Respiratory Pathophysiology APEX- Part 2 Flashcards
1
Q
The __ has the most significant contribution to airflow resistance
A
Radius
2
Q
The __ nerve supplies PNS innervation to the airway smooth muscle
A
Vagus
3
Q
What receptor of the airway causes bronchoconstriction?
A
M3
4
Q
What do mast cells do
A
Massive bronchoconstriction
Mast - Bronchoconstrict
5
Q
What is the role of non-cholinergic C-fibers?
A
Bronchoconstriction
6
Q
Pathway of constriction
A
M3-PLC-IP3-LEUKOTREE- Increase CA
7
Q
Pathway of bronchodilation
A
B2-AC-CAMP-relax- Decrease CA
Non cholinergic PNS- NO-cGMP relax
8
Q
What is the role of NO?
A
Potent smooth muscle relaxant
Stimulates cGMP- more bronchodilation
9
Q
side effects of B2 agonists
A
Tachycardia
Hyperglycemia
Hypokalemia
Tremor
10
Q
Side effects of anticholinergics
A
Dry mouth
blurry vision
Cough
Urinary retention
11
Q
Steroid side effects
A
Dysphonia
Myopathy of laryngeal muscles
Oropharyngeal candidiasis
Possible adrenal suppression
12
Q
Example of a methylxanthine
A
Theophylline
13
Q
Theophylline side effects
A
> 20- N/v/headache
30- Seizure, tachydysrhythmias, CHF
14
Q
MOA of methylxanthines
A
Inhibits PDE- which increases cAMP
Increases catecholamine release
Inhibits adenosine receptors
15
Q
Which receptor do anticholinergics work at?
A
M3
16
Q
MOA of cromolyn
A
Mast cell stabilizer
17
Q
MOA of Leukotriene modifiers
A
Inhibits 5-lipoxygenase- decreases leukotriene synthesis
18
Q
Most sensitive indicator of small airway disease?
A
FEF 25-75 aka MMEF
19
Q
Normal value of FEV1
A
> 80%
20
Q
Normal FEV1/FVC ratio?
A
> 80%
21
Q
DLCO normal value
A
17-25 ml/min/mmHg
22
Q
What is the best test of endurance?
A
MVV
Maximum voluntary ventilation
23
Q
Which test can diagnose OLD vs RLD? How?
A
FEV1-FVC ratio
Normal with RLD, <70% with OLD
24
Q
FEV25-75 is usually __ in obstructive airway disease?
A
Reduced
25
FEV25-75 is usually __ in restrictive airway disease?
Normal
26
Predictors of PPC? (patient specific)
Age >60
COPD
CHF
Smoker (>40 pack years especially)
27
Surgery specific predictors of PPC?
Surgical site- aortic, thoracic, upper abdomen, neuro, vascular, emergency
Procedure >2 hours
GA
28
Diagnostic tests for PPC
Albumin <3.5
29
What doesnt increase risk of PPC?
ABG analysis
Asthma (moderate)
PFT
30
Patient must quit smoking for ___ to see normalization of pulmonary function
6 weeks
31
How does smoking affect the lungs?
Decreased mucociliary clearance
Airway hyperreactivity
Reduced immune function
32
How does smoking affect the CV system?
CV disease risk factor
Decreases DO2
Catecholamine release
Coronary vasoconstriction
Decreased exercise tolerance
33
Smoking will impair ___ healing
Wound
34
How to perform an ARM
Increase PIP to 40 for 8 seconds, then apply PEEP
35
Define Atopy
Hyper-allergic
36
Greatest risk factor for developing asthma?
Atopy- hyper-allergic
37
Most common ABG with asthma
Respiratory alkalosis from tachypnea
Hypocarbia
38
What are the histamine releasing drugs that are bad for asthmatic
Sux
Atracurium
Morphine
Meperdine
39
What drugs can provoke asthma?
ASA
NSAIDS
B agonists
Sulfits
40
What would the EKG of an asthmatic show?
RV strain with R-axis deviation
41
What would a CXR of an asthmatic show?
Hyperinflated lungs with a flattened diaphragm
42
Toradol can __ airway resistance
Increase
Avoid in asthmatics
43
Which beta blocker is best for asthmatics?
Esmolol bc short half life
44
Carboprost, the uterotonic(?), can cause __
bronchoconstriction in ashtmatics
45
Bronchospasm will show what on an ETCO2 waveform?
