Restrictive Lung Disease Flashcards
(132 cards)
1
Q
Hallmark of RLD is inability to increase ______ proportionate to increases in ________
A
Lung volumes; alveolar pressure
2
Q
These disorders lead to reduced SA for gas diffusion, VQ mismatching, and hypoxia: (4)
A
Reduced FEV1 and FVC
Normal or increased FEV1:FVC ratio
Reduced DLCO
All lung volumes decreased, esp. TLC
3
Q
Principal feature of RLD on a flow-volume loop is:
-This is used to classify RLD as mild moderate or severe
A
Decreased TLC
4
Q
Mild RLD: TLC ____% of predicted
Moderate RLD: TLC ____% of predicted
Severe RLD: TLC ____% of predicted
A
Mild: 65-80%
Moderate: 50-65%
Severe: < 50%
5
Q
Pulmonary edema caused by increased capillary permeability is associated with a high concentration of _____ in the edema fluid
A
Protein
6
Q
Increased-permeability pulmonary edema associated with ARDS leads to diffuse
A
Alveolar damage
7
Q
What does CXR say for a pulmonary edema patient?
What is a new means to dx pulm edema?
A
Bilateral, symmetric perihilar opacities
Newer means: Lung US
8
Q
Cardiogenic pulmonary edema is more severe than _______________ and is worsened with increases in ______ such as: (2)
A
Increased-permeability pulmonary edema
Increased preload such as aortic or MV regurgitation
9
Q
Risk of cardiogenic pulmonary edema is increased with conditions that increase:
A
Afterload
SVR (HTN)
LVOT obstruction
Mitral stenosis
10
Q
In Negative pressure PE, negative intrapleural pressure:
______ interstitial hydrostatic pressure
______ venous return
_______ left ventricular afterload
A
Decreased interstitial hydrostatic pressure
Increases venous return
Increases left ventricular afterload
11
Q
Negative pressure PE leads to: (3)
A
Intense SNS activation, HTN, Central displacement of blood volume
12
Q
Increasing/decreasing the transcapillary pressure gradient causes ________
A
Increasing; pulmonary edema
13
Q
Negative pressure PE onsets within:
Symptoms:
Radiographic evidence resolves within
A
Onset: minutes to 2-3 hours
S/s: Tachypnea, cough, desaturation
Radiographic evidence gone in 12-24 hrs
14
Q
Treatment for NPPE?
A
Supplemental O2, maintain patent airway, brief mechanical ventilation
15
Q
Massive outpouring of the SNS impulses from the injured CNS causes generalized _______ and blood volume shifting into the pulmonary circulation
A
Neurogenic pulmonary edema; vasoconstriction
16
Q
What 2 things can injury blood vessels in the lungs leading to pulmonary edema?
A
Pulmonary HTN and Hypervolemia
17
Q
Risk of REPE after relief of pneumothorax or pleural effusion is related to: (3)
A
- Amount of air/liquid in the pleural space
- duration of collapse
- speed of re-expansion
18
Q
What amount of air/liquid in the pleural space increases the risk for REPE?
What duration of collapse increases risk for REPE?
A
> 1 Liter
24 hours
19
Q
Capillary membrane _____ and high _____ content of PE fluid are factors in REPE
A
permeability; protein
20
Q
Exposure to what drugs can cause drug-induced PE?
A
Opioids (Heroin)
Cocaine
21
Q
What causes pulmonary vasoconstriction and acute myocardial ischemia/infarction?
A
Cocaine
22
Q
Does naloxone reverse opioid induced pulm-edema?
A
No
23
Q
If you have a pulmonary edema that is UNRESPONSIVE to diuretics, what type of pulmonary edema is likely?
