Resp PDF Flashcards
1
Q
Which nerve innervates motor function of vocal cords?
A
RLN
2
Q
What innervates the motor function of the cricothyroid?
A
External branch of the SLN
**SLN is all sensory except the cricothyroid
3
Q
Which muscle opens the glottis?
A
Thyroepiglottic
4
Q
Which two muscles close the glottis?
A
Aryepiglottic
Oblique arytenoid
5
Q
Which nerve does the RLN branch off of?
A
Vagus (CN 10)
6
Q
What is the most common cause of voice change following thyroid surgery?
A
injury to the SLN external branch
7
Q
How is a nerve blocked performed on SLN?
A
2mL - Below the border of the greater cornu of the hyoid bone
8
Q
During an SLN block you aspirate air, what does this mean?
A
Needle is too deep
9
Q
How is a transtracheal block performed?
A
Needle is advanced caudal as it penetrates cricothyroid
**after aspiration but before injection have the patient take a deep breath
Inject 5mL, patient will cough and saturate the vocal cords
10
Q
Which nerve causes a laryngospasm?
A
Internal branch of SLN
11
Q
Signs of laryngospasm?
A
Rocking horse
Lower rib flailing
Inspiratory stridor
Suprasternal and supraclavicular retraction during inspiration
12
Q
What is mullers maneuver?
A
Inhalation against a closed glottis
**negative pressure pulmonary edema
13
Q
What increases as the airway bifurcates?
A
-Number of airways
-Cross sectional area
-Muscular layer
14
Q
More likely to right mainstem or left?
A
More likely to right mainstem do to the 25 degree angle
15
Q
Where does the respiratory zone begin ?
A
Respiratory bronchioles
16
Q
Where does the conducting zone begin and end?
A
Begins in the trachea and ends in the terminal bronchioles
17
Q
Does transpulmonary pressure always stay positive or negative?
A
Always positive to keep airways open
**Slightly negative on forced expiration
18
Q
Is intrapleural pressure always positive or negative?
A
Always negative
19
Q
Which two muscles are apart of passive inhalation?
A
Diaphragm + external intercostals
19
Q
What is example of Boyles law?
A
Breathing
20
Q
What determines the rate of CO2 elimination?
A
Alveolar ventilation, NOT minute ventilation
21
Q
How is Alveolar ventilation calculated?
A
TV-dead space * RR
22
Q
Average dead space on an adult?
A
2mL per kilogram
23
Q
What is alveolar dead space proportional to? Inversely proportional?
A
Proportional = CO2 production
Inversely = PaCO2
24
How does hypotension affect dead space?
increases it by reducing pulmonary blood flow
25
How does atropine affect dead space?
Increases it because it is a bronchodilator
26
How does positive pressure ventilation affect dead space?
Increases dead space by increasing ventilation
27
How does a LMA and ETT affect dead space?
Decreases it
28
How does old age affect dead space?
Increases
29
Which law describes alveolar surface tension?
Law of Laplace
Pressure
Radius
Wall tension
30
How does surfactant affect surface tension?
Surfactant decreases surface tension
31
What is the most common cause of hypoxemia in PACU?
V/Q mismatch - specifically atelectasis
32
What is the alveolar gas equations?
PAO2=
FiO2 x (760-47) - (PaCO2/0.8)
33
How does reduced FiO2 affect A-A gradient? Does O2 fix this?
Stays normal - O2 helps
34
How does reduced hypoventilation affect A-A gradient? Does O2 fix this?
Stays normal - O2 helps
35
How does diffusion limitation affect A-A gradient? Does O2 fix this?
Increases it - O2 helps
36
How does V/Q mismatch affect A-A gradient? Does O2 fix this?
Increases it- O2 helps
37
How does shunt affect A-A gradient? Does O2 fix this?
Increases it - O2 does NOT help
38
How does aging affect the A-a gradient?
Increases
39
How do vasodilators affect the A-a gradient?
Increases
40
How does R to L shunt affect A-a gradient?
Increases
Ex: atelectasis, pneumonia, bronchial intubation, cardiac defect
41
What is a normal vital capacity?
35 ml/kg
42
How can FRC be indirectly measured?
nitrogen washout, helium wash in, body plethysmography
43
What conditions increases FRC?
-Advanced age
-Obstructive lung disease (air trapping)
-Peep
44
Which conditions increase closing volume?
