Restrictive Lung Disease - Final Flashcards
(177 cards)
1
Q
Restrictive lung diseases affects lung ____ and ____
A
Expansion
Compliance
2
Q
What is the hallmark of restrictive lung disease?
A
the inability to increase lung volumes proportionate to increases in alveolar pressure
3
Q
What is RLD typically related to?
A
connective tissue diseases, environmental factors, pulmonary fibrosis, increased alveolar or interstitial fluid, and limitations in chest/diaphragmexcursion
4
Q
What do PFTs look like with RLD?
A
reduced FEV1 and FVC
normal or increased FEV1:FVC ratio
reduced DLCO
all lung volumes are decreased, especially TLC
These disorders lead to reduced surface area for gas diffusion, V/Q mismatching and hypoxia
5
Q
Flow volume loop RLD picture
A
6
Q
The principal feature of RLD is a decrease in what?
A
TLC
7
Q
Explain different classifications of RLD based on TLC
A
- Mild disease: TLC 65-80% of the predicted value
- Moderate disease: TLC 50-65% of the predicted value
- Severe disease: TLC <50% of the predicted value
8
Q
Causes of RLD picture
A
9
Q
What can pulmonary edema be caused by?
(not specific reasons, more patho)
A
increased capillary pressure or capillary permeability leading to fluid leakage into the interstitial & alveolar space
10
Q
Pulmonary edema c/b increased capillary permeability is assoc w/ a high concentration of ______ in the edema fluid
A
Protein
11
Q
Increased-permeability pulmonary edema associated with ARDS leads to what?
A
diffuse alveolar damage
12
Q
What does CXR look like with pulmonary edema?
A
appears as bilateral, symmetric perihilar opacities
Lung ultrasound has emerged as a newer means to dx pulmonary edema
13
Q
When is cardiogenic pulmonary edema often seen?
A
Acute decompensated HF
14
Q
What is cardiogenic pulm. edema characterized by?
A
dyspnea, tachypnea, elevated cardiac pressures, and SNS activation that is more severe than increased-permeability pulmonary edema
Assoc w/decreased systolic or diastolic cardiac function
15
Q
Cardiogenic pulm. edema is worsened w/increases in ______ s/a aortic or mitral valve regurgitation
A
Preload
16
Q
Risk for cardiogenic pulmonary edema is also increased with conditions that increases _____ and ____ such as HTN, LVOT obstruction, and mitral stenosis
A
Afterload
SVR
17
Q
What is negative pressure pulmonary edema?
A
AKA post-obstructive pulm. edema
occurs after the relief of an upper airway obstruction s/a laryngospasm, epiglottitis, tumors or OSA
- attempted spontaneous ventilation during obstructioncreates negative pressure, drawing in fluid from the alveolar capillaries
- Negativeintrapleural pressure decreases the interstitial hydrostatic pressure, increasesvenous return, and increases left ventricular afterload
- leads to intense SNS activation, HTN, and centraldisplacement of blood volume
18
Q
What is the onset range for negative pressure pulm. edema?
Symptoms of this?
A
onset ranges from a few minutes to 2-3 hrsafter relief of the obstruction
Sx: tachypnea, cough, and desaturation
19
Q
Treatment of negative pressure pulm. edema
A
supplemental 02 and maintaining a patent airway
mechanical ventilation is occasionally needed for a brief period
radiographic evidence of NPPE resolves within 12-24 hours
20
Q
What is neurogenic pulm. edema?
A
- develops in a small fraction of acute brain injury pts
- occurs minutes-hours after injury and may manifest during the periop period
- massive outpouring of SNS impulses from the injured CNS causesgeneralized vasoconstriction and blood volume shifting into the pulmonary circulation
- the increased pulmonary capillary pressure c/b blood volume shifting leads to fluid transfer into the interstitium and alveoli
21
Q
What other 2 things did we note could injure blood vessels in the lungs when discussing neurogenic pulm. edema?
A
Pulmonary HTN
Hypervolemia
22
Q
What is re-expansion pulm. edema?