A
Drug-induced PE
24
Q
High altitude pulmonary edema (HAPE) occurs at heights _______ meters and influenced by _______
Onset is gradual, but occurs within _____ hrs at high altitude
Cause:
Tx:
A
2500-5000 m
Rate of ascent
48-72 hours
Cause: HPV
Tx: O2 and quick descent from high altitude, inhaled NO might improve oxygenation
25
If your patient has elective surgery, but developed pulmonary edema, do you delay or continue the case?
Delay the case
26
What vent settings do PE patients benefit from?
____TV
____RR
____End-inspiratory pressures
____ PEEP
Low TV
RR 14-18
< 30 cmH2O end inspiratory pressure
Titrate PEEP
27
What type of breathing do RLD patients have?
Rapid, shallow breathing
28
If your patient is tachypneic, but has adequate gas exchange and other assessments are satisfactory, should you delay extubation?
No, you should extubate despite tachypnea
*Tachypnea should not be used as the sole criteria for delaying extubation
29
Aspiration/Clinical pneumonitis has the symptoms of:
Abrupt dyspnea, tachypnea, desaturations
30
When gastric fluid is aspirated, it destroys _________ cells and damages ___________
This leads to increased _________ and atelectasis
Destroys surfactant-producing cells;
Damages pulmonary capillary endothelium
Leads to increased capillary permeability
31
CXR may not demonstrate evidence of aspiration pneumonitis for _____ hrs
If aspiration happens when the patient is supine, where is the XR going to cite evidence?
6-12 hours
Superior segment of RLL
32
If aspiration is noted in your patient: (3)
Suction oropharynx
Turn patient to the side
T-burg position can prevent aspiration once the contents are already in the pharynx
33
Aspiration pneumonitis is best treated with: (2)
No evidence that ____ decrease pulmonary infection or alter outcomes, but consider them if pt is symptomatic after ___ hours and + cultures
Supplemental O2 and PEEP
ABX; 48 hours
34
What additives increase the risk of EVALI
THC, CBD, Vitamin E Acetate, Nicotine
35
Symptoms of EVALI:
CXR findings
TX:
Dyspnea, cough, NVD, abdominal pain, chest pain
Maybe: Febrile
CXR: Diffuse alveolar damage
Tx: ABX & systemic steroids
36
What is the most commonly reported finding of COVID induced RLD and is DIRECTLY related to severity of the initial disease process?
Reduced diffusion capacity
37
Pts with COVID RLD that need _____ are at highest risk for long-term pulmonary complications
Mechanical ventilation
38
COVID RLD patients have
______ exercise capacity
Hypoxia
______ seen on CT
Decreased; Opacities on CT
39
Acute Respiratory Failure is defined as
PaO2 ______ despite O2 supplementation
_____ R to L intracardiac shunt
PaO2 < 60 mmHg despite O2
Absence of R to L shunt
40
A PaC02 _____ without respiratory-compensated metabolic alkalosis is consistent with the diagnosis of ARF
PaCO2 > 50 mmHg
41
ARF is characterized by abrupt
______ PaCO2
_____ pH
Abrupt increase PaCO2
Decreased pH
42
Normal pH for ARF reflects _________ for respiratory acidosis
Renal compensation
43
3 treatment goals of ARF are:
1. Patent airway
2. Hypoxemia correction
3. Removal of excess CO2
44
The problem w/ NC, Venturi mask, NRB, T-piece is that they don't provide O2 concentrations ______ and are only helpful in mild to moderate ________
>50%; VQ mismatching
45
When NC, Venturi, NRB or T-piece are insufficent to keep PaO2 > ____ mmHg, ______ may be initiated
PaO2 > 60 mmHg, CPAP
46
CPAP increase lung volumes by (2) but may increase the risk of
1. Opening collapsed avleoli
2. Decreasing R to L intrapulmonary shunting
Aspiration
47
At a PaO2 > 60 mmHg, the SpO2 is > ____%
> 90%
48
Volume cycled ventilation is a
_____ TV
______inflation pressure
Fixed TV
Variable inflation pressure
49
Pulmonary edema, pneumothorax, kinked ETT, mucus plug might be shown in an elevated ____
Peak airway pressure
50
Disadvantage of volume-cycled ventilation is inability to compensate for:
Leaks in the delivery system
51
What are the primary vent settings for Volume-cycled ventilation?
