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Anesthesia Practice > AP 2 Test 1 > Flashcards

AP 2 Test 1 Flashcards

1
Q

How long must a patient be ventilator dependent to be classified as having respiratory failure

A

Greater than 48 hours after surgery

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2
Q

What is the most important risk factor for post-op pulmonary complication?

A

High risk surgical site

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3
Q

The risk of pulmonary complications increase as the surgical incision gets closer to what muscle?

A

The diaphragm

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4
Q

What procedures are high risk for pulmonary complications post operatively?

A

Aortic, thoracic, upper abdominal procedures

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5
Q

Other than the surgical site, what are other surgical risks for post-op pulmonary problems? (4)

A

Emergency surgery, surgery greater than 3 hours, general anesthesia, multiple transfusions

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6
Q

What are the 2 major patient related risk factors for post-op pulmonary complications?

A

Increasing age (over 60) and increasing ASA status

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7
Q

Other than age and ASA status, what other patient risk factors for post-op pulmonary complications are supported by good evidence? (3)

A

CHF, COPD, functional dependency

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8
Q

What patient related risk factors for post-op pulmonary complications are supported by fair evidence? (4)

A

Unintentional weight loss, smoking cigarettes, alcohol use, abnormal chest CT

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9
Q

What 4 risk factors have been proved to not be a risk factor for post-op pulmonary complications?

A

Controlled asthma, obesity, hip surgery, GU/gynecologic surgery

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10
Q

Which of the following have recently been identified as risk factors for post-op pulmonary complications?

A. Epidural Anesthesia
B. Insulin-treated diabetes
C. Obstructive sleep apnea
D. Immobility
E. Pulmonary Hypertension
A

C and E

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11
Q

In patients with OSA, how many desaturations per hour predicted high risk of pulmonary complications?

A

Greater than 5 desaturations during nocturnal oximetry

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12
Q

What was the percentage of respiratory failures in patients with pulmonary hypertension?

A

20-28%

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13
Q

What neuraxial anesthesia procedure has been proved to reduce post-op pulmonary complications?

A

Post-up thoracic epidural anesthesia - reduced complications by 1/3 to 1/2

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14
Q

What 2 strategies for risk reduction of pulmonary complications post up are supported by good evidence?

A

Post-op lung expansion modalities and post-op epidural anesthesia

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15
Q

What 5 diseases are classified as obstructive lung diseases?

A

Emphysema, cystic fibrosis, chronic bronchitis, asthma, COPD

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16
Q

How does obstructive airway disease affect airway resistance?

A

Increases resistance

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17
Q

How does restrictive airway disease affect airway compliance?

A

Decreases compliance

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18
Q

How does the diameter of the airways affect resistance

A

Smaller the diameter, less flow. Larger diameter, more flow

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19
Q

If airway diameter is reduced by half, how is resistance affected

A

Increases by a factor of 16

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20
Q

If you change the density of a gas, you’re essentially changing what?

A

The driving pressure of the gas

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21
Q

When is heliox most commonly used?

A

When the large airways are narrowed due to upper airway obstructions such as tumors, foreign bodies, or vocal cord dysfunction

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22
Q

Patients with what 3 comorbidities usually have “medium” upper airways?

A

Croup, asthma, copd

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23
Q

Where does laminar flow occur in the airways?

A

In the smaller airways

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24
Q

Where does turbulent flow occur in the airway?

A

Nose, mouth, larger airways

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25
Q

What happens to resistance when lung volume is reduced

A

Airway resistance rises rapidly

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26
Q

What may happen to the smaller airways at very low lung volumes

A

They may completely close

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27
Q

What size of bronchi have the most resistance?

A

Mid-sized bronchi

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28
Q

Obstructive vs Restrictive Diseases - what anatomy is affected in each?

A

Obstructive: airways
Restrictive: lung tissue or thorax

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29
Q

Obstructive vs Restrictive Diseases - what phase of breathing does the difficulty occur?

A

Obstructive - expiration

Restrictive - inspiration

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30
Q

Obstructive vs Restrictive Diseases - what does the pulmonary function test indicate in each?

A

Obstructive - decreased airway flow rates

Restrictive - decreased airway flow rates or capacity

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31
Q

Do patients with obstructive lung diseases have trouble inspiring or expiring?

A

Expiring

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32
Q

What is the primary problem in asthma?

A

Airway inflammation and hyper-irritability

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33
Q

What is presented clinically in patients with asthma?