A
The rapid expansion of a collapsed lung may lead to REPE
- high protein content of pulmonary edema fluid
23
Q
What 3 things are related to the risk of REPE after relief of pneumo or pleural effusion?
A
amount of air/liquid that was in the pleural space (>1 L increases the risk)
the duration of collapse (>24 hours increases the risk)
speed of re-expansion
24
Q
_______ _______ permeability is a factor in REPE
What is the tx?
A
Capillary membrane
Supportive care
25
What is drug-induced pulm. edema?
can occur after exposure to certain drugs, especially opioids (heroin) and cocaine
- the high protein concentration in the pulmonary edema fluid suggests it is a high-permeability pulmonary edema
26
Cocaine caused what 3 things?
pulmonary vasoconstriction, acute myocardial ischemia, and myocardial infarction
27
T/F
Naloxone helps reverse opioid-induced pulmonary edema
False
28
Treatment of drug induced pulm. edema
supportive care, may include intubation and mechanical ventilation
29
What is another condition that is similar to drug-induced pulmonary edema?
How do you tell the difference?
Diffuse alveolar hemorrhage (DAH)
If pulmonary edema does not respond to diuretics, DAH is likely
30
What is high altitude pulmonary edema?
occur at heights ranging from 2500-5000m and is influenced by the rate of ascent
- onset is often gradual, but typically occurs within 48-72 hours at high altitude
- the cause is presumed to be hypoxic pulmonary vasoconstriction, which increases pulmonary vascular pressure
31
What is treatment of high altitude pulmonary edema?
02 administration and quick descent from the high altitude
- inhalation of nitric oxide may improve oxygenation
32
Anesthesia implications for pulm. edema/RLD
current evidence shows benefit from ventilation using low TV & a RR of 14-18 while keeping end-inspiratory pressures <30 cm H2O
titration of PEEP along with inspiratory pausing can optimize lung compliance
pts with RLD typically have rapid, shallow breathing
- tachypnea should not be used as the sole criteria for delaying extubation if gas exchange and other assessments are satisfactory
33
What is chemical pneumonitis?
Aspiration pneumonitis
- When gastric fluid is aspirated, it destroys surfactant-producing cells and damages the pulmonary capillary endothelium
- This leads to increased capillary-permeable pulmonary edema and atelectasis
34
What is something you can do to decrease aspiration risk for chemical pneumonitis?
Elevate HOB during intubation/extubation
35
Chemical pneumonitis symptoms?
CXR may not demonstrate evidence of aspiration pneumonitis for _____ hrs
abrupt dyspnea, tachycardia, and desaturation
6-12 hrs
36
If aspiration occurs in supine position, where is radiographic evidence most likely visible?
Superior segment of RLL
37
Chemical pneumonitis anesthesia management
- If aspiration noted, suction oropharynx turn pt to the side
- T-burg position can prevent aspiration once gastric contents are in the pharynx
- Aspiration pneumonitis is best treated w/ supplemental 02 & PEEP
- There is no evidence that abx decrease the incidence of pulmonary infection or alter outcomes
- Abx may be considered if a pt symptomatic after 48 hrs and + culture results
38
What is EVALI?
E-cigarette vaping associate lung injury
- seen in pts using e-cigarettes/vaping
39
What is EVALI associated with?
pneumonia, diffuse alveolar damage, acute fibrinous pneumonitis, bronchiolitis, and interstitial lung disease (ILD)
40
What other additives have been associated with EVALI?
THC, CBD, vitamin E acetate, nicotine, and other oils
41
Symptoms of EVALI
What does CXR look like?
dyspnea, cough, N/V/D, abd pain, and chest pain
- may be febrile, tachycardia, tachypnea, and hypoxic
CXR findings are similar to the diffuse alveolar damage seen in ARDS
42
Treatment of EVALI
Antibiotics, systemic steroids, and supportive care
43
Severe COVID can progress to what?
Persistent inflammatory interstitial lung disease
44
What do symptoms range from with covid induced RLD?
dyspnea to ventilator dependance and pulmonary fibrosis
45
In covid induced RLD, reduced _____ _____ is the most commonly reported finding, and is directly r/t the severity of initial disease process
Diffusion capacity
46
What type of pt is at the highest risk for long term pulmonary complications when discussing covid induced RLD?