Assist-Control (A/C)
SIMV
52
A type of volume control where a set RR ensures the set number of breaths even if there are no inspiratory effort. If negative pressure is sensed, a TV will be delivered
Assist control
53
allows spontaneous ventilation, while providing a predefined minute ventilation. The circuit provides sufficient gas flow and periodic mandatory breaths that are synchronized with the pt’s inspiratory efforts
SIMV
54
Advantages of SIMV over AC:
Use of respiratory muscles
lower mean airway and pressures
prevention of respiratory alkalosis
Improved pt–ventilator coordination
55
Vent setting that provides gas flow until a preset airway pressure is reached. TV varies with changes in compliance and airway resistance
Pressure-cycled Ventilation (PCV)
56
What is the most important predisposing factor for developing nosocomial pneumonia?
Intubation (ventilator associated PNA)
57
______ increases the risk of barotrauma, by weakening the pulmonary tissue
Infection
58
What is a common cause of hypoxemia during mechanical ventilation?
In acute desaturation, check for: (3)
Atelectasis
ETT migration, Kinks, Mucus plugs
59
Is hypoxia r/t atelectasis responsive to increasing FiO2?
No
60
What are causes of sudden hypoxemia usually accompanied by hypotension?
PE and tension pneumothorax
61
Lung ultrasound may identify atelectasis by showing what?
Static air
62
What value reflects the adequacy of O2 exchange across alveolar capillary membranes?
How do you measure this?
PaO2
PAO2 - PaO2
63
What is useful for evaluating gas exchange, lung function and distinguishing the cause of arterial hypoxemia?
PAO2 - PaO2 gradient
64
Low-Inspired Oxygen (at altitude) is characterized by:
____PaCO2
____ PAO2-PaO2 ratio
_____response to supplemental O2
Normal- decreased PaCO2
Normal PAO2-PaO2 ratio
Improved response to supplemental O2
65
Hypoventilation (Drug overdose) is characterized by:
____PaCO2
____ PAO2-PaO2 ratio
_____response to supplemental O2
Increased PaCO2
Normal PAO2-PaO2 ratio
Improved response to supplemental O2
66
VQ mismatching (COPD/Pneumonia:)
____PaCO2
____ PAO2-PaO2 ratio
_____response to supplemental O2
Normal-decreased PaCO2
Increased PAO2-PaO2 ratio
Improved response to supplemental O2
67
R to L intrapulmonary shunting (pulmonary edema)
____PaCO2
____ PAO2-PaO2 ratio
_____response to supplemental O2
Normal-decreased PaCO2
Increased PAO2-PaO2 ratio
Poor to none response to supplemental O2
68
Diffusion impairment (pulmonary fibrosis)
____PaCO2
____ PAO2-PaO2 ratio
_____response to supplemental O2
Normal-decreased PaCO2
Increased PAO2-PaO2 ratio
Improved response to supplemental O2
69
Arterial blood desaturation happens when PaO2 < _____ and this is also when compensatory responses kick in
Chronic hypoxemia is compensated when PaO2 < ____
< 60 mmHg
< 50 mmHg
70
The 3 main causes of arterial hypoxemia:
1. VQ mismatch
2. R-L pulmonary shunting
3. Hypoventilation
71
What are the 3 responses to hypoxemia to compensate?
1. Carotid-body induced increase in alveolar ventilation
2. HPV
3. Increased SNS to increase CO enhancing tissue O2 delivery
72
Chronic hypoxemia leads to an increase in ____ mass to improve O2 carrying capacity
RBC
73
What reflects the efficacy of CO2 transfer across alveolar capillary membranes?