A

Episodic attacks of dyspnea, coughing, wheezing

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34
Q

What are the causes of airway obstruction in patients with asthma?

A

Bronchial smooth muscle contraction, edema, increased secretions

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35
Q

What types of things can precipitate airway obstruction in patients with asthma?

A

Airborne substances, ingestion, exercise, emotional excitement, viral infections

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36
Q

What medications/agents can trigger an asthma attack in asthmatic patients?

A

Aspirin, NSAIDS, sulfiting agents, yellow dye (tartrazine)

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37
Q

Upon being exposed to an asthma triggering agent, what occurs?

A

Release of inflammatory mediators

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38
Q

What inflammatory mediators are released when asthma is triggered? [Hey, taylor likes peanut butter]

A

Histamine, tryptase, leukotrienes, prostaglandins, bradykinin

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39
Q

What mediators are involved in the early-phase asthmatic response, and what do they cause?

A

DIRECT mediators, cause acute bronchoconstriction

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40
Q

What mediators are involved in the late-phase asthmatic response, what white blood cells are involved, and what is the result?

A

INDIRECT mediators direct EOSINOPHILS and NEUTROPHILS to the airway, this causes epithelial damage, edema, extra mucus secretion, and hyper responsiveness

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41
Q

What division of the nervous system plays a major role in maintaining normal bronchial tone, and is overactive in patients with asthma?

A

Parasympathetic

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42
Q

Vagal activation can be triggered by what substances/actions?

A

Histamine, noxious stimuli, cold air, irritants, instrumentation

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43
Q

What does reflex vagal activation result in?

A

Bronchoconstriction

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44
Q

What mediates the bronchoconstriction cause by reflex vagal activation?

A

Intracellular cyclic GMP

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45
Q

In acute asthma attacks, residual volume increases by ___% and FRC increases by ___%

A

400%, 100%

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46
Q

In acute asthma attacks, the number of alveoli with low V/Q ratio increases, resulting in what?

A

Hypoxemia

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47
Q

In acute asthma attacks, increased breathing leads to what?

A

Hypocapnia

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48
Q

Why should you worry about a normal or high PaCO2 in patients with acute asthma attacks?

A

This indicates the patient can no longer maintain work of breathing, respiratory failure is impending

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49
Q

As asthma attacks resolve, airway resistance is first normalized in what region of the airways?

A

The larger airways

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50
Q

What classes of drugs are used to treat asthma (6) [Betty Met Gino At Lowe’s Monday]

A

Beta-adrenergic agonists, methylxanthines, glucocorticoids, anticholinergics, leukotriene blockers, mast cell stabilizing agents

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51
Q

Why are methylxanthines not used frequently to treat asthma?

A

They have a narrow therapeutic range so patients often complain of PONV and anxiety

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52
Q

What is the only available IV preparation of methylxanthines to treat asthma?

A

Aminophylline

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53
Q

What effects do glucocorticoids cause that helps in the treatment of asthma?

A

Anti-inflammatory and membrane stabilizing effects

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54
Q

Drugs such as beclomethasone, triamcinolone, flutasone, and budesonide are used as maintenance therapy for what obstructive lung disease?

A

Asthma - used in maintenance dosed inhalers

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55
Q

What drugs are given IV for severe asthma attacks

A

Hydrocortisone/methylprednisolone

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56
Q

Why are anticholinergics used to treat asthma

A

They produce bronchodilation

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57
Q

What drug, that acts like atropine, can be given by MDI or aerosol to treat asthma

A

Ipratropium

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58
Q

What class of drugs PREVENT asthma?

A

Inhaled corticosteroids

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59
Q

What class of drugs CONTROL asthma?

A

Long acting beta 2 agonists

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60
Q

What class of drugs RELIEVE asthma?

A

Short acting beta 2 agonists

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61
Q

What special considerations should be assessed pre-operatively when going over the history of a patient with asthma

A

Recent course of the disease, whether the patient has been hospitalized for an attack

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62
Q 
What preoperative considerations would NOT be helpful in a patient with a history of asthma?
A) Clinical history
B) Current state of the disease
C) CBC test
D) Xray
E) PFTs (pulmonary function tests
A

CBC tests - the other options should be considered

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63
Q

How should you treat an active bronchospasm for emergent surgery?