Increased Alpha angle- sharkfin
Same as bronchospasm
46
____ causes panlobular empyhsema
How?
Alpha 1 antitrypsin deficiency
Causes increased protease which degrades pulmonary connective tissue
47
What is the treatment for alpha 1 antitrypsin deficiency?
Liver transplant
48
Bronchitis is associated with __
Hypertrophied mucus glands and chronic inflammation
Cough and sputum
A lot of RBC
49
Emphysema is associated with __
Enlargement and destruction of lower airways
50
Etiologies of COPD
Smoking
Alpha 1 antitrypsin deficiency
Environmental pollutants
Respiratory infections
51
Where is alpha 1 antitrypsin produced?
Liver
52
When can you not consider regional anesthesia for COPD patients?
If sensory block is required over T6
53
Can you consider N2O for COPD patients?
No, rupture pulmonary blebs will lead to PTX
54
Which block isn't the best for COPD patients?
Interscalene
55
Do you use PEEP for COPD patients?
Yes, they help alveoli
56
Examples of Restrictive lung disease
Sarcoidosis
Flash edema
Flail chest
Pulmonary fibrosis (amiodarone induced)
Obesity/ pregnancy/ ascites
Ankylosing spondylitis
Pleural effusion
57
Examples of obstructive lung disease
COPD
Asthma
CF- creates mucus plus and cant exhale
58
What happens to FEV1, FVC, and the ratio in RLD?
Decreased <70%
Decreased <70%
Normal
59
RLD ventilatory strategies
Low Vt- 6ml/kg
High RR
1:1 I:E
60
OLD ventilatory strategies
Medium Vt- 6-8
Higher I:E- 1:3
PEEP but stay alert for dynamic hyperinflation
61
Diseases of the chest wall- RLD
Kypho
AS
Flail chest
PTX
Pleural effusion
Mediastinal mass
Muscular dystrophy
Guillian barre
Spinal cord transection
62
Acute intrinsic RLD
Flash edema
Cocaine OD
Reversal of opioid OD- narcan
Reexpansion of collapsed lung
Upper airway obstruction- flash edema?
Aspiration
63
How to reduce the incidence of VAP
Oral care
Reduce vent time
Limit sedation
Handwashing
Subglottic suction
HOB >30
64
Mendelson syndrome
Gastric PH <2.5
Gastric volume >25ml
65
Treatment for aspiration
Left head tilt
Suction
Secure airway
PEEP
Head down
66
When are PPIs useful?
To prevent aspiration pneumonitis- but not VAP
67
Patients who aspirate can go home unless they experience the following within 2 hours:
New cough
Aa >300
SPO2 drops by 10
CXR of pulmonary injury
68
Most common bacterias of VAP
Pseudomonas
Staph Aureus
69
Where to do needle chest decompression after a tension pneumo
2 ICS Mid clavicular
4th IC anterior axillary
70
Tension pneumo causes a shift to the __lateral side
Contralateral
71
Thoracotomy indications
1L drainage or 200ml/hr
Large air leak
White lung on CXR
72
When can a patient have VATS instead of thoracotomy?
Hemodynamically stable
<150 ml/hr
73
VAE risk positions
Sitting
Supine
Prone
Lateral- the treatment
74
VAE will __ ETCO2
Decrease
75
Signs of VAE
Milwheel on dopper
Air on TEE
Low etco2
HOTN
Hypoxia
76
Treatment of VAE in order
fio2 1.0
Flood with saline
Decompress stomach
Left lateral
Aspirate from CVC
Pressors
77
PDE inhibitors
Methlyxanthines- theophylline, viagara, cilais
Vasodilaiton
Bronchodilation
78
Which reduces PVR?
Increased PaO2, hypocarbia (opposite of increased PVR)
Nitric oxide
Hyperventilation decreases CO2 and thus, blood volume
Nitroglycerine - see below
Antihypertensives- PDE inhibitors, ACE inhibitors, CCB, NTG
79
What increases PVR?
PEEP
Acidosis
N2O
Hypothermia
Hypoxia/ hypercarbia
Desflurane
Ketamine
80
Pulmonary hypertension is mean PAP > ___
25mmHg
81
Causes of pulmonary hypertension
COPD
LV dysfunction
MV disease
Hypoxemia/ hypercarbia
82
PVR formula and reference range
mean PAP- PAOP
/
CO
x 80
200 dynes/s/cm^5
83
What agents produce CO the most when dessicated?