It indicates the areas in the lungs that receive adequate ventilation but inadequate blood flow
VD:VT ratio
74
Normal VD:VT ratio?
Increased to ___ when there is more Dead space ventilation?
< 0.3
≥ 0.6
75
Increased VD:VT occurs in: (3)
1. ARF
2. Decreased CO
3. PE
76
What is a normal shunt fraction, which provides assessment of _____ and estimates response to treatments
Physiologic shunt is dumping into the L side of circulation via (2 veins)
Calculating shunt fraction is done with what % O2?
VQ matching
Physiologic shunt fraction is 2-5% of CO
Bronchial and Thesbian veins
100% O2
77
Guidelines for extubation:
* Vital capacity of _____
* Alveolar-arterial oxygen difference ______ on 100% 02
* Pa02 of _____ on Fi02 of _____
* Negative inspiratory pressure of more than _____
* _____pHa
* RR ____
* VD:VT of _____
*PEEP ____
*PaCO2 ___ and pHa ___
* Vital capacity of >15 mL/kg
* Alveolar-arterial oxygen difference <350 cmH2O on 100% 02
* Pa02 of >60 mm Hg on Fi02 of <0.5
* Negative inspiratory pressure of more than −20 cmH2O
* Normal pHa
* RR <20
* VD:VT of < 0.6
*PEEP < 5
*PaCO2 < 50 and pHa > 7.3
78
What signifies inability to tolerate extubation?
Increased RR and Low TV
79
If the patient appears ready for vent withdrawal: 3 options are considered
1.SIMV, which allows progressively fewer mandatory breaths until pt breathing on their own
2.Intermittent trials of total removal of mechanical support
3. Use of decreasing levels of pressure support ventilation
80
Supplemental O2 is needed after extubation due to
VQ mismatching
81
What pathology is associated with the highest risk of ARDS?
What is the major cause of ARDS?
Sepsis
Inflammation
82
Persistent arterial hypoxemia and decreased compliance can progress ARDS to
Fibrosing alveolitis
83
Supportive care for ARDS is
When can ECMO be considered?
Ventilation
ABX
DVT Prophylaxis
Early enteral feeding
Prone positioning (repositions the heart to recruit lung units)
Severe hypoxemia/hypercapnic respiratory failure
84
a group of lung pathologies leading to diffuse parenchymal disease
examples:
o Sarcoidosis
o Hypersensitivity Pneumonia
o Pulmonary Langerhans Cell Histiocytosis
o Pulmonary Alveolar Proteinosis
o Lymphangioleiomyomatosis
Interstitial lung diseases
85
ILD is presented with
Dyspnea and non-productive cough
86
Progressive pulmonary fibrosis causes loss of _______ leading to _______ & cor pulmonale
loss of pulmonary vasculature
Pulmonary HTN
87
Systemic granulomatous disorder involving many tissues, mainly the lungs and thoracic lymph nodes. Often _____ and found on ______
Symptoms: wheezing, dyspnea & cough
Asymptomatic; CXR
Sarcoidosis
88
Myocardial Sarcoidosis causes:
Neurologic sarcoidosis displays as:
Laryngeal sarcoidosis interferes with
Dysrhythmias; Unilateral nerve palsy ; Intubation
89
Electrolyte disorder associated with sarcoidosis
_____ enzyme activity is increased because it is produced by granuloma cells
What can you give to suppress symptoms and treat e- disorder?
