ACE Review - Pulm Flashcards
1
Q
Cause of neurogenic pulm edema
A
Sympathetic discharge
2
Q
When does neurogenic pulm edema occur
A
Within 12 hrs. As as soon as 4 hrs
3
Q
Common cause of neurogenic pulm edema
A
Head trauma
4
Q
in a tension pneumo, where should a large bore needle be placed
A
mid clavicular 2nd intercostal
5
Q
in a tension pneumo, where should a chest tube be placed
A
mid clavicular 6th intercostal
6
Q
If an abg had an air bubble in it,how would the pao2 and paco2 be affected
A
Increased pao2 and decreased paco2
7
Q
How does the pao2 increase bc of an air bubble?
A
Air fio2 is 0.21, thus partial pressure is 160mmhg(.21x760). O2 will diffuse into blood that only has an o2 partial pressure of 60-100 if pt is on room air
8
Q
How does the paco2 decrease with an air bubble.
A
Same idea. Air partial co2 pressure is 0.04%
9
Q
how many steps are there in lung injury when aspiration occurs
A
two steps
10
Q
what is the first step of aspiration lung injury
A
loss of type 1 alveolar cells leads to pulmonary edema
11
Q
what is the second part of aspiration lung injury
A
lung acute reactive airway disease
12
Q
what is the first goal of aspiration
A
provide oxygenation and
13
Q
what is the recommended tx for liquid aspiration
A
suction with a large bore catheter
14
Q
should you do bronch lavage with liquid aspiration
A
no, it will push the contents down further
15
Q
should you give antibiotics
A
no, because you are now making the patient more prone to vent assoc pna with resistant bacteria
16
Q
should you give steriods
A
no, because it has been shown to increase risk of mortality in criticlly ill patients
17
Q
what patient would benefit cpap
A
patients suffering soley from hypoxemia, like osa
18
Q
what patient would benefit from bipap
A
pts suffering from hypercarbia or mixed hypercarb/hypoxemia
19
Q
4 most common reasons for bipap
A
postop thoracic / ab surgery, pulm edema 2ndry heart failure, acute copd exacerbation, immunosupression
20
Q
6 contraindications to bipap
A
ams, decreased resp drive, aspiration risk, untreated pneumothorax, hemodynamic instable, refusal
21
Q
What is the leading cause of
A
TRALI
22
Q
What are the other 2 major causes for transfusion associated mortalities
A
TAS - Transfusion Associated Sepsis, ABO Hemolytic transfusion reactions
23
Q
what component makes transfusion more likely to have TRALI
A
plasma components
24
Q
what is an example of plasma rich component
A
plateletes…it is 1000x more likely than prbc
25
what is the percent of death by trali
5-10%
26
what is the mechanism of action of trali
neutrophils are sequestered in the lungs…they are then triggered by high concentration of leukocyte antibodies
27
what kind of donors have higher likely hoold of giving blood components with high chance of trali
female multiparous pts bc they have developed more HLA antibodies
28
what kind of compenents have multiparous female donors have shown to increase risk of trali
ffp and plateletes, cryo and prbc not shown much difference
29
where does angioedema occur
mucocutaneous tissues primarily in lungs and bowel
30
who are prone to angioedema
hereditary…those who lack c1 easterase inhibitor enzyme
31
what drugs are associated with angioedema
pcn and sulfa drugs
32
what drugs causes pseudo-angioedema
NSAIDS…bc they inhibit prostaglandin synth
33
what is the most common cause for angioedema admission to ER
ACE inhibitors 17-38%
34
what is the moa for ace-I causing angioedema
it accumulates bradykinin that causes increase in vascular permeability
35
what 3 drugs are used to treat angioedema
epi, benadryl, steriods
36
how long should a pt with angioedema be followed
at least 24 hours bc relapse can occur
37
do patients with hereditary cause of angioedema have any preventative meds for acute angio tx
epsilon-aminocaproic acid and danazol(steriod)
38
does lasix cause angioedema
no
39
what is the calculation for static compliance of the lungs
tidal volume/ Plateau pressure minus peep
40
what is the purpose of static lung compliance
it is to test the elasticity of the respiratory system
41
when is static lung compliance measured
at the end of inspiration when lung volume is kept constant
42
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43
what can increase pulmonary hypertension
hypercarbia, acidosis, hypoxia
44
what is ards
oxygenation problem 2ndry non cardiogenic protienacious pulmonary edema
45
what has been assoc with decrease mortality in pt w ards
prevention of ventilator associated lung injury
46
what are the ventilator goals for decreasing ards assoc vent mortality
less than 6cc/kg of predicted body wt tidal volume and peak pressures less than 30mmHg
47
should we target to get a Pao2/Fi02 over 300 for ards pt
no
48
what may be used to help oxygenation in ards pt
peep
49
should high peep pressure be used in ards pt