Pts who need mechanical ventilation
47
With covid induced RLD, pts may have long term:
decreased exercise capacity, hypoxia, and opacities on
48
What does PaO2 and PaCO2 look like with acute respiratory failure?
- Pa02 is <60 mmHg despite 02 supplementation, in the absence of a right-to-left intracardiac shunt
- A PaC0 >50 mmHg without respiratory-compensated metabolic alkalosis is consistent with the diagnosis of ARF
49
ARF is characterized by abrupt increased ___ and decreased ____
PaCO2
pH
50
In chronic respiratory failure, ____ is increased but ____ is normal
What does this reflect?
PaCO2
pH
This normal pH reflects renal compensation for respiratory acidosis
51
3 treatment goals of ARF?
1) a patent airway
2) hypoxemia correction
3) removal of excess C02
52
What are some ways O2 can be provided?
Why are these only helpful in mild to moderate v/q mismatching?
NC, venturi mask, nonrebreather, or T-piece
These devices seldom provide 02 concentrations >50%
53
When normal methods fail to maintain PaO2 >60, what can be initiated?
What is the goal of this device?
CPAP
CPAP may increase lung volumes by opening collapsed alveoli and decreasing right-to-left intrapulmonary shunting
54
What is one caution when using CPAP?
CPAP mask may increase the risk of aspiration, esp in pts with N/V
55
What is volume cycled ventilation?
fixed TV w/inflation pressure as dependent variable
- A pressure limit can be set; when pressure exceeds this value, the pressure relief valve prevents further gas flow and triggers an alarm to alert providor
56
Elevated peak airway pressure may indicate what?
pulmonary edema, pneumothorax, kinked ETT, or a mucous plug
57
What is a disadvantage to of volume cycled ventilation?
the inability to compensate for leaks in the delivery system
58
What are the primary modes of volume cycled ventilation?
assisted/controlled (A/C) ventilation and synchronized intermittent mandatory ventilation (SIMV)
59
What is a/c ventilation?
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
60
What is SIMV?
allows SV, 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
61
What are the advantages of SIMV over A/C?
use of respiratory muscles, lower mean airway and pressures, prevention of respiratory alkalosis, and improved pt–ventilator coordination
62
What is pressure-cycled ventilation?
provides gas flow until a preset airway pressure is reached. TV varies with changes in compliance and airway resistance
63
What is the most important predisposing factor for developing nosocomial pneumonia?
What's another name for nosocomial pneumonia?
Intubation
- caused by micro-aspiration of contaminated secretions around the ETT cuff
Ventilator associated PNA
64
Barotrauma may present as:
subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium, pulmonary interstitial emphysema, arterial gas embolism, or tension pneumothorax
65
In barotrauma, the presentation examples reflect passage of air from what?
Ruptured alveoli
66
How does infection increase the risk of barotrauma?
Weakening of pulmonary tissue
67
What is the common cause of atelectasis?
Hypoxemia during mechanical ventilation
68
In acute desaturation, what do you need to check for?
ETT migration, kinks, or mucous plugs
69
T/F
Hypoxemia d/t atelectasis is not responsive to an increase in Fi02
True
70
Other causes of sudden hypoxemia include tension ____ and ____, which are usually accompanied by HoTN
Pneumothroax
PE
71
What may be necessary to remove mucous plugs?
Bronchoscopy
72
How will atelectasis be identified on lung ultrasound?
Bronchogram showing static air
73
Pa02 reflects the adequacy of 02 exchange across _____ ____ membranes
This exchange is measured by the difference btw the ____ PA02 and the ____ Pa02
alveolar capillary
Alveolar/Arterial
74
What is PA02 − Pa02 gradient useful for?
evaluating gas exchange, lung function, and distinguishing the cause of arterial hypoxemia
75
Mechanisms of arterial hypoxemia chart
76
Desaturation of arterial blood occurs when the Pa02 is <___ mmHg
60
77
What are the 3 main causes of arterial hypoxemia?
Increasing the Fi02 improves the Pa02 in all of these conditions, except for what?