Des, iso, then Sevo
84
CO has _x times higher affinity for HGB than oxygen
200
85
What equipment is required to diagnose carboxyhemoglobinemia?
CO-ox
86
Presentation of CO poisoning
Cherry red appearance
87
Treatment for CO poisoning
100% oxygen will reduce 1/2 life to one hour (so 5 hours in total to rid CO)
Which is until CoHGB is <5% for 5-6 hours
88
Hyperabaric oxygen after CO poison is indicated if the CoHGB exceeds _%
25%
89
Soda lime is hydrated to _%
15%
90
When will Sevo cause compound A?
Dessicated soda lime
Minimal CO2 production, but high Compound A!
91
What is the risk of Compound A?
Fire!
+ Liver damage ?
92
Indications for intubation:
Vital capacity
IF
PaO2
Aa
PaCO2
RR
<15
<25
<200
>450
>60
>40 or <6
93
NAVEL
Narcan
Atropine
Vaso
Epi
Lido
94
Reference range for:
Vital capacity
IF
PaO2
Aa
PaCO2
RR
75 ml/kg
75 cm H2O
>60
5-15
35-45
10-25
95
Absolute indications for OLV
Infection control of one lung
Bronchopleural fistula- similar to a PTX? and needs to be fixed
Massive hemmorage of one lung
Large unilateral cyst
Life threatening hypoxemia due to lung disease of one lung
96
When would a right sided DLT be indicated?
Left sided distorted anatomy- tumor, TAA
Left sides procedures- L pneumonectomy, Left sleeve resection
97
DLT sizes and depth
Female- 35-37 (160cm cut off)- 27cm
Male- 39-41 (170cm cut off)- 29cm
98
DLT is not to be used in ages under _
What to do instead?
8
Bronchial blocker
Mainsteming the ETT into the preferred lung
99
PPC predictors (PFTs)
DLCO <40%
FEV1 <40%
VO2 Max < 15ml/kg/min
100
Cuff volume for bronchial vs tracheal lumen
Bronchial- 1ml
Tracheal- 10
101
Normal VO2 max
Men- 40 ml/kg/min
Women- 30 ml/kg/min
102
During anesthesia in the lateral position, which lung is best perfused vs best ventilated?
Dependent- best perfused
Nondependent- best ventilated
VQ mismatch!
103
Stepwise approach to hypoxemia during OLV
100% fio2
Check position of tube
CPAP non dependent luung
PEEP dependent lung
Inflate nondependent lung
104
Ventilation/ anesthetic strategies for OLV
Fio2- 100%
Vt- 6ml/kg
RR-15 to maintain normal EtCO2
ARM before initiating OLV
Consider TIVA to maintain HPV
105
HPV minimizes _
shunt
106
The bronchial blocker cannot:
Prevent contamination
Ventilate the isolated lung
Suction the ventilated lung
107
Can the bronchial blocker be used intranasally?
Yes
108
Can the bronchial blocker insufflate O2 into the isolated lung? What about suction?
Yes
Can suction AIR, but not secretions
109
Most serious complications of mediastinoscopy
1- Hemorrhage (aorta, vena cava near scope insertion site)
2- Pneuomthorax- R side
110
Absolute contraindication to mediastinoscopy
Previous mediastinoscopy! You can only have 1 done
111
When doing a mediastinoscopy, where to place vital sign measurements and why?
Pulse ox + A-line - right hand
BP cuff- left arm
Will assess innominate artery (right side) for occlusion
112
Post op rules for tracheal resection
Keep neck flexed for several days to reduce tension on incision
If reintubation is needed, use Flexible FOB
113
Steps for tracheal resection intubation
Intubate above lesion
Makes incision
Second ETT below lesion into L main
Suture anastomosis
Remove second ETT, then advance first ETT into L main
114
ARDS ventilation strategies
Low vt- 4-6ml/kg
PEEP
PCV
SPO2 goal- 88-95- keep below 50% if possible- high O2= oxidative stress
Plateau pressure <30
115
ARDS berlin definition
<1 week onset
CXR- bilateral opacities
NOT explained by cardiac failure
PF 100-300 for severity of mild, moderate, and severe
116
Causes of ARDS
PNA most common intrapulmonary
Sepsis most common extra pulmonary
Covid
Aspiration
Drowing
Smoke injury
Trali/ TACO
Burns
117
FRC is _ in RLD
Reduced
118