Hypercalcemia
ACE
Corticosteroids
90
Markers of sarcoidosis
Dx:
*Other markers include: serum amyloid A, adenosine deaminase, and serum soluble IL2 receptor
*Dx: Kveim skin test is used to detect sarcoidosis (similar to TB test)
91
Disease: interstitial granulomatous inflammation after inhalation of fungus/spores particles
Sx: Dyspnea and cough ___ hrs after inhalation f/b leukocytosis, eosinophilia, hypoxemia
CT:
Tx:
Hypersensitivity Pneumonitis
4-6 hrs after exposure
CT: Ground-glass opacities in mid-upper lung zones
Tx: antigen avoidance, glucocorticoids, and lung transplant
92
Disease: inflammation around smaller bronchioles, causing destruction of the bronchiolar wall and surrounding parenchyma
-Strong association with smoking tobacco
CT:
Tx:
Pulmonary Langerhans cell Histocytosis
CT: Cysts/Honeycombinng in the upper zones
Tx: Smoking cessation & glucocorticoids
93
Disease characterized by lipid-rich protein material in the alveoli
It usually presents in the _____ w/sx of dyspnea and hypoxemia
*May occur independently or assoc w/ chemotherapy, AIDS, or inhaled dust
CXR:
Tx:
What kind of tube?
40-50's
Pulmonary alveolar Proteinosis
CXR: Batwing alveolar opacities in middle-lower lung zones
Tx: Lung lavage under GA - Double lumen ETT to lavage each lung seperately and optimize oxygenation
94
* Rare multisystem disease causing proliferation of smooth muscle of the airways, lymphatics, and blood vessels
* occurs mostly in _______
Tx:
Sx: Dyspnea, hemoptysis, pneumothorax, pleural effusions
Lymphangioleiomyomatosis
-Women of reproductive age
Tx: Immunosuppression (Sirolimus)
95
Aging is associated with (2)
____ RV
____VC
Geriatric patients breathe at _____ lung volumes with ______ FRC
decreased chest wall compliance and elastic recoil
Increased RV
Decreased VC
Higher lung volumes w/ increased FRC
96
Kyphosis and AP of diameter _____ which _____ efficiency of diaphragm
increase; decrease
97
_____ and ____ decline with age
FEV1 and FVC
98
Deformities of the sternum, ribs, vertebrae, & costovertebral structures include: ankylosing spondylitis, flail chest, scoliosis, and kyphosis
Thoracic extrapulmonary causes
99
The 2 types of costovertebral skeletal deformities are
Lead to _______
beings in late childhood
Severity of resp. compromise correlates with degree of ______
Scoliosis and kyphosis
severe restrictive lung function
spinal curvature
100
aka “pigeon chest:” deformity of sternum characterized by the outward projection of the sternum & ribs
* cause unknown, does run in families
* usually more of a cosmetic concern, but may cause respiratory symptoms or asthma
* Pectus carinatum
101
Rib fractures cause flail chest and paradoxical _____ movement
Tx of flail chest:
inward
Tx: PPV and stabilization
102
Lung contusions reduce
Chest wall compliance and FRC
103
What is the preferred method of dx pleural effusion?
Bedside US
104
occurs most often in tall, thin men age ______ and is c/b rupture of apical subpleural blebs
Idiopathic pneumothorax
20-40 y/o
105
medical emergency and develops when gas enters the pleural space during inspiration and can't escape during exhalation
Trachea deviated ____ from the PTX
Signs if pt. is on ventilator?
Tx: evacuation via catheter placed into the _______ space
Tension pneumothorax
Deviated away
Inc. airway pressure and decreased TV
Tx: Second anterior intercostal
106
______ may follow hemothorax, empyema, or surgical pleurodesis
* If symptomatic, surgical decortication to remove thick fibrous pleura is considered
Pleural Fibrosis
107
_____c/b bacterial contamination after esophageal perforation
* Sx: chest pain & fever
* Tx: broad-spectrum abx & surgical drainage
Acute mediastinitis
108
Pre-op, a patient w/ a mediastinal mass should have
What test evaluates degree of airway obstruction?
measurement of a flow-volume loop, chest imaging, and assessing for airway compression
Fiberoptic bronchoscopy
109
What technique is preferred for a symptomatic patient with mediastinal mass that requires tissue biopsy?