Close-P
COPD
LV failure
Obesity
Smoking
Extreme age
Pregnancy
45
What is the oxygen carrying content equation?
(1.34xHgbxSaO2) + (PaO2x0.003)
46
What is the DO2 equation?
CaO2 x CO x 10
47
What is a normal VO2?
3.5mL/kg/min
250mL/min
48
What shifts the oxyhemoglobin curve to the Left?
Decreased everything
+ Increased PH (alkalosis)
49
What shifts the oxyhemoglobin curve to the Right?
Increased everything
+ Decreased PH (acidosis)
50
What is the Bohr effect?
IncreasedCO2 and hydrogen ions cause a change in the Hgb molecule and release O2
51
What are the three key processes involved in aerobic glucose metabolism?
1. Glycolysis
2. Krebs cycle
3. Electron transport
52
What does glycolysis turn glucose into?
The goal is 1 glucose = 2 pyruvic acid
53
What does pyruvic acid turn into?
2 pyruvic acid = Acetyl CoA
54
How many ATP is produced during the Krebs cycle?
2 ATP
55
How many ATP are produced during glycolysis?
2 ATP
56
How many ATP are produced during oxidative phosphorylation?
34 ATP
57
What is produced when no oxygen is available?
Lactic acid
++Causes anion gap metabolic acidosis
*lactate is cleared by the liver
58
How is the majority of CO2 transported?
70% Bicarb
59
What is the breakdown of CO2 transport? (Form and %)
-70% Bicarb
-23% Bound to Hgb
-7% dissolved in plasma
60
What enzyme is required for required to convert CO2 to bicarb?
Carbonic anhydrase
61
When compared to O2, how many more times soluble is CO2?
20x
Henrys Law
62
What is the Haldane effect?
Causes hgb to release CO2
63
What does hypercapnia cause?
-Increased ICP
-Hypoxemia
-Increased p50
-Cardiac+smooth muscle depression
-SNS stimulation
-Increased alveolar depression
-Increased K + Ca
-Decreased LOC
64
What does increased CO2 cause the lungs to do?
Vasoconstrict - Pulmonary HTN
65
What happens when CO2 passes 80mmHG?
Respiratory depressant
66
What does a left shift on the ventilatory response curve indicate?
Respiratory alkalosis
Metabolic acidosis
67
What does a right shift on the ventilatory response curve indicate?
Metabolic alkalosis
Respiratory acidosis
Caused by carotid, anesthetics, opioids
68
What is considered the pacemaker of breathing?
Dorsal respiratory group
69
Where is the dorsal and ventral respiratory group located?
Medulla
70
Where are the pneumotaxic and apneustic centers located?
Pons
71
What causes expiration?
Ventral respiratory
72
What diffuses through the BBB?
CO2?
HCO3?
H?
Just CO2
73
Once CO2 diffuses through the BBB what happens?
Reacts with carbonic anhydrase and turns into H+ and HCO-
74
What is the most important stimulus for the central chemoreceptor?
Hydrogen ion concentration
75
What is the chief responsibility of the peripheral chemoreceptors ? Where are they located?
Monitor PaO2
Carotid Body and Aortic arch
*carotid body plays a larger role
76
What are the secondary functions of the peripheral chemoreceptors?
-Monitor PaCO2, H+, perfusion pressure
77
What is the afferent pathway of the Hypoxic ventilatory response?
Hering's nerve then along the glossopharyngeal nerve (CN IX)
78
Which procedure severs the afferent limb of the hypoxic ventilatory response ?
Carotid endartectomy
79
What happens if bilateral carotid endartectomys are performed at the same time or close together?
May completely wipe out the hypoxic ventilatory response
80
What conditions do not impair the hypoxic ventilatory response?
-Anemia
-Carbon monoxide poisoning
81
What is the Hering Breuer INFLATION reflex? What nerve?
When the lungs inflate 1.5L above the FRC, it stops further inspiration
Vagus nerve
82
What is the Hering Breuer DEFLATION reflex? What nerve?
When lung volume is too low, stimulate a breath
83
What are J receptors?
Causes tachypnea through C fiber response?
84
What conditions stimulate J receptors?
PE, Pulmonary congestion from CHF
85
What is the paradoxical reflex of head?
Causes newborn babies to take a breath
86
What stimulates the HPV? What does not?
A reduction in alveolar oxygen tension - NOT arterial PO2
87
What is the HPV mechanism?