V/Q mismatch, right-to-left pulmonary shunting, and hypoventilation
a significant right-to-left pulmonary shunting
78
Compensatory responses are stimulated by an acute decrease in Pa02 <___ mmHg
In chronic hypoxemia, these responses are occur when Pa02 is <___
60
50
79
What are the compensatory responses stimulated by an acute decrease in PaO2?
1. Carotid body–induced increase in alveolar ventilation
2. Hypoxic pulmonary vasoconstriction to divert blood flow away from hypoxic alveoli
3. Increased SNS activity to increase COP and enhance tissue oxygen delivery
80
Chronic hypoxemia leads to an increase in RBC mass to improve:
02 carrying capacity
81
Explain dead space
TV ratio (VD:VT) reflects the efficacy of C02 transfer across alveolar capillary membranes
- indicates areas in the lungs that receive adequate ventilation but inadequate blood flow
- Ventilation to these alveoli is described as wasted or dead space
82
Normally the VD:VT is <___, but it may increase to ≥____ when there is an increase in dead space ventilation
0.3
0.6
83
When does an increased VD:VT occur?
ARF, decreases in cardiac output, and pulmonary embolism
84
The shunt fraction provides an assessment of ___ ______ and an estimate of the response to treatments
V/Q matching
84
What happens in right to left pulm. shunting?
perfusion of nonventilated alveoli
- The net effect is a decrease in Pa02
85
How much of COP is a physiologic shunt?
What does this reflect?
2-5%
This reflects the passage of pulmonary arterial blood directly to the left side of the circulation through the bronchial and thebesian veins
86
What are considerations to include with vent weaning?
the pt is alert and cooperative and can tolerate SV without tachypnea, tachycardia, or respiratory distress
87
Guidelines for extubation
* 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
88
When a pt appears ready for a trial of vent withdrawal, what 3 options are considered?
SIMV, which allows progressively fewer mandatory breaths until pt breathing on their own
Intermittent trials of total removal of mechanical support
Use of decreasing levels of pressure support ventilation
89
For vent weaning:
The Pa02 should remain >___ mmHg on Fi02 <0.5
PaC02 should remain <___ mmHg, and the pHa >7.30
Additional criteria: PEEP <__ cmH2O, RR <___, and VC >___ mL/kg
60
50
Additional: 5, 20, 15
90
Why is supplemental O2 often needed after extubation?
V/Q mismatching
91
What is ARDS?
What is ARDS caused by?
Proinflammatory cytokines increase alveolar capillary membrane permeability and alveolar edema
caused by inflammation and manifests as acute hypoxemic respiratory failure
92
What is the associated with the highest risk of ARDS?
Sepsis
93
Symptoms of ARDS
rapid-onset respiratory failure, hypoxemia, and CXR findings similar to cardiogenic pulmonary edema
94
Acute ARDS usually resolves, but may progress to what?
fibrosing alveolitis with persistent arterial hypoxemia and decreased pulmonary compliance
95
Supportive care for ARDS includes?
ventilation, abx, DVT prophylaxis, and early enteral feeding
96
What are the two main ARDS management strategies?
What is the aim of these?
Prone positioning
ECMO
The aim of this strategy is to rest the lungs until hypoxemia, and respiratory acidosis resolve
97
How does prone positioning help?
Prone positioning exploits gravity and repositioning of the heart to recruit lung units and improve V/Q matching
98
What are additional supportive therapies for ARDS?
fluid mgmt, NMB, inhaled nitric oxide, prostacyclins (PGI2), recruitment maneuvers, surfactant replacement, glucocorticoids, and ketoconazole
99
What is ILD?
a group of lung pathologies leading to diffuse parenchymal disease
100
Pts usually present with _____ and _____ _____, ultimately leading to chronic restrictive lung disease
Dyspnea
Nonproductive cough
101
Progressive pulmonary fibrosis causes loss of pulmonary vasculature, leading to what 2 things?
pulmonary htn & cor pulmonale
102
What is sarcoidosis?
Systemic granulomatous disorder involving many tissues, mainly the lungs and thoracic lymph nodes
- Often asymptomatic, and identified incidentally on CXR
103
Symptoms of sarcoidosis?
wheezing, dyspnea & cough
104
Myocardial sarcoidosis may cause what?
