Thoracic/Respiratory/Monitoring Test 5 Flashcards
(185 cards)
1
Q
factors that increase PPC
A
- preop FEV1 < 2L or < 40% of predicted (greatest risk )
- inability to climb flight of stairs
- desaturation > 4% with exercise
2
Q
cushings s/s listed on PP
A
metabolic alkalosis
hypokalemia
hyperglycemia
3
Q
10 - 25% of tumors secrete this hormone what are Sx
A
PTH * inc Calcium*
confusion, vomiting, bradycardia, polyuria, abd cramps, neuro changes
4
Q
COPD findings on Xray
A
hyperinflation Inc A-P diameter
diaphragm flattening
prominent PA (PHTN)
wide right side border (PHTN)
5
Q
ECG signs of RV hypertrophy secondary to pulmonary HTN
A
V1 - tall R wave
Lead I RAD
biphasic P wave (RVH causes R atrial hypertrophy)
6
Q
ECHO changes in RVH
A
RV wall thickness
chamber enlargement
septal shift
tricuspid regurgitation
increased PVR
7
Q
albumin level at risk for PPC
A
< 3.6 G/dL
8
Q
this (cardiac function/measurements related) is associated with prolonged mechanical ventilation and greater lung injuries
A
high filling pressure
(heart)
9
Q
PAC indication
A
high severity in any of these
CV
valvular disease
PHTN
10
Q
consequences if you dont support head while patient is in lateral position
A
lateral flexion of neck
leads to
compression of jugular veins and vertebral arteries
compromises cerebral circulation
11
Q
pleural pressure increases by ___ cm H2O per ___ cm of lung dependency
A
pleural pressure increases by 0.25 cm H2O per 1 cm of lung dependency
12
Q
this determines flow of blood in Zone 2
A
arterial - Alveolar pressure gradient
(this increases the further down the lung you go)
13
Q
pressure gradient that determines blood flow in Zone 3
A
arterio-venous
(maintains constant blood flow in dependent portions of lungs)
14
Q
in open chest, why does mediastinum fall
A
loss of negative intrapleural pressure (ITP) in NDL
15
Q
diminishes effects of mediastinal shift
diminishes paradoxical respirations
(open chest anesthetized lateral)
A
PPV
16
Q
absolute indications for OLA
A
one lung has to be isolated from the other
- to prevent contamination of healthy lung
- to control distribution of ventilation
- unilateral lung lavage
17
Q
examples of absolute indications for OLA
deal with preventing contamination
A
to prevent
absess
hemorrhage
18
Q
examples of absolute indications for OLA
dealing with controlling distribution of ventilation
A
to prevent
- bronchopleural fistula
- giant unilateral cyst of bullae (rupture w/ PPV!)
- bronchial disruption or trauma
19
Q
relative indications for OLA
(generally speaking)
A
when surgical exposure is improved by deflating lung
20
Q
relative indications for OLA
give examples of high priority cases
A
Pneumonectomy
Upper Lobectomy
Repair of Thoracic Aneurysm
Mediastinal exposure
Thoracoscopy
21
Q
relative indications for OLA
give examples of low priority cases
A
- middle and lower lobectomy
- esophageal surgery
- T-spine procedures
22
Q
One-lung ventilation can be accomplished with with use of what?
A
One-lung ventilation can be accomplished with:
single lumen ETT
double lumen endobronchial tube
use of bronchial blockers
23
Q
disadvantage of single lumen tubes
A
inability to ventilate the operative lung if necessary
in right lung placement, upper lobe most usually occludes
24
Q
left bronchial tubes CI in what conditions?
A
bronchial lesions
descending thoracic aortic aneurysm
25
most **common** complication of DLT
**malposition**
26
DLT
Resistance on insertion met for M vs F
**F 27**
**M 29**
27
when would you use bronchial blocker devices
cases w/
## Footnote
**difficult AW**
**tracheostomy**
**already intubated (dangerous to do tube exchange for DLT)**
**small children**
28
HPV causes what PVR changes
**INC up to 300%**
29
Factors reducing the effectiveness of HPV:
Factors reducing the effectiveness of HPV:
* **Alkalosis (hypocapnia)**
* **Hemodilution and hypervolemia**
* **Hypothermia**
* **Excessive TV and PEEP**
* **Volatiles (\>1.5 MAC)**
* **Vasodilators, PDEI, CCBs**
30
specific drugs that reduce effectiveness of HPV:
specific drugs that reduce effectiveness of HPV:
* **nitroglycerin**
* **dobutamine**
* **nicardipine**
* **verapamil**
* **dopamine**
* **phenylephrine**
* **epi**
31
thoracotomy is one of the most painful operations that can lead to 3 things:
**decreased respiratory effort**
**hypoxemia**
**acidosis**
32
thoracic epidulars for thoracotomy put at what level?
infused with what?