Increases PVR , shunts blood away from poorly ventilated areas
88
What impairs the HPV?
Mac > 1.5
Vasodilators and Constrictors
89
What does not impair HPV?
IV anesthetics
90
How does Beta2 stimulation cause bronchodilation?
Gs protein is stimulated
Activates adenylate cyclase
Adenylate cyclase activates cAMP
cAMP reduces Ca
91
How is the Beta2 pathway turned off?
Phosphodiesterase 3 deactivates cAMP by converting it to AMP
92
How does Nitric oxide effect the smooth muscle ?
Potent smooth muscle relaxant
Stimulates cGMP which relaxes and causes bronchodilation
93
How does the PNS affect bronchioles?
Bronchoconstriction
M3 is coupled by Gq
Gq activates Phospholipase C
Phospholipase C activates IP3
IP3 stimulates Ca
94
what other mediators cause bronchoconstriction?
Mast cells, other proinflammatory cells
95
What is FEV1? Normal?
Volume of air that can be exhaled in 1 second
Declines with Age
Normal - >80%
96
What is Forced vital Capacity? Normal?
Volume that can be exhaled after a deep inhalation breath?
Males - 4.8L
Females - 3.7L
97
What is the ration of FEV1 to FVC?
80%
98
What is the Forced expiratory flow at 25-75% Vital Capacity?
Measures flow in the middle of expiration
100 +/- 25% predicted value
99
What is the best test to assess medium size airways?
Forced expiratory flow at 25-75%
100
What is Maximum Voluntary Ventilation?
Maximum amount of air inhaled and exhaled over 1 minute
Test of endurance
Males - 150L
Females- 100L
101
What is diffusing capacity?
Tests ability to exchange CO2
17-25
102
What test assesses nutritional value?
If albumin is <3.5g/dl
103
Does short term cessation of smoking reduce risk of pulmonary complications?
NO
104
**What is the best way to recruit alveolar?
****Increase PIP to 40Cm for 8 seconds
105
What is the issue with obstructive lung disease?
Getting air out
106
What is the issue with restrictive lung disease?
Getting air in
107
What two PFTs are normal in restrictive disease?
****
FEV1/FVC ratio
FEF 25-75%
*** all other tests are DECREASED
108
Which two PFTs are significantly decreased with obstructive disease??
FEF 25-75
FEV1/FVC ration
*(opposite of restrictive)
109
What does the pressure volume look like with a variable extra thoracic obstruction?
Normal EXhalation
110
What does the pressure volume look like with a variable intra thoracic obstruction?
normal INhalation
111
What is the most common ABG finding with asthma?
Respiratory alkalosis without hypocarbia
112
What does an elevated PaCO2 suggest with asthma?
***air trapping, muscle fatigue
**Impending respiratory failure****
113
Which drugs should be avoided in asthma?
-Histamine releasing drugs (Morphine, meperidine,sux, atracurium)
-Toradol
-H2 antagonists
114
Which drug should NOT be used with a bronchospasm?
Montelukast ******
115
Which deficiency is linked to COPD?
Alpha-1 Antitrypsin
116
In chronic bronchitis, what happens to RBCs?
They are overproduced to compensate for the V/Q mismatch
117
What should the I:E ratio be in restrictive lung disease?
1:1 - prolong inspiration
118
What is Mendelson's syndrome?
Chemical aspiration pneumonitis
Gastric pH <2.5
Gastric volume >25mL
*common in OB
119
What shouldn't be apart of aspiration pneumonia treatment?
Steroids don't help
Antibiotics only if a fever or Increased WBC after 48 hours
120
How does a PPI affect VAP?
increases chance
121
What are hallmark signs of a tension pneumo?
Increased airway pressures
Hypoxemia
Hypotension
Tachycardia
Increased CVP
122
Treatment of tension pneumo?
14g angiocath into the 2nd intercostal space at the midclavicular line
OR
4th intercostal at the axillary line
123
What is a key step with a tension pneumo?
***TURN OFF NITROUS
124
Key characteristic of a flail chest?
Paradoxical chest movement
125
What happens to the chest wall during inspiration with a flail chest?
Chest wall moves inward during inspiration
126
What happens to the chest wall during expiration with a flail chest?
Chest wall moves outward during exhalation
127
Hallmark sign of a venous air embolism?