Local anesthesia
110
“Jeune syndrome:” disorder with skeletal dysplasia and multiorgan dysfunction
o associated with cysts in kidney, pancreas, and liver
o retinal abnormality with short ribs, short limbs, narrow thorax, and polydactyly
Asphyxiating thoracic dystrophy
111
genetic variation in bone morphogenetic protein (BMP)
Fibrodysplasia ossificans
112
partial or complete absence of pectoral muscles, commonly affecting one side. May also have paradoxical respiratory motion due to the absence of multiple ribs
Poland syndrome
113
In contrast to thoracic cage disorders, where effective cough is _____, the expiratory muscle weakness of neuromuscular disorders _____ adequate expiratory airflow to provide sufficient cough
Preserved; Prevents
114
*Pts w/severe neuromuscular disorders are dependent on their state of _____ to maintain adequate ventilation
wakefulness
115
During sleep, hypoxemia and hypercapnia may develop and contribute to the development of _____
cor pulmonale
116
20-25% pts require mechanical ventilation
* needed on average for 2 months
Guillain- Barre syndrome
117
most common disease affecting neuromuscular transmission that may result in respiratory failure
Myasthenia gravis
118
These pts are predisposed to pulmonary complications
* chronic alveolar hypoventilation occurs d/t inspiratory muscle weakness
* expiratory muscle weakness impairs cough
* weakness of swallowing muscles may lead to pulmonary aspiration
* Nocturnal ventilation devices may be useful
Muscular dystrophy
119
In quadriplegic pts w/ injury below ____, breathing is maintained by the diaphragm
Higher levels of injury result in ______
T4; Diaphragmatic parlysis
120
In spinal cord injury: the diaphragm is active only during inspiration, ____ is almost totally absent
With diaphragmatic breathing, there is a paradoxical ____ motion of the upper thorax during inspiration, resulting in ______TV
coughing; inward; diminished
121
* Quadriplegic pts have mild bronchial constriction caused by unopposed ____ activity
* _______ bronchodilators useful
PNS; Anticholinergic
122
Obesity is associated with _____ in FEV1, FVC, FRC, ERV
* BMI > ____ leads to a decreased RV and TLC
* With extreme obesity, ____may exceed ________ and approach RV
* The ______ ratio is usually preserved
Decreased; > 40; FRC; Closing volume; FEV1:FVC
123
Adipose cells release _____ that play a part in systemic inflammation triggered by obesity-related hypoxemia
Adipocytokines
124
During pregnancy, the subcostal angle of the rib cage and lower chest wall circumference ______ and the diaphragm moves ______
Increase; cephalad
125
Pregnancy: Increased levels of _____ cause stretching of the lower rib cage ligaments
Changes peak at the ____ week of pregnancy
Relaxin
37th week
126
Chest wall normalizes about ____ months postpartum, except for the subcostal angle, which remains wider by about ______
* The enlarging uterus pushes the diaphragm up by about _____
6 months; 20%; 4 cm
127
During anesthesia, pts with RLD: may require ________ inspiratory pressures
Avoid drugs with _____ resp. depressant effects
_____ contributes to the risk of perioperative complications
Post-op mechanical ventilation is needed with pts with imparied pulmonary function
increased; prolonged; RLD
128
____ is helpful for visualizing the airways and obtaining samples for bx and culture
Fiberoptic bronchoscopy
129
PTX occurs in _______ of pts after transbronchial lung biopsy and in ______ after percutaneous needle biopsy
5-10%
10-20%
130
The major contraindication to pleural biopsy is:
coagulopathy
131
What type of anesthesia is used for a mediastinoscopy?
Risks?
GA
Pneumothorax mediastinal hemorrhage, venous air embolism, and RLN injury
132
During mediastinoscopy, the mediastinoscope can exert pressure on the _______ causing loss of pulses in the right arm and compromise of _____ carotid artery blood flow
Right innominate artery; right