**T6 - T8**
**infused with opioids**
**dilute locals**
33
benefit of regional in thoracic sx
**reduce atelectasis**
**reduce pneumonia**
**reduce resp failure**
34
primary goals of OLV
**maintain oxygenation**
**protect individual lung**
**provide favorable surgical field**
35
this maneuver can reduce cytokine response to support HPV
**permissive hypercapnea**
36
keep CO2 \< 60 to reduce incidence of 3 things
**dysrhythmias**
**hypotension**
**pulm HTN**
37
incidence of hypoxemia with OLV
more common in which lung?
**5 - 10%**
**right lung procedures especially**
**(**more baseline perfusion and larger)
38
diagnosis and treatment for **mediastinal mass** is made by:
**thoracotomy**
**thoracoscopy**
**mediastinoscopy**
39
tumors located where (anatomically) in the mediastinum can compress the trachea and inc air resistance, making GA dangerous
**tumors in Anterior mediastinum**
40
Sx of SVC syndrome
**dilation of collateral veins in upper body**
**rubor and edema in upper body**
**edema around eyes**
**head ache**
**visual disturbance**
**altered mentation**
**also: low CO, low cerebral perfusion**
41
Complications in Mediastinoscopy:
* **hemorrhage**
* **pneumothorax**
* **dysrhythmias**
* **bronchospasm**
* **nerve damage**
* **tracheal or esophageal laceration**
* **chylothorax**
42
Mediastinoscopoy
Scope passes near which structures?
Scope passes near the
* **left common carotid**
* **left subclavian,**
* **innominate artery and veins**
* **vagus nerve**
* **left recurrent laryngeal nerve**
* **thoracic duct**
* **superior vena cava**
* **aortic arch**
43
ETCO2: measuring CO
ETCO2: measuring CO
## Footnote
**capnometry**
44
ETCO2: recording of the measurement
ETCO2: recording of the measurement
## Footnote
**capnography**
45
ETCO2: Visual display of continuous CO2 monitoring
ETCO2: Visual display of continuous CO2 monitoring
## Footnote
**Capnogram**
46
* **\_\_\_\_ \_\_\_\_\_** of gas mixtures determines the amount of CO2 relative to other gases
* what law is this
* **Infrared analysis** of gas mixtures determines the amount of CO2 relative to other gases
* **Beer-Lambert Law**
47
* ETCO2 Disadvantages
* need for scavenging of sampled gas and risk of contamination from secretions or condensation
48
EtCO2
* Can be inaccurate during certain situations such as: (2) reasons
* Can be inaccurate during certain situations such as:
* **large increases in deadspace (low CO2 concentration)**
* **small tidal volumes (low CO2 readings reflecting inadequate alveolar ventilation)**
49
* **Oxyhemoglobin** absorbs more infrared light at a wavelength of **\_\_ nm**
* **Deoxyhemoglobin** absorbs more red light at a wavelength of __ **nm**
* **Oxyhemoglobin** absorbs more infrared light at a wavelength of **940 nm**
* **Deoxyhemoglobin** absorbs more red light at a wavelength of **660 nm**
50
* The ___ the ratio of red/infrared absorption, the ___ the oxygen saturation
* The **greater** the ratio of red/infrared absorption, the **lowe**r the oxygen saturation
* **inverse relationship**
51
* These dyes result in a significant but transient drop in measured oxygen saturation because the dye alters absorption of infrared light
Injectable dyes
* **methylene blue**
* **indigo carmine**
* **transient** change in O2 sat
* typically, last **15 – 30 seconds**
52
* Factors that alter O2 binding
* **H+ concentration (acid base)**
* **CO2 tension**
* **Temperature**
* **2,3-diphosphoglycerate**
* **Abnormal hemoglobin**
53
**Pulmonary Risk Factors**
* **Albumin level \<3.5 g/dL**
* **Advanced age**
* **ASA class \> 2**
* **Alcohol use**
* **Abnormal chest exams**
* **CHF**
* **Cigarette use**
* **COPD**
* **Emergency sxUpper abdominal and thoracic sx**
* **GA**
* **Head and neck sx**
* **Impaired cognition**
* **Neuro sx**
* **Prolonged procedures**
* **Vascular sx**
54
elimination t 1/2 of CO
4 - 6 hrs
55
* Mucociliary and pulmonary immune function improves significantly **\_\_ to \_\_** weeks after smoking cessation
* Mucociliary and pulmonary immune function improves significantly **6-8** weeks after smoking cessation
56
* Airway management may be made more difficult if cessation occurs prior to this amount of time (4- 8 weeks) because why?