Neurologic sarcoidosis often displays what?
Dysrhythmias
unilateral facial nerve palsy
105
_______ sarcoid is common
______ sarcoidosis occurs in up to 5% and may interfere with intubation
Endobronchial
Laryngeal
106
What is a classic manifestation of sarcoidosis?
What else may develop?
Hypercalcemia
Cor pulmonale
107
_________ activity is increased w/sarcoidosis, bc it is produced by granuloma cell
Angiotensin-converting enzyme
108
What are other markers for sarcoidosis?
serum amyloid A, adenosine deaminase, and serum soluble IL2 receptor
109
How is diagnosis done with sarcoidosis?
Kveim skin test is used to detect sarcoidosis (similar to TB test)
- tissue or lavage fluid for dx may be obtained by mediastinoscopy and bronchoscopy
110
_________ are used to suppress sx of sarcoidosis and treat hypercalcemia
Corticosteroids
111
Advanced pulmonary fibrosis may lead to what?
Pulmonary HTN
112
What is hypersensitivity pneumonitis?
interstitial granulomatous inflammation after inhalation of fungus/spores particles
- may present as acute, subacute, or chronic
113
Symptoms of hypersensitivity pneumonitis?
What does CT show?
dyspnea & cough 4-6 hrs after inhalation, followed by leukocytosis, eosinophilia, and hypoxemia
ground-glass opacities in the mid to upper lung zones
114
How is diagnosis done with hypersensitivity pneumonitis?
bronchoscopy, trans-tracheal or bronchial biopsy, and cryobiopsy
115
Repeated episodes of hypersensitivity pneumonitis may lead to what?
Pulmonary fibrosis
116
Treatment of hypersensitivity pneumonitis?
antigen avoidance, glucocorticoids, and lung transplant
117
What is Pulmonary Langerhans Cell Histiocytosis?
inflammation around smaller bronchioles, causing destruction of the bronchiolar wall and surrounding parenchyma
- usually affects the upper and middle zones of the lung
- strong association with smoking tobacco
118
What does CT and lung biopsy look like with Pulmonary Langerhans Cell Histiocytosis?
CT shows cysts or honeycombing in upper zones with costophrenic sparing
Lung bx shows inflammatory lesions around the bronchioles containing langerhans cells, eosinophils, lymphocytes, and neutrophils
119
Treatment of Pulmonary Langerhans Cell Histiocytosis
smoking cessation, systemic glucocorticoids, and symptomatic support
120
What is Pulmonary Alveolar Proteinosis (PAP)?
Disease characterized by lipid-rich protein material in the alveoli
- It usually presents in the 40s-50s w/sx of dyspnea and hypoxemia
121
Pulmonary Alveolar Proteinosis may occur independently or associated with what?
chemotherapy, AIDS, or inhaled dust
122
What does CT show with Pulmonary Alveolar Proteinosis (PAP)?
batwing alveolar opacities in middle and lower lung zones
123
Treatment of Pulmonary Alveolar Proteinosis (PAP)
What is the airway management for this during anesthesia?
Tx of severe cases requires lung lavage under GA to remove the alveolar material and improve macrophage function
Airway mgmt during anesthesia for lung lavage includes DLT to lavage each lung separately and optimizing oxygenation during the procedure
124
What is Lymphangioleiomyomatosis?
Who does this mostly occur in?
Rare multisystem disease causing proliferation of smooth muscle of the airways, lymphatics, and blood vessels
Women of reproductive age
125
What do PFTs show with Lymphangioleiomyomatosis?
Symptoms?
PFTs show restrictive & obstructive disease with decreased diffusing capacity
Sx: dyspnea, hemoptysis, recurrent pneumothorax, pleural effusions
126
What is treatment of Lymphangioleiomyomatosis?
Sirolimus (immunosuppressive)
127
Aging is associated with decreased _______ and _______
This leads to increased ___ and decreased ____
Chest wall compliance
Elastic recoil
RV/VC
128
Geriatric pts breathe at a _____ lung volumes with _____ FRC
_____ and ____ decline with age
Higher
Increased
FEV1 and FVC
129
What two factors of aging decrease the efficiency of the diaphragm?