A

Give oxygen, aerosol beta 2 agonists, give IV glucocorticoids

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64
Q

From an arterial blood gas sample, what would indicate an asthma attack

A

Hypoxemia, hypocapnia

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65
Q

What common drugs used perioperatively by anesthetists can trigger a bronchospasm due to histamine release?

A

Sux, morphine, demerol

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66
Q

What might you consider during emergence in a patient with asthma?

A

Deep extubation or a lidocaine bolus

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67
Q

What 2 diseases are encompassed in COPD?

A

Chronic bronchitis and emphysema

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68
Q

The prevalence of COPD increases with what?

A

Age

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69
Q

COPD is mainly associated with what habit?

A

Smoking

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70
Q

What gender is most at risk for COPD?

A

Men - up to 20% of men have COPD

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71
Q

What produces the airway obstruction that causes chronic bronchitis

A

Secretions for enlarged bronchial glands, mucosal edema

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72
Q

How does chronic bronchitis affect residual volume

A

Increases residual volume

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73
Q

What is caused by the prominent intrapulmonary shunting that occurs with chronic bronchitis

A

Hypoxemia

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74
Q

What 3 things can hypoxemia lead to if left untreated?

A

Erythrocytosis, pulmonary hypertension, RV failure

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75
Q

What gas drives ventilation in patients with chronic bronchitis?

A

Oxygen

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76
Q

Why do you want to limit FiO2 in patients with chronic bronchitis?

A

Since their ventilatory drive is based on O2 instead of CO2, increased oxygen could reduce their drive to breath

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77
Q

What disease causes “Blue Bloater” syndrome, and why does it occur?

A

Chronic bronchitis - their FRC increases and causes the bloating, and the severe hypoxemia causes the bluish tint

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78
Q

How is emphysema diagnosed?

A

By CT of the chest showing irreversible enlargement of the airways distal to the terminal bronchioles and destruction of alveolar septa

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79
Q

Although emphysema is mostly associated with smoking, it can also be due to a deficiency in what?

A

Alpha 1-antitrypsin

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80
Q

In patients with emphysema, what is caused by the loss of dynamic recoil in smaller airways

A

Airway collapse during exhalation

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81
Q

What is caused by the destruction of pulmonary capillaries in patients with emphysema

A

Decreased carbon monoxide diffusion capacity, leads to pulmonary hypertension

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82
Q

What is a prominent feature of large cystic bullae/blebs in patients with emphysema

A

Increased dead space

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83
Q

What lung volumes are increased in patients with emphysema

A

Residual volume, total lung capacity, FRC

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84
Q

What disease causes the “Pink Puffer” syndrome and why does it occur?

A

Emphysema - vascular beds are destroyed so the body hyperventilates to compensate (puffing), and these patients have less V/Q mismatch than blue bloaters, causing a pink appearance

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85
Q

How could you use a patient’s PaCO2 to decipher if they had chronic bronchitis or emphysema

A

Patients with CB will have an elevated PaCO2 over 40mmhg, whereas patients with emphysema will have normal PaCO2

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86
Q

Which disease encompassed under COPD is associated with copious sputum production

A

Chronic bronchitis

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87
Q

Which disease encompassed under COPD is associated with elevated hematocrit

A

Chronic bronchitis

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88
Q

What is the most important intervention for COPD treatment

A

Tell the patient to stop smoking

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89
Q

What drug therapy is useful in COPD treatment

A

Bronchodilator therapy with b2 agonists, glucocorticoids, ipratropium

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90
Q

How is cor pulmonale (right ventricular failure) prevented in the treatment of COPD

A

Diuretics are used to control peripheral edema

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91
Q

What anesthetic technique is best to use for COPD patients and why?

A

Regional, minimizes the use of airway instrumentation

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92
Q

How should the I:E ratio be adjusted for patients with COPD

A

Increase expiratory time

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93
Q

What gas should be avoided in patients with bullae and pulmonary htn?

A

Nitrous oxide

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94
Q

How should you adjust tidal volumes in patients with COPD

A

Small to moderate tidal volumes (6cc/kg)

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95
Q

Patients with pulmonary bullae have a high risk of developing what?

A

Pneumothorax

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96
Q

What extubation technique is usually best for patients with COPD?

A

Deep - decreases risk of reflex bronchospasm

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97
Q

Patients with FEV1 less than __% are most likely to require post-op ventilation

A

50%

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98
Q

For every 10% increase in FiO2, how much does PaO2 increase?