* Airway management may be made more difficult if cessation occurs prior to this amount of time (4- 8 weeks) because there is an **increase in pulmonary secretions during the first month of smoking cessation**
57
* Patients that continue to smoke have a **\_\_\_\_**the risk postop complications and **\_\_\_**the risk of **pneumonia**; for patients that have smoked 60 pack years or more.
* Patients that continue to smoke have a **Double** the risk postop complications and **3X** the risk of **pneumonia**; for patients that have smoked 60 pack years or more.
58
* Pack years: formula
* **30 years @ 2 PPD**
* **30 years @ 5 cig per week**
* Pack years: # of years smoked x number of packs per day
* **30 years @ 2 PPD**
* **PPD=60 pack years**
you guys correct me if im wrong
* **PPD = 30 x 5/20**
* **5 cigs per 5 days would be 1 cig per day**
* **so**
* **5 cig per 7 days would be 5/7 = 0.71 cig per day**
* convert from cigs to packs
* **0.71 / 20 = 0.035 Packs per day**
* **0.035 x 30 years = 1.065 pack years**
59
* **95% of all acute URI are result of some infectious cause like ____ or ____ \_\_\_\_\_\_**
* diagnosis is made from ___ \_\_\_
* **95% of all acute URI are result of some infectious cause like viral or bacterial nasopharyngitis**
* diagnosis is made from clinical s/s
60
* Airway hyper-reactivity may require\_\_ weeks to improve
Airway hyper-reactivity may require **\>6** weeks to improve
61
Intraoperative management of acute URI should include:
* Intraoperative management should include:
* **adequate hydration**
* **reduction in secretions w/ suction**
* **limiting manipulation of the airway**
* **LMA may be good choice as alternative to ETT b/c reduces manipulation of airway and reduces risk of bronchospasm**
62
* Reported adverse events in an acute URI case include:
* Reported adverse events include:
* **laryngospasm**
* **airway obstruction**
* **bronchospasm**
* **desaturation**
* **atelectasis**
* **post-intubation croup**
63
OHS triad of Sx
* **obesity**
* **daytime hypoventilation with hypercapnia**
* **sleep-disordered breathing without an alternative cause**
64
* (OHS and OSA) **chronic \_\_\_\_** and **\_\_\_\_\_\_** lead to an inflammatory state and secondary disorders such as (4):
* (OHS and OSA) **chronic hypoxemia** and **hypercarbia** lead to an inflammatory state and secondary disorders such as:
* **hypertension**
* **stroke**
* **diabetes**
* **atherosclerosis**
65
* **Hallmark of OSA** is **\_\_\_ ____ and ___ \_\_\_\_**, which can lead to daytime somnolence
* **Hallmark of OSA** is **habitual snoring** and **fragmented sleep**, which can lead to daytime somnolence
66
* **\_\_\_%** of OSA have OHS
* **5%** of OSA have OHS
67
* **Obstruction incidence w/ OSA**:
* **\_\_%** of pediatric patients with OSA after tonsillectomy
* **\_\_%** in those without OSA after tonsillectomy
* **Obstruction incidence w/ OSA**:
* **25%** of pediatric patients with OSA after tonsillectomy
* **1%** in those without OSA after tonsillectomy
68
**obstructive disorders (examples)**
difficulty taking air out
low airflows
**COPD**
**asthma**
**bronchiectasis**
69
**restrictive dz examples**
stiffness inside lung tissue or chest wall cavity
difficulty taking air in
low lung volumes
**interstitial lung disease**
**scoliosis**
**neuromuscular cause**
**Marked obesity**
70
* Asthma Characterized by (3):
* Characterized by:
* **chronic airway inflammation**
* **reversible airflow obstruction**
* **bronchial hyper-reactivity**
71
**Asthma**
* __ to __ % of population
**Asthma**
* **5-7%** of population
72
* single greatest risk factor for development of asthma
* **genetic tendency** to develop allergic diseases
* **Atopy**
73
* Asthma Results from ___ and ___ factors.