no, may cause barotrauma…hi peep not recommended
50
should increasing fi02 to maintain o2% greater than 94% be targeted in ards pt
no…may lead to oxygen toxicity in pt
51
what is the cause of hereditary angioedema
it is autosomal dominant lesion that leads to a C1 esterase Inhibitor deficiency
52
what is the prob with hereditary angio edema
it causes swelling of mucos membranes including those of airway and gi tract
53
what are 2 prophylactic meds for hereditary angioedema
attenuated androgens, antifibrinolytics
54
what are examples of attenuated analbolic androgens
danazol and stanozolol
55
whare is an example of antifibrinolytic
epsilon amino caproic acid
56
which is prefered for prophylactic use for hereditary angio edema
androgen steriods bc antifibrinolytics have been assoc with thrombosis
57
what are drugs used for acute attacks of hereditary angio edema
FFP and synthetic C1 easterase inhibitors
58
what are 2 examples of C1 esterase inhibitor synthetics
CinRyze and Berinert P
59
which is c1 esterase inhibitor can be used for acute attack
only Berinert P can be used for acute attacks
60
is FFP better than synthetic C1esterase inhibitor
no because it is assoc with TRALI
61
if patient is to get a short proceedure, and they have Hereditary angioedema…what is the recommeneded treatment
avoide airway manipulation with the following: androgens 2 days before surgery, c1esterase inhibitors 24 hrs before surgery,or ffp 6-12 hours before surgery
62
what if airway manipulation is required?
ideal to achieve normal c1easterase inhibitor levels, but 40-50% is ok
63
how to achieve normal c1 esterase levels
5-7 days of androgen steriods, FFP on day of surgery, Berinert P on day of surgery
64
What prostacyclin is used to treat pulm hypertension.
Epoprostenol flolan
65
How does epoprostenol work
It vasodilates and inhibits platelet aggregation.
66
How is epoprostenol administered.
It is given as an infusion.
67
What phosphodiesterase inhibitor is used for pulm htn
Sildenafil
68
What drug in obstetric patients is contraindicated in pulm hypertension
15-methylprostaglandin- it vasconstricts. This is also known as hemabate
69
What is the p50 in adults
26.7
70
Which way does the oxyhemoglobin curve shift with carbon monoxide.
Left
71
Which way does the oxyhemoglobin curve shift with methemoglobin
Left
72
Which way does the oxyhemoglobin curve shift with fetal hg
Left
73
Which way does the oxyhemoglobin curve shift with preggos
Right
74
What settings can be set for high oscillatory freq ventilatoin
Fio2, inspiratory time, bias gas flow rate, frequency, amplitude,
75
What are alcoholics at risk for postoperatively
Postoperative pneumonia
76
which way does carbon monoxide shift oxyhemoglobin curve
left because it makes the o2 that is bound higher affinity to heme group...and not get kicked out
77
how does carbon monoxide work
besides competing for heme, it also inhibits cytochrome oxideases
78
what is similar to carbon monoxide in moa
cyanide...which also inhibits cytochrome oxidases
79
what is the most common presentation of carbon monoxide
altered mental status
80
how is carbon monoxide tested for
co-oximetry
81
how to treat carbon monoxide posioning
high flow non rebreather o2 mask, then ett with o2, then hyperbaric oxygen
82
what drug inhibit hypoxic pulm vasoconstriction
inhaled anesthtic
83
What problem can pectus excavatum cause
The sternum can cause Compression of the right heart And cause right ventricle outflow tract compression
84
What kind of PFT Is seeing with pectus excavatum
restrictive pattern
85
What common cardiac lesion is associated with pectus excavatum
50% of patients have mitral insufficiency
86
If Marfan's is associated with pectus excavatum , What must you look out for him
Aortic insufficiency aortic dissection aortic aneurysm
87
What is adult P 50
26.5 mmHg
88
What is Fetal P 50
20 mmhg
89
What a sickle cell P 50
30 mmhg
90
What is the effect called when increased CO2 causes decreased O2 affinity in hemoglobin
bohr effect
91
What do inhaled anesthetic gases do to the Oxyhemoglobin curve
right shift
92
obesity...what happens to work of breathing
increse work of breathing
93
obesity...what happens to frc
decrease
94
obesity...what happens to vital capacity
decrease
95
obesity...what happens to dead space
no change
96
obesity...what happens to closing capacity
increase
97
obesity...what happens to hemoglobin
increase - polycythemia
98
obesity...what happens to fev1
decrease
99
obesity...what happens to fvc
decrease
100
obesity...why is there less time for 100% saturation on induction
supine postion decreases frc, increases shunt fraction, and worsen vq mismatch
101
Myasthenia gravis...what is the oral med used in MG
Pyridostigmine
102
Myasthenia gravis...what test is done before surgery to check if the patient needs optimization for surgery
Pulmonary function test.
