Pulmonary Reduced

Question 1

Characteristics COPD and asthma:

Answer 1

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

Question 2

Causes of asthma exacerbations:

Answer 2

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

Question 3

S/s of asthma:

Answer 3

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

Question 4

Pre-op assessment of asthma:

Answer 4

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

Question 5

Pre-op labs for asthma:

Answer 5

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

Question 6

Pre-op meds for asthmatics:

Answer 6

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

Question 7

Overall goal for induction of anesthesia in asthmatics

Answer 7

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
        
        • _{<span>avoid Sodium metabisulfite prep </span>}
        • _{<span>Higher end of induction doses</span>}
      • 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

Question 8

Maintenance of anesthesthesia in asthmatics:

Answer 8

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

Question 9

Ventilation goals for asthmatics:

Answer 9

Ventilation

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

Question 10

Treatment of intra-op bronchospasm:

Answer 10

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

Question 11

Emergence/post-op care for asthma:

Answer 11

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

Question 12

COPD pathology

Answer 12

• Progressive airway obstruction
  
  • not reversible or incompletely reversable
• Cell death and destruction of alveoli d/t
  
  • impaired lung parenchyma, degraded matrix, toxic action of macrophages nad neutrophils (inflammatory respnse)
• Resultant enlargement of airspaces, fibrosis and mucous production
• Inflammatory process →
  
  • steroids have limited effect(reduce frequency of exacerbations
  • bronchodilators have only modest effects
• Chronic bronchitis and/or emphysema
• Smoking #1 risk factor

Question 13

COPD staging:

Answer 13

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

Question 14

“Blue bloaters”:

Answer 14

1. Chronic bronchitis
2. PaO₂ <60 →cyanosis and dusky appearance
3. PaCO₂ > 45
4. Copious secretions cause obstruction
5. Cough
6. Diminshed breath sounds
7. Pulmonary hypertension d/t HPV
8. Marked cor pulmonale/righ sided heart failure
9. Overweight
10. CXR: increased bronchovascular markings

Question 15

“Pink puffers”:

Answer 15

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

Question 16

Smoking cessation timeline:

Answer 16

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)

Question 17

Induction in COPD patients:

Answer 17

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

Question 18

Maintenance in COPD patients:

Answer 18

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

Question 19

Ventilation goals in COPD patients:

Answer 19

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)}

Question 20

Emergence and post-op management in COPD patients:

Answer 20

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 <strong>soon as possible</strong>, they wil do better!}
   • _{<strong>Education</strong> →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}

Question 21

Causes of reduced lung compliance:

Answer 21

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

Question 22

Four types of restrictive lung disorders with examples:

Answer 22

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)

Question 23

Describe re-expansion pulm edema:

Answer 23

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

Question 24

Describe negative pressure pulmonary edema:

Answer 24

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

Question 25

Aspiration Pneumonitis s/s and treatment:

Answer 25

**_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

Question 26

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

Answer 26

**_Chronic Intrinsic restrictive disorder_** ## Footnote 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

Question 27

Consiterations with chronic extrinsic lung disease:

Answer 27

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

Question 28

S/s of pneumothorax:

Answer 28

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

Question 29

Regional anesthesia in restrictive lung disease:

Answer 29

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

Question 30

**Induction** in restrictive lung disease:

Answer 30

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

Question 31

**Maintenance** in restrictive lung disease:

Answer 31

1. AVOID **nirtrous** due to risk of barotrauma!! 2. Volitile agents have **accelerted** **uptake** * decreased FRC and increased RR 3. **Mechanical ventilation:** 1. USE: **ETT** (LMA not a good choice→loss of accessory mucsle and inability to maintain oxygenation) 2. Decreased Tidal Volume (**4-8 mL/kg**) 3. Increased RR (**14-18 breaths per minute**) 4. Expecct higher peak airway pressures but the goal is to keep **2O** 5. Consider the risk for **barotrauma** → high risk!!! 6. Avoid excessive FiO₂

Question 32

Pre-operative **assessment** and **optimization** for patients with restrictive lung disease

Answer 32

Assessment: 1. What is their **exercise** **tolerance** & baseline dyspnea 2. Can use PFTs, flow volume loops & ABGs to **grade the severity** of the restrictive disease 3. **Increased risk:** * Decreased **Vital Capacity (70 ml/kg is normal)** * Resting **Hypercarbia** **Optimization** (5 things) 1. Treat any active pulmonary **infection** 2. Improve **sputum** clearence 3. Treat **cardiac** dysfunction 4. IS- to improve respiratory muscle **strength** & stamina 5. **Smoking** cessation

Question 33

Respiratory criteria for extubation

Answer 33

**_Respiratory Criteria for extubation_** 1. PaO₂ **\> 60** mmHg 2. SaO₂ \> **90%** 3. PaCO₂ mmHg 4. Respiratory Rate breaths/minute 5. Tidal Volume **\> 300** mL (6 ml/kg) 6. Vital capacity **\> 10-15** mL/kg (or SV of 2-3 ml/kg) 7. Full reversal of NMB 8. Return of laryngeal reflexes 9. Adequate LOC & muscle strenght (head lift \>5 sec)

Question 34

**Post anesthethetic management** for restrictive lung diseases

Answer 34

**_Have a lower threshold for:_** 1. Post -op mechanical ventilation 2. Monitoring in a postoperative bed & maybe a slow wean in ICU **_High Risk of Post-op respiratory failure!!_**_{d/t ↓ lung volumes & impaired cough} 1. **Transport** to PACU with supplimental **O₂** 2. treat **pain** adequately, but avoid respiratory depression * ​​regional comes in handy * consiter the **surgical** **site -** thoracis surgery - you don't want splinting but try to avoid atelectasis ​remember, pts present with: 1. ​decreasde lung **volumes** and **impaired cough** 2. **rapid** **shallow** breathing pattern 3. abdominal **impingement** of diaphram

Question 35

Anesthetic management of ACUTE restrictive disease in critically ill Patients

Answer 35

1. If the surgery is elective →**CANCEL** **IT!** 2. If **emergency** surgery indicated 1. Use **diuretics** for fluid overload 2. **vasodilators** and **inotropes** for cardiac failure 3. Consider **drainage** of pleural **effusions**/**ascites** pre-op 4. May need an **ICU vent** -(for the propper settings) 5. **AGGRESSIVE** **hemodynamic** **monitoring** * art line, CVP, +/- PA catheter

Question 36

Pharmacologic treatment for Asthma and COPD

Answer 36

**BOTH Asthma and COPD** * Inhaled **ß-agonists** (albuterol) - bronchodilation * Inhaled and systemic **corticosteroids** - decrease inflammation * **Mast cell Stabilizers** (Cromolyn) - decrease histamine release * **Phosphodiesterase inhibitors** - bronchodilation via increased cAMP (Thophyline/methyxanthines) **COPD** - **parasympatholytics** - (atropine inhalers) **ASTHMA** - **leukotriene inhibitors** (singulair)