* Results from **genetic** and **environmental factors** (Viruses, allergies, occupational exposure etc)
74
Asthma may manifest as (5):
Asthma may manifest as
* **dyspnea**
* ***_eosinophilia_***
* **cough**
* **tachypnea**
* **hyperventilation**
75
* (in asthma) these can flare up an attack:
can flare up an attack
* **Beta antagonists**
* **NSAIDs**
* **exercise**
* **respiratory infection**
* **emotional stressors**
76
* **Mild asthma** is usual accompanied by what changes to PaO2 and PaCO2
* **Mild asthma** is usual accompanied by a **normal PaO2 and PaCO2**
77
* **Severe asthma**
* PaO2 and PaCO2 changes
* Severe asthma
* **PaO2 \<60 (hypoxia), PaCO2 \>50**
78
* (asthma) Chest radiographs may show:
(asthma) **Chest radiographs** may show **hyperinflation of the lungs**
79
**\_\_\_ and \_\_\_** are direct spirometry readings that can be used to measure severity of **expiratory airflow obstruction** (asmtha main issue)
* **FEV1 and MMEF** (maximum mid expiratory flow rate) are direct spirometry readings that can be used to measure severity of **expiratory airflow obstruction** (asmtha main issue)
80
* Typical asthmatic patient presenting for treatment will have what FEV1 and MMEF changes
* Characteristic flow volume loop shown
* Typical asthmatic patient presenting for treatment will have
* **FEV1** \<**35% of normal**
* **MMEF 20% or less of normal**
* Characteristic flow volume loop shown with **“downward scooping”**
81
Treatments fall into 2 categories (asthma)
**controller**
**rescue**
82
Asthma Controller treatments:
* Asthma Controller treatments:
* **Control of the disease with**
* **corticosteroids**
* **antileukotrienes**
* **theophylline**
* **Modify airway environment so acute narrowing will occur less frequently**
83
* Rescue treatments:
* Rescue treatments:
* Relief or rescue of symptoms with
* **beta2 agonists**
* **Albuterol**
* **Abluterol + anticholinergics**
84
The goal of preoperative evaluation (asthma)
* The goal of preoperative evaluation
* formulate an anesthetic plan that **prevents or blunts expiratory airflow obstruction**
* Prevent **bronchoconstriction** dt **airway stimulation**
* **maximize lung fx** (continue any therapy)
85
who may benefit from preop steroid supplementation
goal of this is to prevent what suppression
* Pay attention to doses however or high frequency.
* If taking oral steroids such as **prednisone** then they probably will need preop steroid administration.
* prevents **hypothalamic pituitary adrenal axis suppression**
86
* Asthma Increased perioperative risk related to recent hospitalizations
* **Increased perioperative risk**
* **more than 2 hospitalizations in 12 months**
87
* Incidence of clinically significant bronchospasm reported at **\_\_ to \_\_%** of all procedures performed in asthma patients
* Incidence of clinically significant bronchospasm reported at **0.2-4.2%** of all procedures performed in asthma patients
88
* Bronchospasm Signs include
* Bronchospasm Signs include
* **wheezing**
* **increased peak pressure**
* **decreasing exhaled TV**
* **slowly rising ETCO2 waveform**
89
non asthma bronchospam causes
* **mechanical obstruction in circuit**
* **pulm aspiration**
* **edema**
* **PE**
* **pneumothorax**
90
aminophylline and theophylline MOA
(PDEi)
## Footnote
**inhibit cAMP breakdown**
**lots of cAMP = Bronchodilation**
91
drugs and doses of **steroid tx for status asmaticus**
* **Cortisol 2mg/kg** followed by **0.5 mg/kg/hr infusion**
* **Methylprednisolone 60-125 mg IV Q6 hours**
92
can **improve lung function** and **reduce hospitalization rate for status asthmaticus**
(drugs for status other than steroids)
* Some studies show that **IV Mag sulfate** can improve lung function and reduce hospitalization rate for status asthmaticus
93
* How does Prolonging expiratory phase help in bronchospasm
* Prolong expiratory phase
* **allows complete exhalation to overcome the spasm**
* **prevents auto-peep (initiation inspiration prior to full expiration)**
94
* Most common pulmonary d/o encountered in anesthesia
**COPD**
95
**COPD**
* Mainly caused by **\_\_\_**and more common in **\_\_\_** patients
* Mainly caused by **smoking** and more common in **male** patients
96
5 COPD consequences:
* 5 COPD consequences:
1. **Deterioration of elasticity** and **loss of recoil** within lung parenchyma
* Normally parenchyma helps to maintain airway in the open position; in COPD, now more likely to collapse
2. **Decreased rigidity** of the bronchiolar wall predisposing them to **collapse during exhalation**
3. Increased **gas velocity in narrowed bronchioli favoring collapse**
* Due to lowered pressures inside alveoli