103
Myasthenia gravis...what to look for in pulmonary function test
Vital capacity...they should have a vital capacity greater than 2 liters...or else that means that they will most likely end up intubated post thymectomy
104
Myasthenia gravis...ok, you got a low vital capacity...what should you do
Plasmapheresis
105
Myasthenia gravis...how should the patient be induced
Rapid sequence because they are at high risk for aspiration.
106
myasthenia gravis...how do these patients respond to succinylcholine
They are more resistant
107
Myasthenia gravis...why are they resistant to succinylcholine
Because the antibodies occupy most ach receptors...thus only a few ach receptors left for succ to work on....
108
Myasthenia gravis...how do they respond to nondepolarizing mm relaxants
They are more sensitive...only the few ach receptors left over need to be blocked
109
Myasthenia gravis...are neuraxial anesthesia contraindicated?
No...actually they help. They decrease the use of narcotics...and thus less chance of respiratory depression by narcotics
110
Myasthenia gravis...what are the 4 indicators of postoperative ventilator dependance
1. Pyridostigmine dose greater than 750 daily. 2. Vital capacity less than 2.9liters, 3. MG for greater than 6 years 4. Coexisting copd
111
Myasthenia gravis...what other treatment can be used before surgery to decrease chance of postoperative intubation
Immunoglobulin administration
112
Beach chair...what happens to alveolar dead space in this position
There is increase alveolar dead space
113
Beach chair...what is the mechanism for increased alveolar dead space
It causes more dead space at the apex of the lungs...and also positive pressure ventilation causes decrease preload
114
Trali...what are 4 criteria
Onset within 6hrs of transfusion, hypoxia, chest X-ray bilateral infiltrate, pulm artery occlusion pressure below 18mmhg
115
Trali...how do u know there is hypoxia
Pao2/fio2 ratio less than 300, or spo2. Less than 90 on room air at sea level
116
Trali...what is the treatment
Supportive with oxygen supplementation
117
Axillary roll. What is the purpose
To prevent the head of the humerus from compressing the brachial plexus...to prevent brachial artery occlusion.
118
Axillary roll. Where should it be placed...
Caudal to the axillary pulse.
119
Axillary roll. What danger can be caused if it is placed to cephalad
Brachial nerve injury, arm ischemia, compartment syndrome
120
Axillary roll. What is a common complaint in people using axillary roll
Nondependant shoulder pain.
121
Axillary roll. What is a treatment for Nondependant shoulder pain
Interscalene block. ..but ketorlac is the first line treatment.
122
Sepsis. What are the 4 goals of early goal directed therapy for sepsis patients
Cvp 8-12, map 65-90, central venous oxygenation greater than 70.
123
Sepsis. What if you cannot get central venous oxygenation above 70?
Transfuse to get the hematocrit above 30
124
Sepsis. What kind of shock is septic shock
Distributive shock
125
ards. what is the treatment
low tidal volumes to prevent vent associated trauma
126
ards. what treatment may improve hypoxemia
prone positioning
127
Preoxygenation. Where does the extra oxygen go to
Frc
128
Preoxygenation. Does that affect the hypoxic pulmonary vasoconstriction
No. It does not alter it.
129
Preoxygenation. Does it affect the second gas effect.
No it does not alter it.
130
Preoxygenation. Does it alter diffusion hypoxia
No it does not alter it.
