
Q

Should you use cyanosis to diagnose hypoxemia in your patient

A

NO- it is unreliable, very late indicator, and subjective

depends on >5g/dL deoxygenated hemoglobin to be present
so if anemic, you might never see it
or even if Hb- 15g/dL, you still wont see it until 37mmHg PaO2 which is severely low

79
Q

indirect measurement of oxygen content in blood
relies on detecting the difference in absorption of particular wavelengths of light by oxygenation and reduced hemoglobin

A

pulse oximetry

80
Q

Oxygenated Hb absorbed _____________ (940nm) while deoxygenated /reduced Hb absorbs _____________ (660nm)

A

Infrared light (940nm)
red light (660nm)

81
Q

What are the disadvantages of pulse ox for SpO2 measurement

A

relies on pulse of arterial system to discriminate between arterial blood saturation and venous

cannot distinguish dysfunctional hemoglobin

only reads up to 100% which may not be helpful when patient is on 100% FiO2 but might not reflect PaO2 under general anesthesia (misleading)

Adversely affected by: bright overhead lighting, vasoconstriction, dark pigmenet, hypothermia, hypoperfusion

82
Q

What factors adversely affect SpO2 reading via pulse ox

A

bright overhead lighting
vasoconstriction
dark pigment
hypothermia
hypoperfusion
dysfunctional hemoglobin

83
Q

T/F: SpO2 reading via pulse ox is affected by icterus

A

false

84
Q

What SpO2 readings tell you normal, hypoxemic, and severely hypoxemic

A

Normal >95%
Hypoxemia <95%
Severe hypoxemia <90%

85
Q

Why is SpO2 reading under general anesthesia not helpful

A

Because when you are supplying 100% oxygen (100% FiO2) you cannot distinguish a PaO2 of 100mmHg vs 400mmHg

86
Q

Helps you differentiate different types of hemoglobin using 4-8 wavelengths of light

A

Co-oximetry
measures:
1) oxygenated hemoglobin
2) Deoxygenated hemoglobin
3) Carboxyhemoglobin
4) Methemoglobin
5) Oxygen content

87
Q

What does co-oximetry tell you

A

differentiate different types of hemoglobin using 4-8 wavelengths of light
1) oxygenated hemoglobin
2) Deoxygenated hemoglobin
3) Carboxyhemoglobin
4) Methemoglobin
5) Oxygen content

*expensive

88
Q

What has a 200x greater affinity for Hb than O2 and can falsely elevate SpO2 to 100%

A

Carbon monoxide forming Carboxyhemoglobin
*Housefires

89
Q

Why might patients in a house fire have a falsely elevated SpO2 reading (100%)

A

Carbon monoxide has a greater than 200x greater affinity for Hb than O2 and can form Carboxyhemoglobin

90
Q

Carboxyhemoglobin

A

Carbon monoxide has a greater than 200x greater affinity for Hb than O2 and can form Carboxyhemoglobin
falsely high SpO2- usually 100%

91
Q

What is methemoglobinemia

A

seen in acetaminophen (chocolate colored mucous memebranes and SpO2 of 85%) Fe3+ is oxidized
also in topical benzocaine products
Pheazopyridine products
Phenazopyridine ingestion (urinary tract analgesic)
Nitrites
Nitrates
Skunk musk
Hydroxycarbamide
Methb reductase deficiency

92
Q

Why might you have brown/chocolate looking mucous membranes

A

acetaminophen toxicity
also in topical benzocaine products
Pheazopyridine products
Phenazopyridine ingestion (urinary tract analgesic)
Nitrites
Nitrates
Skunk musk
Hydroxycarbamide
Methb reductase deficiency

93
Q

What will the pulse ox read in an animal with memthemoglobinemia

A

always 85%

94
Q

You have a patient with chocolate colored gum and an SpO2 of 85%. What do you think?

A

Methemoglobinemia
causes:
acetaminophen toxicity
topical benzocaine products
Pheazopyridine products
Phenazopyridine ingestion (urinary tract analgesic)
Nitrites
Nitrates
Skunk musk
Hydroxycarbamide
Methb reductase deficiency

95
Q

You cant calculate the A-a gradient when on 100% oxygen. What can you do instead

A

P/F ratio= PaO2/FiO2

normal >400mmHg
acute lung injury (ALI)= 200-300mmHg
acute repsiratory distress syndrome (ARDS)= <200mmHg

96
Q

What is the P/F ratio

A

P/F ratio= PaO2/FiO2
can be used when animal is on supplemental oxygen

normal >400mmHg
acute lung injury (ALI)= 200-300mmHg
acute respiratory distress syndrome (ARDS)= <200mmHg

97
Q

What is the P/F ratio of animals with acute lung injury

A

200-300 mmHg

98
Q

What is the P/F ratio of animals with acute respiratory distress syndrome (ARDS)