4. **Bronchospasm and obstruction** from increased **secretions**
5. **Enlargement of air sacs** and **destruction of parenchyma**
97
**COPD** Risk factors
**COPD** Risk factors
* **Smoking**
* **frequent**
* **respiratory infections**
* **occupational exposure to dust ( mining and textiles)**
* **genetic factors (alpha-1 antitrypsin deficiency)**
98
* **\_\_\_ \_\_\_\_\_**
1. A substance that protects the elastic tissue of the lungs from **neutrophil elastase**. The defective form accumulates in the\_\_\_resulting in **\_\_\_\_** and the lack of the normal form in the lungs results in pulmonary disease like\_\_\_ and \_\_\_\_
2. The deficiency is a rare **\_\_\_\_\_\_**condition
* **Alpha-1 antitrypsin**
1. A substance that protects the elastic tissue of the lungs from **neutrophil elastase**. The defective form accumulates in the **liver** resulting in **cirrhosis** and the lack of the normal form in the lungs results in pulmonary disease like **asthma and emphysema**
2. The deficiency is a rare **homozygous** condition
99
**chronic bronchitis**
* mechanism of obstruction:
* dyspnea (mild, mod, severe)
* FEV1
* PaO2
* PaCO2
* Diffusion capacity
* Hct
* Cor pulmonale
* prognosis (good, poor)
**chronic bronchitis**
* mechanism of obstruction: **dec AW lumen dt mucus/inflammation**
* dyspnea (mild, mod, severe) **moderate**
* FEV1 **decreased**
* PaO2 **marked decrease**
* PaCO2 **increased**
* Diffusion capacity **normal**
* Hct **INCREASED**
* Cor pulmonale **makred**
* prognosis (good, poor) **Poor**
100
**emphysem'er**
* mechanism of obstruction: **loss of elastic recoil**
* dyspnea (mild, mod, severe) **severe**
* FEV1 **decreased**
* PaO2 **modest decrease**
* PaCO2 **normal to decreased**
* Diffusion capacity **decreased**
* Hct **normal**
* Cor pulmonale **mild**
* prognosis (good, poor) **good**
**emphysem'er**
* mechanism of obstruction:
* dyspnea (mild, mod, severe)
* FEV1
* PaO2
* PaCO2
* Diffusion capacity
* Hct
* Cor pulmonale
* prognosis (good, poor)
101
characteristic of COPD (3)
* characteristic of COPD
* **Chronic productive cough**
* **progressive exercise limitation**
* **expiratory airflow obstruction**
102
* COPD: As the **expiratory airflow increases in severity** in these patients, you will starts to see some common symptoms such as: (4)
* As the **expiratory airflow increases in severity** in these patients, you will starts to see some common symptoms such as:
* **Tachypnea**
* **Prolonged expiratory phases**
* **Decreased breath sounds**
* **Expiratory wheezes**
103
* Main mechanism of airway obstruction
* **Chronic bronchitis** → main cause
* **Emphysema** → main cause
* Main mechanism of airway obstruction
* **Chronic bronchitis** → is a decrease in diameter of airway lumen due to mucus and inflammation
* **Emphysema** → loss of elastic recoil
104
**COPD**
* 2 most important therapies
* help alter the natural progression of COPD
* **Smoking cessation**
* **long-term oxygen supplementation**
105
* **COPD: Long term 02 supplementation** recommended for:
* Pa02 \<55
* Hct \> 55%
* Evidence of Cor Pulmonale.
* **Pa02 \<55**
* **Hct \> 55%**
* **Evidence of Cor Pulmonale.**
106
* **\_\_\_\_\_\_\_\_** are the predominant drug therapy in COPD
* Decrease the hyperinflation and decrease dyspnea
* Can improve exercise tolerance
* **Bronchodilators** are the predominant drug therapy
* Decrease the hyperinflation and decrease dyspnea
* Can improve exercise tolerance
107
* indication for diuretics in COPD
* used if any evidence of
* **cor pulmonale**
* **RVF resulting in peripheral edema**
108
* Median sternotomy or VATS for overdistended emphysema cases
* Improvements after procedure:
* ***increase in elastic recoil***
* increases expiratory airflow
* ***decreased hyperinflation***
* improved diaphragmatic and chest wall mechanics
* ***improvement of V/Q matching***
* **improve alveolar gas exchange
109
* People with COPD that present to the operating room with any type of procedure assess these to predict risk/pulm complications:(4)
* People with COPD that present to the operating room with any type of procedure assess to predict risk/pulm complications:
* **Exercise tolerance**
* **Chronic coughing**
* **Unexplained Dyspnea**
* **Wheezing**
110
COPD: Regional anesthesia is suitable for ____ \_\_\_\_\_ and ____ \_\_\_\_ procedures as long as large doses of sedatives are not needed
Regional anesthesia is suitable for **lower intra-abdominal** and **lower extremity** procedures as long as large doses of sedatives are not needed
111
* ______ is the choice if upper abdominal or thoracic procedures are to be performed.
* **General** is the choice if upper abdominal or thoracic procedures are to be performed (COPD).