Air on TEE
Mill wheel murmur
Decreased EtCO2
Increased PA pressure
128
Treatment for venous air embolism?
100% FiO2
Flood field with NS
Discontinue insufflation
Place in Left lateral decubitus
Aspirate air
Hemodynamic support
129
Carboxyhemoglobin sign and symptoms?
Cherry red appearance
SNS activation
NEED co-oximeter
130
Treatment of Carboxyhemoglobin?
100% FiO2
Hyperbaric
131
*************What are the best predictors for patients undergoing pulmonary surgery?
FEV1 < 40%
DLCO <40% predicted
VO2 Max < 15ml/kg
132
What are the sizes for DLT in men and women? Insertion depth?
Men 39-41 = 29cm
Women 37-39 = 27cm
133
Once the DLT is confirmed to be in the correct position, what step is next when troubleshooting?
1. Apply 10 CPAP to the non- dependent lung
134
After applying CPAP to the dependent lung, what step is next when troubleshooting?
1. Apply 5-10 of PEEP to the dependent lung
135
What conditions increase PVR?
-Hypoxia
-Hypercarbia
-High PEEP
-High airway pressures
136
What is an absolute contraindication for a mediastinoscopy?
Previous mediastinoscopy
137
Mallampati Score
138
What three axis are aligned during the sniffing position ?
Oral
Pharyngeal
Laryngeal
139
What is a normal incisor gap?
4cm
2-3 finger breaths
140
What is a normal thyromental distance? What does this tell you?
6-9cm
How much submandibular space there is to displace the tongue
141
Classes of the mandibular protrusion test
Class 1: But above lip
Class 2: can touch teeth or upper lip
Class 3: Cannot touch teeth
142
What conditions impair the antlanto occipital joint mobility?
Joint disease
RA
Ankylosing spondylitis
Truma
Fixation
Kippel-Fei
Down syndrome
143
What are the NPO guidelines?
2 hours - Clears
4 hours - Breast milk
6 hours - Food
144
What are two causes of angioedema?
Ace inhibitors
Hereditary
145
What is Ludwigs Angina? How to intubate?
Bacterial infection on floor of mouth
-Awake nasal intubation or trach
146
What is contraindicated when patients have an infection above the trachea?
Retrograde intubation
147
What three syndromes have C Spine anomalies?
Goldenhar
Klippel-Feil
Down syndrome
148
Which two oral airways have a hole for intubation?
Williams and Ovassapian
149
How to measure oral and nasal airways?
Oral - Corner of mouth to angle of mandible
Nasal- Nare to the angle of the mandible
150
When should a nasal airway never be used?
Coagulopathy
Pregnancy
Raccoon Eyes
Periorbital edema
Basilar skull fracture
Lefort 2 or 3 fracture
151
What is the max airway pressure with an LMA? Max cuff pressure?
20cm H20
Cuff- 60
152
LMA sizes
153
When is a ProSeal and Supreme indicated?
-Has a lumen to suction BUT must past an OG to suction
154
Which LMA allows for a higher pressure of 30 cm H2O?
Proseal and Supreme
155
What are the sizes for a combitube? Max amount of pressure?
<4 feet no option
4-6 feet - size 37
>6 feet - size 41
Do not exceed 60cm H2O
156
Which cuff is inflated first on the Combitube? What does this accomplish?
The proximal cuff first
-Occludes the hypopharynx
50 -100 mL of air
157
Which cuff is inflated second on the Combitube? What does this accomplish?
Distal balloon - Occludes the esophagus
10mL of air
158
If the tip of the Combitube is in the esophagus, which lumen should be used to ventilate?
Blue or proximal lumen
159
If the tip of the Combitube is in the trachea, which lumen should be used to ventilate?
Clear or distal
160
Contraindications with the combitube?
-Intact Gag
-Prolonged use over 3 hours
-Esophageal disease
-Incorrect sizing
161
When using a trachlight, what should the tip be bent to? What about in children?
90 degrees in adults
60-80 degrees in children
162
What should the PSI be for jet ventilation?
50 PSI
163
Risks of jet ventilation?
Hypercapnia
Barotrauma
Pneumothorax
Subcutaneous emphysema
164
Contradictions to jet ventilation?
Upper airway obstruction
Laryngeal injury
165
ABSOULTE contraindications to a cricothyroidotomy ?
Children < 6 (some say 10)
166
Contradictions to a tracheostomy?
None