A

50-60mmHg

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99
Q

What is indicated by a decreased pH and increase pCO2?

A

Respiratory acidosis

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100
Q

What is the normal CO2 content?

A

22-26mEg/L

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101
Q

What premedications could be considered in a patient with asthma and COPD?

A

Albuterol, versed, benadryl, glycopyrrolate

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102
Q

What airway device should be used in a patient with asthma and COPD?

A

LMA because it requires less instrumentation

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103
Q

What volatile agent should be used in a patient with asthma and COPD?

A

Sevo

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104
Q

What would you NOT use to control pain in a patient with asthma and COPD?

A

NSAIDs like toradol, ofirmev, etc

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105
Q

What is the limit on FiO2 you should use in a patient with asthma and COPD?

A

40%

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106
Q

What cavity sits above the diaphragm, and what structures does it hold?

A

Thoracic cavity - contains heart, trachea, esophagus, thymus, lungs

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107
Q

What cavity sits below the diaphragm, and what major structures does it hold?

A

Abdominopelvic cavity - contains liver, pancreas, GI tract, spleen, GU tract

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108
Q

Where does the upper respiratory tract begin and end

A

Mouth to larynx

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109
Q

Where does the lower respiratory tract being and end

A

Larynx to alveoli

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110
Q

What type of flow occurs in the upper airways

A

Convection

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111
Q

Where do the conducting airways begin and end

A

Trachea to terminal bronchioles

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112
Q

What part of the upper airway is most vulnerable to foreign particles?

A

Right main stem

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113
Q

What are the 3 basic functions of the upper respiratory tract?

A

Warm, humidify, filter

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114
Q

What receptors are responsible for the sympathetic innervation of the conducting airways?

A

B2 receptors

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115
Q

What receptors are responsible for the parasympathetic innervation of the conducting airways?

A

Muscarinic receptors

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116
Q

Which receptors lead to constriction of the smooth muscle lining the airways?

A

Muscarinic receptors of the parasympathetic ns

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117
Q

Where does the respiratory zone of the airways begin and end?

A

Respiratory bronchioles to alveoli

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118
Q

What is the function of the respiratory zone of the airways

A

Gas exchange

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119
Q

What is the function of alveolar type I cells?

A

Help establish the structure of the alveoli

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120
Q

What is the function of alveolar type II cells?

A

Secrete surfactant

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121
Q

What is the function of surfactant

A

Lowers surface tension on the alveoli to help equalize pressure and keep alveoli open

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122
Q

How much blood does each ventricle pump per minute

A

5.5 L/min

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123
Q

Does the pulmonary circulation have low or high resistance and pressure?

A

Low resistance, low pressure

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124
Q

What 2 things are the main determinants of pulmonary blood flow?

A

Gravity and HPV (hypoxic vasoconstriction)

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125
Q

Gravity is responsible for uneven blood flow in the lungs. What is the blood flow like when a patient is supine?

A

Uniform

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126
Q

What is blood flow distribution like when a patient is standing?

A

Lowest flow at the apex, highest at the base of the lung

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127
Q

In Zone 1 of the lung, which pressure is highest and how is blood flow to the area?

A

Alveolar pressure is highest which compresses capillaries and decreases blood flow

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128
Q

In Zone 2 of the lung, which pressure is highest and why?

A

Arterial pressure is highest and progressively increases as you go down the lung because of hydrostatic pressure and gravity

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129
Q

In Zone 3, which pressure is highest and which is lowest?

A

Arterial pressure is highest, alveolar pressure is lowest

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130
Q

How does hypoxia affect blood vessels?

A

It causes vasoconstriction

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131
Q

What is inspiratory reserve volume?

A

The extra volume the comes with a forced inspiration

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132
Q

What is expiratory reserve volume?

A

Extra volume that comes out with a forced expiration

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133
Q

What is residual volume?

A

Volume that is always left in the lungs, even after forced expiration

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134
Q

Which volume cannot be measured with spirometry?

A

Residual volume

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135
Q

What 2 lung volumes make up inspiratory capacity?

A

Tidal volume and inspiratory reserve volume

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136
Q

What 2 lung volumes make up functional residual capacity?

A

Expiratory reserve volume and residual volume

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137
Q

What is the definition of functional residual capacity

A

Volume remaining in the lungs after an expired tidal volume

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138
Q

What is the definition of vital capacity

A

The most volume you can ever expire, with forced inspiration and forced expiration - maximal breath

139
Q

What 3 lung volumes make up vital capacity

A

Inspiratory reserve, tidal volume, expiratory reserve

140
Q

What populations have increased vital capacities?