112
* Do not want a sensory level above \_\_\_\_\_, can impair muscle that add in adequate exhalation. This is the problem with COPD, long expiratory phase and air trapping.
* Do not want a sensory level above **T-6**, can impair muscle that add in adequate exhalation. This is the problem with COPD, long expiratory phase and air trapping.
113
Postop therapy for COPD:
* **lung expansion maneuvers**
* **positive pressure**
* **chest physiotherapy**
114
* Extremely useful for upper abdominal and inter-thoracic surgeries
* **recommended for high risk thoracic, abdominal or major vascular surgeries.**
**NA opioids**
cuation w/ sedation from rostral spread with duramorph
115
* Continued Mechanical Ventilation in Severe COPD post op for what procedures and preop FEV1/FVC ratio/PaCO2
* **esp. major abdominal or thoracic procedures**
* **preoperative FEV1/FVC ratios of less than 0.5**
* **preoperative PaCO2 of more than 50 mmHG**
116
risks associated with lowering I:E ratio
* can lower TV and MV
* --\> exacerbate **hypercapia, hypoxia and acidosis**
* **↑ PVR** — **more strain on the RV**.
117
* Another cause of expiratory air obstruction
* Similar to expiratory airflow obstruction seen in COPD.
* **Chronic disease of the airways characterized by localized, irreversible dilation of a bronchus caused by destructive inflammatory processes involving the bronchial wall**
**Bronchiectasis**
118
Bronchiectasis accounts for a significant number of cases of **\_\_\_\_ \_\_\_\_\_** which may require surgical resection of the involved lung segment or arterial embolization
* **Massive hemoptysis**
119
* **Bronchiectasis: Massive hemoptysis:** how many mL/ 24 hours
* **\> 200 ml in a 24 hr period**.
120
* **Cystic fibrosis:** Autosomal ______ disorder caused by a mutation on chromosome \_\_
* resulting in defective _____ ion transport in the _____ cells of the\_\_\_, \_\_\_, ___ , \_\_\_, and ___ (organs)
* **Autosomal recessive** disorder caused by a mutation on **chromosome 7**
* resulting in defective **chloride ion** transport in the **epithelium cells** of the lungs, pancreas, liver, GI tract and reproductive organs.
121
**CF:** clinical manifestations (3)
* **cough**
* **chronic purulent sputum**
* **exertion dyspnea**
122
* **\_\_\_\_\_** is present in almost all adults with CF
* **COPD** is present in almost all adults with CF
123
* CF: ways to maintain secretions in a less viscous state
* **Humidification of inspired gases**
* **adequate hydration**
* **avoidance of anticholinergics**
* **frequent suctioning**
* **helps to ↓ complications post op and intra op**
124
Triad of Ciliary Dyskinesia we talked abou wth Ciliary Dyskinesia
**Kartagener's syndrome**
125
Kartagener's syndrome triad
1. **chronic sinusitis**
2. **bronchiectasis**
3. **situs inversus**
126
how many patients with congenitally nonfunctioning cilia manifest situs inversus?
**1/2**
| (198 co-exisiting)
127
childhood disease most often the result of respiratory syncytial virus (RSV) and rare caues of COPD