Kyphosis and the anteroposterior (AP) diameter of the chest increase
130
What are thoracic extra pulmonary causes of chronic extrinsic RLD?
Deformities of the sternum, ribs, vertebrae, & costovertebral structures
Work of breathing is increased d/t abnormal mechanics and increased airway resistance that results from decreased lung volumes
Poor ability to cough leads to recurrent pulmonary infections
131
What disease processes are included when discussing deformities of the sternum, ribs, vertebrae, & costovertebral structures?
ankylosing spondylitis, flail chest, scoliosis, and kyphosis
132
What are the 2 types of costovertebral skeletal deformities?
This may present as what?
scoliosis and kyphosis
They may present in combination as kyphoscoliosis, which leads to severe restrictive impaired lung function
133
When do costovertebral skeletal deformities begin?
What does this result in?
Commonly begins in late childhood/early adolescence and may progress during periods of rapid skeletal growth
results in a decreased ventilatory capacity & increased work of breathing
134
The severity of respiratory compromise when discussing costovertebral skeletal deformities correlates with what?
the degree of spinal curvature
135
What is pectus carinatum?
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
136
Explain how multiple rib fractures can be an issue?
especially when in a parallel vertical orientation, can produce a flail chest w/paradoxical inward movement of the unstable portion of the thoracic rib cage
137
Symptoms of multiple rib fractures?
lung contusions reduce what 2 things?
pain, increased work of breathing, inability to cough, and atelectasis
chest wall compliance & FRC
138
Treatment of flail chest?
positive pressure ventilation and stabilization
139
What is pleural effusion?
How is diagnosis made?
fluid (blood, serous fluid, pus, lipids) in pleural space
Dx made with CXR, CT, or bedside US (preferred)
140
What is pneumothorax?
What is idiopathic spontaneous pneumothorax, and who does this occur in?
gas in the pleural space
occurs most often in tall, thin men age 20-40 and is c/b rupture of apical subpleural blebs
141
What is a tension pneumo?
medical emergency and develops when gas enters the pleural space during inspiration and can't escape during exhalation
142
Symptoms of tension pneumo
respiratory distress, tachypnea, SOB, hypoxia, pleuritic chest pain, tachycardia, HoTN
- trachea may be deviated away from ptx
- breath sounds are decreased/absent on the side of ptx
- if the pt is on vent, increased airway pressures and decreased TV
143
Treatment of tension pneumo
Immediate evacuation through a needle or small-bore catheter placed into the second anterior intercostal space
144
Pleural fibrosis may follow what 3 things?
What is treatment?
may follow hemothorax, empyema, or surgical pleurodesis
If symptomatic, surgical decortication to remove thick fibrous pleura is considered
145
What is acute mediastinitis caused by?
Symptoms and treatment?
bacterial contamination after esophageal perforation
Sx: chest pain & fever
Tx: broad-spectrum abx & surgical drainage
146
What are examples of anterior mediastinal masses?
thymomas (20%, most common), germ cell tumors, lymphomas, intrathoracic thyroid tissue, & parathyroid lesions
147
What are examples of middle mediastinal masses?
tracheal masses, bronchogenic and pericardial cysts, enlarged lymph nodes, and proximal aortic disease (i.e., aneurysm or dissection)
148
What are examples of posterior mediastinal masses?
neurogenic tumors and cysts, meningoceles, lymphomas, descending aortic aneurysms, and esophageal neoplasms
149
Treatment of mediastinal mass is d/o ______
Many require what?
Underlying pathology
surgery, radiation, chemo, or surveillance
150
What is important to do in preop for treatment of mediastinal mass?
measurement of a flow-volume loop, chest imaging, and assessing for airway compression
## Footnote
- CT can establish the size of the mass and degree of compression
- Fiberoptic bronchoscopy is useful for evaluating the degree of airway obstruction
- Preop mass radiation to decrease its size should be considered whenever possible
151
What anesthetic technique is preferred for symptomatic pts requiring diagnostic tissue biopsy for mediastinal mass?