A

Males, large body sizes, physically conditioned

141
Q

What causes vital capacity to decrease over time?

A

Age

142
Q

What is dead space

A

Volume in the airways that does not participate in gas exchange

143
Q

What is anatomic dead space and how much volume does it hold

A

Volume of the conducting airways, holds about 150ml

144
Q

What is physiologic dead space

A

Volume of the lungs that does not participate in gas exchange

145
Q

What creates functional dead space

A

V/Q mismatch

146
Q

In normal patients, how does physiologic dead space volumes compare to anatomic dead space volumes

A

The 2 volumes are equal

147
Q

What muscles are involved in inspiration

A

Diaphragm, external intercostals, accessory muscles

148
Q

What is the intrapleural space

A

Space between the visceral and parietal pleura

149
Q

What are the 4 parts of the pleura lining the thoracic cavity?

A

Cervical, costal, diaphragmatic, mediastinal

150
Q

What 2 forces hold the thoracic wall and lungs in close opposition?

A

The intrapleural fluid cohesiveness and the negative intrapleural pressure

151
Q

What is transmural pressure, and is it normally negative or positive?

A

Difference between alveolar and intrapleural pressure, normally negative

152
Q

What 2 things cause lung compliance to increase?

A

Emphysema, age

153
Q

What 3 things cause lung compliance to decrease?

A

Fibrosis, lack of surfactant, increases in pulmonary venous pressure

154
Q

What is alveoli interdependence

A

If alveoli start to collapse, surrounding alveoli are stretched and then recoil, which exerts expanding forces to open the collapsing alveoli

155
Q

What forces help keep alveoli open?

A

Transmural pressure gradient, surfactant, interdependence

156
Q

What forces promote alveolar collapse?

A

Elasticity of pulmonary connective tissue, surface tension on alveoli

157
Q

How are elasticity and compliance related

A

Elasticity is the inverse of compliance

158
Q

What is a pneumothorax

A

Air in the pleural space

159
Q

How does a pneumothorax affect lung pressures

A

It abolishes the transmural pressure gradient

160
Q

What happens to the lungs when transmural pressure is abolished

A

They collapse

161
Q

What 3 main factors affect airway resistance

A

Bronchial smooth muscle, lung volume, viscosity/density of inspired gas

162
Q

What gas laws affect gas exchange in the alveoli

A

Dalton’s law, Fick’s law of diffusion, Boyle’s law

163
Q

What 2 main ways is O2 transported throughout the body

A

Dissolved in solution or bound to hemoglobin

164
Q

What is each molecule of hemoglobin made up

A

4 polypeptide chains (2 alpha, 2 beta) and 4 hemes

165
Q

What is oxyhemoglobin

A

Ferrous iron plus O2

166
Q

What is deoxyhemoglobin

A

Ferrous iron, no O2

167
Q

What does the oxygen dissociation curve depict?

A

The effect of pO2 on unloading/loading

168
Q

What does a shift to the right on an oxygen dissociation curve mean?

A

That hemoglobin has a reduced affinity to bind oxygen, meaning oxygen is unloaded at tissues

169
Q

What things can cause the O2 curve to shift right

A

Increased temperature, increased 2-3 DPG, increased H+ (low pH)

170
Q

What does a shift to the left on an oxygen dissociation curve mean?

A

Affinity of hemoglobin to bind oxygen increases

171
Q

What things can cause O2 curve to shift left

A

Decreased temp, decreased 2-3 DPG, decreased H+ (high pH), carbon monoxide

172
Q

Which direction does smoking cause the O2 dissociation curve to shift

A

Left

173
Q

What 3 forms is CO2 carried in

A

Bicarbonate, dissolved, carbaminohemoglobin

174
Q

How is most CO2 in the body transported

A

Bicarbonate ion

175
Q

What is the “chloride shift”

A

Bicarbonate leaves red blood cells and diffuses into plasma, making the rbc become more positive and attract a chloride ion in

176
Q

Where is the chloride shift reversed?

A

In the pulmonary capillaries

177
Q

Where are the respiratory centers located in the brain?

A

Medulla oblongata and pons

178
Q

What 2 cranial nerves control sensory input involved in breathing?

A

Vagus, glossopharyngeal

179
Q

What nerve controls motor output involved in breathing?