* **Bronchiolitis obliterans**
128
* **Tracheal stenosis** - most often the result of **\_\_\_\_ ____ \_\_\_\_**
* most common due to prolonged ET tracheal intubation
* minimized with ____________ Cuffs
**tracheal mucosal ischemia**
minimized with **High Volume-Low pressure** Cuffs
129
* Tracheal stensis: Symptomatic in adults with trachea **\_\_\_**in diameter
Symptomatic in adults with trachea **\< 5 mm** in diameter
130
**Tracheal Stenosis:** Flow-Volume loops will have what characteristics?
* Flow-Volume loops will be **flattened (inspiratory and expiratory phases)**
131
Treatment for Tracheal Stenosis
* Surgical resection of the stenotic segment and re-anastomosis is often required
132
**Pulmonary Edema (causes)**
* **acute intrinsic restrictive lung disease**
* **aspiration**
* **opioid overdose**
* **re-expansion of collapsed lung**
* **CHF**
* **negative pressure, etc.**
133
* **Cardiogenic pulmonary edema** is characterized by: (3)
* **extreme dyspnea**
* **tachypnea**
* **signs of SNS activation**
134
* Aspiration Pneumonia is best treated by
**supplemental oxygen** and **PEEP**
135
* Aspiration pneumonitis occurring during anesthesia in which the greatest risk is associated with __ ml or more of __ pH
* **Mendelson's Syndrome**
* Aspiration pneumonitis occurring during anesthesia in which the greatest risk is associated with **25** ml or more (**0.4 ml/kg**) of **\< 2.5** pH
136
pathophys of pulm edema
High negative intrapleural pressure:
* **decreases the interstitial hydrostatic pressure**
* **increases venous return**
* **increases left ventricular afterload**
* **increases the transcapillary pressure gradient**
* **produces edema**
137
* Pulm Edema: May occur **after relief** of acute upper airway obstruction due to:
* **Laryngospasm**
* **Tumors**
* **Epiglottitis**
* **hiccups**
* **OSA in spontaneously breathing patients**
138
Vent management: Pulm Edema
* **Low TV (6 ml/kg)** with a **compensatory increase in rate (14-18)** is usually appropriate
139
Patients with restrictive lung disease typically have this breathing pattern
Patients with restrictive lung disease typically breath **rapid and shallow**
140
* **Chronic** **intrinsic** **restrictive lung disease**
* General basis- **Inflammatory** disease with the presence of abnormal cells called **granulomas.**
**Sarcoidosis**
141
Sarcoidosis involves many tissues with predilection for these:
* **intrathoracic lymph nodes**
* **lungs**
142
most common form of neurologic involvement in sarcoidosis is what? (trivia from co-existing)
**unilateral facial nerve palsy**
143
classic manifestation (sarcoidosis)
**hypercalcemia**
**\<10 % of patients**
144
(soliosis/kyphosis) respiratory failure failure most likely in patients with **\_\_\_\_\_** associated with a vital capacity of less than __ % of predicted value and scoliotic angle of more than **\_\_** degrees
(stoelting)
(soliosis/kyphosis) respiratory failure failure most likely in patients with **kyphoscoliosis** associated with a vital capacity of less than **45** % of predicted value and scoliotic angle of more than **110** degrees
(stoelting)
145
* scoliotic angle is greater than 100 degrees may cause these
* **Chronic Alveolar hypoventilation**
* **Hypoxemia**
* **secondary erythrocytosis**
* **PHTN**
* **Cor pulmonale**
* Increased risk of **PNA** and **hypoventilation post op especially when exposed to CNS depressants**
146
* **Flail chest.** Results from multiple rib fractures most often, especially from __ or ___ orientation
Flail chest. Results from multiple rib fractures most often, especially from **parallel or vertical** orientation
147
imaging confirmation of pleural effusion
* Most confirmed by chest **x-ray** of **25-50 ml** seen
* Can be diagnosed with **ultrasound or CT** scan as well
148
* **Cigarette smoking** increases the risk of primary spontaneous pneumothorax by \_\_\_-fold
149
* Mediastinal Mass: A large tumor that can be associated with:
* progressive airway obstruction
* loss of lung volumes
* **pulmonary artery** or **cardiac compression**
* **SVC** obstruction
150
* Usually will develop after a Valsalva maneuver or after some kind of increase in intrathoracic pressure like from major coughing or emesis
**pneumomediastinum**
151
* **Fluid or air-filled cysts** in the mediastinum or the lung parenchyma
**Bronchogenic cysts**
152
* Gas enters pleural space during inspiration and is prevented from exiting during expiration
* Evacuation of gas can be life saving
**Tension Pneumothorax**
153
most common sign Sx of pneumothorax
* **tachycardia** (most common physical finding)
* Dyspnea
* ipsilateral chest pain
* cough
* arterial hypoxemia
* hypotension
* hypercarbia
154
managing severe aw obstruction (tracheobronchial compression)
**may alleviate by lateral or prone position**
**maintain spontaneous ventilations!**
**avoid general**
**LA best option**
**sitting position may help minimize obstruction by tracheal compression**
155
in restrictive dz avoid sensory block above ___ to maintain adequate ventilation (associated with impairment of respiratory muscle activity)
Stoelting p204
**avoid regional \> T 10**
| (restrictive dz)
156
* Is characterized by the inability to maintain adequate arterial oxygenation and/or adequate elimination of CO2
* * **PaO2 \< 60 mmHg** despite oxygen supplementation in the absence of a right to left intracardiac shunt
**and/or**
* **PaCO2 \> 50 mmHg** in the absence of respiratory compensation for metabolic alkalosis
**Acute respiratory failure**
157
* **Chronic respiratory failure**, the *pH is normally maintained* in normal value range 7.35-7.45 due to compensation by:(3)
* **renal tubular reabsorption of bicarbonate**
* **ammonia production**
* **H+ ion excretion**
158
if respiratory failure persists what are some cardiac consequences
**RV strain** from:
* **inc PVR**
* **P HTN**
159
several different things that can result in **ARDS**
* **PNA**
* **fat emboli**
* **pulmonary contusions**
* **drug overdose**
* **trauma associated with shock**
* **pancreatitis**
160
* Associated with the highest risk of progression of acute lung injury to ARDS
**sepsis**
* Patients that die from ARDS typically do so as a result of sepsis or multiple organ failure rather than the actual respiratory failure itself.