131
Preoxygenation. What is the second gas effect.
It is the high concentration effect of one gas that causes the increase in concentration of another gas.
132
Preoxygenation. What is diffusion hypoxia.
During extubation. When a patient begins to breaths room air, and nitrous oxide is discontinued, hypoxemia then develops.
133
Lung mechanics. What is elastance.
Inward recoil of the lung.
134
Lung mechanics. How is elastance and compliance related
Inverse of eachother
135
Lung mechanics. What are the components of total lung compliance.
Lung paranchyma and chest wall compliance
136
Lung mechanics. What conditions decrease compliance.
Fibrosis. Pulm edema. Consolidations
137
Lung mechanics. What condition is increase compliance.
Emphysema.
138
Lung mechanics. What does general anesthesia do to compliance.
Decrease compliance
139
pneumonectomy. what is a complication that can mimick ards
postpneumonectomy pulm edema
140
pneumonectomy. what side of operation is at risk for pppe
right side
141
pneumonectomy. what kind of fluid management is associated with pppe
excessive fluid resuscitation
142
pneumonectomy. what peak pressures are associated with pppe
peak pressures greater than 25mmhg
143
pneumonectomy. what pt factor can cause increase in pppe
alcohol abuse
144
pneumonectomy. what is the rate of pppe in a lobectomy
1-7%
145
pneumonectomy. what is the rate of pppe in a total pneumonectomy
4-7%
146
pneumonectomy. what is the mortality of pppe
30-100% regardless of lobectomy or pneumonectomy
147
carbon monoxide. which is the order of anesthetic gases that make carbon monoxide over dessicated soda lyme
desflurane>enflurane>isoflurane,sevoflurane>halothane
148
carbon monoxide. which co2 absorbant has higher carbon monoxide production if dessicated
baralyme more than sodalyme
149
Plateau pressure. When is this measured
At the middle of an inspiratory hold.
150
Plateau pressure. What does it represent
Pressure in the small airways and alveoli
151
Plateau pressures. How do you measure pressures of the large airways and trachea.
It is not plateau pressure but it is the peak pressure.
152
Plateau pressure. What can it be used to measure.
The static compliance of the respiratory system.
153
Compliance. How do you calculate static compliance.
Tidal volume/(plateau pressure - PEEP)
154
Compliance. How do calculate dynamic compliance.
Tidal volume /(peak pressure - PEEP)
155
Mediastinal mass. What 3 symptoms can u see with this
Orthopnea, chest pain. Superior vena cava syndrome.
156
Mediastinal mass. What dangers can occur after muscle relaxant.
Compression Of tracheal bronchial tree after relaxation.
157
Mediastinal mass. Would tracheostomy be useful in this case.
No. Because the obstruction may be distal to the tracheostomy.
158
Mediastinal mass. How would a pt be optimized for surgery.
Radiation or chemo to reduced the size of the lesion.
159
Mediastinal mass. How should anesthesia be given to the pt.
Pt should be kept spontaneous.
160
Mediastinal mass. What should you have ready when induction of these pt
Rigid brochoscope. To visualize and ventilate through.
161
Mediastinal mass. What should be done for these pt with your use of muscle relaxants.
It should be avoided.
162
Mediastinal mass. How is the pt positioned for awake fiber optic.
Semifowler position.
163
Mediastinal mass. What should you have ready if there is tracheal tree bronchial obstruction.
Be able to intubate with reinforced tube, have a ventilating rigid bronch, have cardiopulmonary bypass available.
164
Mediastinal mass. What should you have ready if there is pulmonary artery obstruction
Avoid negative ionotrops and have cardiopulmonary bypass available.
165
Mediastinal mass. What should you do to IV line if there is superior vena cava syndrome.
Place IV lines in the lower limbs.
166
pulmonary hypertension. what factors can increase pulmonary hypertension
hypoxia, hypercapnea, acidosis, peep, hypOthermia
167
pulmonary hypertension. what agents can be used to decrease pvr
phosphodiesterase inhibitor, nitric oxide, prostaglandins, btype naturetic peptide
168
pulmonary hypertension. how does milrinone work
inhibits phosphodiesterase III in the heart, increasing cAMP, influx of calcium, improve ionotropy, pulm and systemic vasodilation
169
pulmon hypertension. how does nitric oxide work
it acts to increase guanylate cyclase activity...thus increase cGMP on smooth cells...thus pulm vasc relax
170
pulmonary hypertension. how does b-naturetic peptide work to decrease pvr
it increase cGMP like nitric oxide
171
pulmon hypertension. how long does b-naturetic peptide work
around 18 minutes
172
pulmonary hypertension. what kind of prostaglandins work for pulm htn
pge1 and pgi2
173
Aspiration. What should be done when there is gastric content seen in the oral pharynx
Head down position. Suction of gastric. Content. Intubation. Suction of ett.