A

<200mmHg

99
Q

The P/F ratio is _______ / _______

A

PaO2 / FiO2

100
Q

What are methods to monitor ventilation

A

1) PaCO2
2) PvCO2
3) ETCO2
4) Capnography

101
Q

PvCO2 is usually ________ ________ than PaCO2

A

5mmHg higher than PaCO2

PvCO2 is a reflection of arterial CO2 inflow, local tissue CO2 production, and tissue blood flow

102
Q

ETCO2 is normally ________ ________ than PaCO2 and it varies due to _____________

A

ETCO2 is normally 5mmHg lower than PaCO2 and it is increased in the presence of dead space

103
Q

What are the uses of capnography

A

1) Confirm endotracheal intubation
2) Assess ventilation
3) Estimate alveolar dead space ventilation
4) Monitor efficacy of CPCR

104
Q

What are the different phases of capnography

A

0: inspiration, no CO2 measured (low)
I: early expiration, emptying of anatomic dead space, no CO2 is measured
II: expiraton, alveolar and dead-space gas, steep increase in CO2
III: alveolar plateau, alveolar CO2 measured
IV: ETCO2

105
Q

What is the peak of a capnograph

A

the end-tidal CO2 (phase IV)

106
Q

what is the plateau on a capnograph

A

the alveolar CO2 is being measured (phase III)

107
Q

What is the upslope of the capnograph

A

expiration of alveolar and dead-space gas (phase II) leading to a steep increase in CO2

108
Q

What is the flat low parts of capnograph

A

phase o: inspiration, no CO2 measured

109
Q

What are the different techniques to deliver oxygen to a patient?

A

1) Flow by oxygen
2) Face mask
3) Nasal oxygen
4) Oxygen cage
5) High flow nasal oxygen
6) Intubation and ventilation

110
Q

How much oxygen is supplied by flow-by, facemask, O2 cage, and nasal

A

Flow by: 2-3L/min (25-40%)
Facemask: 8-12L/min (50-60%)
O2 cage (21-60%)
Nasal: 50-150mL/kg/min (30-70%)

111
Q

What are the pros and cons of flow by and face mask

A

Pros: fast, easy, able to handle patient

Cons: not long term, waste, not able to provide high FiO2 (only 25-40% or 50-60%, respectively)

112
Q

What are the pros and cons of nasal prongs for O2 delivery

A

Pros: long-term, higher FiO2 (30-70%), easy to place, generally well tolerated

Cons: discomfort, may fall out, must be humidified

113
Q

What are the pros and cons of O2 cage

A

Pros: long term, higher FiO2 (21%-60%), vented to prevent CO2 buildup

Cons: Expensive, hyperthermia, cannot handle patients, cannot hear patient

114
Q

What are the pros and cons of high flow nasal oxygen

A

Pros: can deliver up to 100% oxygen at high flow rate, air is humidified, and warmed

Cons: not made for out patient’s face, expense

115
Q

What are the pros and cons of intubation and mechanical ventilation

A

Pros: Allows for FiO2 100%, can control ventilation, can provide positive and expiratory pressure
maximal support that you can provide

Cons: expensive, technically challenging, 24 hour

116
Q

What are the 4 indications for mechanical ventilation *

A

1) Severe hypoxemia despite therapy (PaO2 <60mmHg)
2) Severe hypoventilation despite therapy (PaCO2 >60mmHg) “rule of 60s at sealevel, 50s at altitude”
3) Increased work of breathing- maintaining normoxemia/ normocapnea at the expense of increased respiratory rate and effort
4) Severe hemodynamic instability

117
Q

Increased work of breathing puts a patient at risk for ______________ and may be identified by ____________

A

puts patient at risk for fatigue

may be identified by
-Increasing PaCO2
-Decreasing chest wall excursions
-Physical appearance

*Treat with sedation and mechanical ventilation

118
Q

a 10yo FS Lab in Fort Collins has a 2-3 day history of vomiting with a 1 day history of respiratory distress, coughing, and fever
pH: 7.480
PaCO2= 24mmHg
PaO2= PaO2
HCO3-= 22mmol/L

What is the patient in. and what is cause

A

Primary respiratory alkalosis without metabolic compensation
hypoxemia

PAO2= FIO2 (Pb-PH20) - PaCO2/0.8
=0.21(640-47)-24/0.8
=44mmHg (elevated)

Can be due to V/Q mismatch, Diffusion impairment or shunt

response to oxygen will tell you underlying cause of disease and it will also decrease work of breathing for the dog
can also fo P/F ratio to tell the repsonse

119
Q

You have a dog on 40% oxygen and take arterial blood.
PaO2= 120mmHg
PaCO2= 30mmHg
What is the P/F ratio

A

P/F= 120/0.4= 300 mmHg

since they are on 40% oxygen- the PaO2 should be 160-200mmHg but its not (4-5x the % oxygen)

Normal >400 mmHg
ALI 200-300mmHg
ARDS <200mmHg

120
Q

If you have a dog on 40% oxygen what should the estimated PaO2 be

A

about 4-5x the % oxygen
example: 160-200mmHg PaO2

121
Q
A

Fluids, Respiratory, Muscles (7 decks)

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