LA technique
152
What is asphyxiating thoracic dystrophy?
“Jeune syndrome:” disorder with skeletal dysplasia and multiorgan dysfunction
- associated with cysts in kidney, pancreas, and liver
- retinal abnormality with short ribs, short limbs, narrow thorax, and polydactyly
153
What is fibrodysplasia ossificans?
genetic variation in bone morphogenetic protein (BMP)
154
What is Poland syndrome?
partial or complete absence of pectoral muscles, commonly affecting one side. May also have paradoxical respiratory motion due to the absence of multiple ribs
155
Abnormalities of the spinal cord, peripheral nerves, NMJ, or skeletal muscles may result in restrictive pulmonary defects characterized by what?
an inability to generate normal respiratory pressures
156
Pts w/severe neuromuscular disorders are dependent on what to maintain adequate ventilation?
their state of wakefulness
157
During sleep, hypoxemia and hypercapnia may develop and contribute to the development of what?
cor pulmonale
158
For Guillain-barre, what percent of pts require mechanical ventilation?
For how long?
20-25%
On average 2 months
159
What is the most common disease affecting neuromuscular transmission that may result in respiratory failure?
Myasthenia gravis
160
Why are muscular dystrophy pts predisposed to pulm. complications?
What type of device may be helpful?
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
161
In quadriplegic pts w/ injury below ___, breathing is maintained by the diaphragm
If higher, because the diaphragm is active only during inspiration, ____ is almost totally absent
T4
Coughing
## Footnote
Higher levels of injury result in diaphragmatic paralysis
162
With diaphragmatic breathing, there is a paradoxical _____ motion of the upper thorax during inspiration, resulting in diminished ___
Inward
TV
163
Quadriplegic pts have mild ______ constriction caused by the PNS tone that is unopposed by SNS activity from the spinal cord
What is helpful for this?
bronchial
Anticholinergic bronchodilators
164
Obesity is associated with decreases in what? (think PFT)
The _____ ratio is usually preserved
FEV1, FVC, FRC, ERV
FEV1:FVC
165
BMI > ___ kg/m2 leads to a decreased RV and TLC
With extreme obesity, ____ may exceed closing volume and approach RV
40
FRC
166
Why do obese pts have respiratory issues? (think patho)
Adipose buildup in the anterior abdominal wall hinders diaphragmatic mvmt, diminishes basal lung expansion, and causes closure of peripheral lung units
- This leads to V/Q abnormalities and hypoxemia, especially during sleep
- Adipose cells release adipocytokines that play a part in systemic inflammation triggered by obesity-related hypoxemia
167
How does pregnancy sometimes lead to restrictive lung physiology? (think patho)
When do these changes peak?
the subcostal angle of the rib cage and lower chest wall circumference increase and the diaphragm moves cephalad
- Increased levels of relaxin cause stretching of the lower rib cage ligaments
- The rib cage circumference expands
37th week of pregnancy
168
Chest wall normalizes about ___ months postpartum, except for the subcostal angle, which remains wider by about ___%
6
20
169
The enlarging uterus during pregnancy pushes the diaphragm up by about ___ cm
4
170
For RLD anesthesia management, since the lungs are poorly compliant, ______ _____ _____ may be necessary
increased inspiratory pressures
171
________ _______ is helpful for visualizing the airways and obtaining samples for bx and culture
Fiberoptic bronchoscopy
172
_____ occurs in 5-10% of pts after transbronchial lung biopsy and in 10-20% after percutaneous needle biopsy
Pneumothorax
173
What is the major contraindication to pleural biopsy?
Coagulopathy
174
What type of anesthesia do you use for mediastinoscopy?
General
175
What is a mediastinoscopy?
blunt dissection along the pretracheal fascia is performed, which permits biopsy of paratracheal lymph nodes down to the level of the carina
176
What are the risks for mediastinoscopy?
ptx, mediastinal hemorrhage, venous air embolism, and RLN injury
the mediastinoscope can also exert pressure on the right innominate artery, causing loss of pulses in the right arm and compromise of right carotid artery blood flow