174
flow volume loops. what is the positive y axis
expiration
175
flow volume loops. what is the negative y axis
inspiration
176
flow volume loops. what is the x axis.
measurement of the lung volume
177
flow volume loops. what is the capacity as demonstrated by the width of the loop
vital capacity
178
flow volume loops. what are 2 characteristics to look at when describing lesions
intra vs extrathoracic. fixed or variable
179
flow volume loops. what do you see with a fixed airway obstruction
both values of extra and intrathoracic flows are decreased (the y values are decreased)
180
flow volume loops. what do you see wiht a variable extrathroacic obstruction
you see a decrease in the inspiration flow value (less negative y value)
181
flow volume loops. why do u see dampened inspiration flow with a variable extrathoracic obstruction
because during inspiration, a variable extrathroacic obstruction causes obstruction. but during expiration, the positive intrathoracic pressure releaves and resolved the variable obstruction...thus almost normal expiration flow loop
182
flow volume loops. what do you see with a variable intrathoracic obstruction.
you see decrease amplitude on the positive y axis...aka the expiratory flow is decreased in amplitude.
183
flow volume loops. why do you see a dampened expiratory flow loop with variable intrathoracic obstruction
because when you expire, the positive intrathoracic pressure will cause that mass or obstruction to clamp down on airways and decrease expiratory flow. however, during inspiration, the negative intrapleural pressure will pull up on the obstruction and help have a normal inspiratory flow
184
flow volume loops. what is unilateral paralyzed vocal cord considered as for an obstruction
variable extrathoracic obstruction
185
flow volume loops. what is special about the V25-75% of the flow volume loops
this portion is not effort dependant..but is independant of the patients effort
186
flow volume loops. what disease has alterations of the v25-75% area of the expiratory limb
copd...this is a dease of the small airway disease that is obstructed intrathoracic....these small airways is not dependant on pt effort to get obstruction
187
flow volume loops. what does a restrictive lung look like
a very narrow skinny loop
188
flow volume loops. why is it skinny loop vor restrictive lung disease
because there is a decrease in lung capacity...but the inspiratory and expiratory flows are normal
189
flow volume loops. what is a restrictive lung disease loop an inverse of?
it is an inverse of a fixed obstructive leison
190
mediastinal mass. what must be available
rigid bronchoscope to intervene when intubation cannot ventilate
191
mediastinal mass. what if the pt does not have svc compression...should u still place a central line above the diaphram?
no...bc the svc may be clamped in these cases...so u need ivc access.
192
mediastinal mass. what population of pt are at highest risk for airway compromise
pediatric pts
193
Tongue. Motor.
Hypoglossal. Cn12
194
Tongue. Taste. Posterior 1/3
Glossylpharyngeal. Cn9
195
Tongue. Taste. Anterior 2/3.
Cn7. Chordatymapni branch.
196
Tongue. Taste. Epiglottis and Root.
Cn10.
197
Tongue. Sensation. Anterior 2/3
Cn5. Mandibular v3 portion
198
Tongue. Sensation. Posterior 1/3.
Cn9. Glossylpharyngeal.
199
atelectasis. what IV agent does not cause atelectasis
ketamin
200
obstructive lung disease. what is decreased
max breathing capacity, max midexpiratory flow rate, fev1/fvc ratio
201
obstructive lung disease. what is increased
residual volume, total lung capacity
202
obstructive lung disease. what happens to vital capacity
normal
203
obstructive lung disease. what happens to total lung capacity
increased but can be normal
204
restrictive lung disease. what is decreased
vital capacity, total lung capacity, residual volume
205
restrictive lung disease. what is increased
fev1/fvc ratio...it can be normal as well
206
restrictive lung disease. what happens to max breathing capacity
normal
207
restrictive lung disease. what happens to max mid expiratory flow rate
normal