161
* **First sign of ARDS**
* **Arterial hypoxemia resistant to treatment with supplemental O2**
* other signs: PHTN can occur due to pulmonary artery vasoconstriction
162
PaO2/FiO2 ratio in ARDS
and ALI
**ARDS \< 200 mmHg\***
**ALL(less severe ARDS) is \< 300 mmHg\***
**Normal ratio (500 - 600)**
\* with diffuse infiltrates, normal PCWP, appropriate mechanisms
163
* The **three principle goals**of treatment (ARDS)
* **Correcting hypoxemia**
* **removing excess CO2**
* **securing a patent airway**
* (other) O2 supplementation, tracheal intubation, mechanical ventilation, application of PEEP, inotropic support, nutritional support, beta agonists
164
* ____ is one of the most beneficial treatments for ARDS
* **PEEP** is one of the most beneficial treatments for ARDS
* PEEP doesn’t decrease the amount of fluid in the lungs it **redistributes the edematous fluid to different interstitial lung regions** which causes the previously flooded alveoli to be better ventilated
165
Dx: Dependent on presence of:
* **acute refractory hypoxemia**
* **diffuse infiltrates** on chest x-ray that signify PE
* **PCWP \< 18**
166
* **Not a reliable guide** for monitoring intravascular fluid volume in a patient with ARDS (use urine output instead)
**CVP**
167
Sx may suggest tension pneumo
* **hypotension**
* **worsening hypoxemia**
* **increased airway pressure**
168
Barotrauma may present as:
* **subcutaneous emphysema**
* **pneumomediastinum**
* **pulmonary interstitial emphysema**
* **pneumoperitoneum**
* **gas embolism**
* **tension pneumothorax**
169
* The most consistent symptom of acute PE
**dyspnea**
170
* PE: Suggest **pulmonary infarction** from **embolism near the pleural surface**
* **Pleuritic chest pain**
* **cough**
* **hemoptysis**
171
EKG changes with PE
* **RBBB**
* **Afib**
* **Peaked p waves**
172
why would/could cardiac enymes be elevated with PE
**RV strain**
173
most common cause of PE
**DVT** from venous stasis
**venous stasis** dt
* immobility
* GA
* CHF
* Obestiy
* Varicose veins
174
* Under anesthesia PE may present as:
* **unexplained arterial hypoxemia**
* **hypotension**
* **tachycardia**
* **bronchospasm**
175
treatment for PE and cornerstone tx
* anticoagulation
* thrombolytic therapy
* IVC filter
* surgical embolectomy
* **Heparin is cornerstone treatment**
* Initial dose of 5,000-10,000 units IV followed by infusion
176
Induction (PE management)
Avoid
* **hypoxemia**
* **hypotension**
* **PHTN**
177
Fat emoblism:
* Obstruction of blood vessels and release of __ \_\_ __ cause acute diffuse \_\_\_especially in ____ and ___ vasculature
Fat emoblism:
* Obstruction of blood vessels and release of **free fatty acids** cause acute diffuse **vasculitis** especially in **pulmonary** and **cerebral** vasculature
178
* Syndrome with fat embolism is typically seen around **\_\_ to __ hours**
* Usually after a **\_\_ __ fracture**
* Especially fractures of the **\_\_\_**and the **\_\_\_**
* Source is most likely what?
* Syndrome with fat embolism is typically seen around **12 to 72 hours**
* Usually after a **long bone fracture**
* Especially fractures of the **femur** and the **tibia**
* Source is most likely **disruption of adipose tissue in bone marrow**
179
other causes of fat embolism
* acute pancreatitis
* cardiopulmonary bypass
* parenteral infusion of lipids
* liposuction
180
Fat embolism **triad:**
* **hypoxemia**
* **mental confusion**
* **petechia**
181
association with arterial hypoxemia (fat embolism)
**always present**
182
* Oxygen is carried in the blood in two forms
* give formulas as well
* **Bound to Hgb** (Hgb x 1.34 x SaO2)
* **dissolved in the blood** (PaO2 x 0.003)
183
* Hemoglobin carries\_\_\_ml of O2 per \_\_g of hemoglobin at 100% saturation
Hemoglobin carries **1.34** ml of O2 per **1**g of hemoglobin at 100% saturation
184
* To calculate the amount of CO2 dissolved in the blood:
* **multiple the PaCO2 by 0.067**
* answer in **mL/dL**
185