A

Phrenic

180
Q

What are central chemoreceptors sensitive to and how do they affect breathing

A

Sensitive to decreases in the pH of CSF, cause increase in breathing

181
Q

What molecules/ions in the body do central chemoreceptors detect

A

CO2 and H+

182
Q

Where are peripheral chemoreceptors located

A

Carotid and aortic bodies

183
Q

What molecule do peripheral chemoreceptors respond to

A

Low levels of O2

184
Q

How low must PaO2 get before peripheral chemoreceptors respond

A

Below 60

185
Q

Where are lung stretch receptors

A

Smooth muscles of the airway

186
Q

What is the Hering-Breurer Reflex

A

Dissension of the airways causes decrease in breathing frequency

187
Q

Where are irritant receptors located and how are they stimulated

A

In airway epithelial cells, stimulated by noxious stimuli - dust/pollen

188
Q

Where are J receptors located and how do they affect breathing

A

Located in walls of alveoli, engorgement of capillaries causes rapid breathing

189
Q

How are joint/muscle receptors activated

A

During movement of limbs, exercise

190
Q

With Restrictive Lung Diseases, what aspect of lung function is affected and what aspects remain normal?

A

Lung expansion is restricted, but airway resistance and expiratory flow rates are normal

191
Q

How are lung volumes and compliance changed in a patient with a restrictive lung disease?

A

Decreased lung volumes, decreased compliance

192
Q

Restrictive lung diseases include diseases affecting what 4 parts of the body?

A

1) Lung parenchyma
2) Pleura
3) Chest wall
4) Neuromuscular system

193
Q

Low lung volumes, seen in patients with restrictive lung disease, can lead to what 3 events?

A

Atelectasis, V/Q mismatch, and hypoxemia

194
Q

In patients with a restrictive lung disease, what 2 changes in lung mechanics causes especially rapid desaturation?

A

They have decreased oxygen diffusion and a reduced FRC

195
Q

What problems can restrictive lung disease lead to if it becomes severe enough?

A

Pulmonary hypertension and cor pulmonale (pulmonary heart disease, right ventricle enlargement and failure)

196
Q

How does the body of a patient with restrictive lung disease compensate to maintain minute ventilation?

A

Increase respiratory rate - rapid, shallow breathing

197
Q

What is the gold standard definition of Restrictive Lung Disease

A

A spectrum of disorders characterized by a decrease in Total Lung Capacity

198
Q

What is Total Lung Capacity, and how much must it be affected to be considered a severe problem?

A

It is the maximum volume of air in lungs - including vital capacity and residual volume. A reduction greater than 50% is considered severe

199
Q

What 2 methods are used to measure a person’s total lung capacity?

A

1) Helium dilution

2) Body plethysmography

200
Q

How are FEV1, FVC, and FEV1/FVC values changed in patients with RLD?

A

FVC (forced vital capacity) and FEV1 (forced expiratory volume in 1 second) are decreased, but the FEV1/FVC ratio is normal

201
Q

What is affected in Intrinsic Restrictive Lung Diseases?

A

Pulmonary parenchyma or airspace (i.e. lung problem)

202
Q

What is affected in Extrinsic Restrictive Lung Diseases?

A

Lung expansion is impaired but lungs are normal (i.e. extrapulmonary problem)

203
Q

RLDs are subcategorized into what 2 etiologies?

A

Acute and chronic

204
Q

How are acute intrinsic RLDs defined?

A

Reduced lung compliance due to an increase in extravascular lung water, either from an increase in pulmonary capillary pressure or increase in pulmonary capillary permeability

205
Q

What are some examples of acute intrinsic RLDs?

A

ARDS, aspiration pneumonitis, infectious pneumonia, LV failure, many variations of pulmonary edema

206
Q

Should a patient with an acute intrinsic RLD have an elective surgery?

A

No, it should be delayed until cardiorespiratory function has been treated and optimized

207
Q

How should you set the ventilator to provide lung protective ventilation to your patient with an acute intrinsic RLD?

A

Low tidal volume, high respiratory rate, peak inspiratory pressures below 30, PEEP

208
Q

What extra monitor should be included in your intraop care of a patient with an acute intrinsic RLD?

A

Invasive hemodynamic monitoring

209
Q

What is Acute Respiratory Distress Syndrome?

A

An acute inflammatory response to the lung resulting in noncardiogenic pulmonary edema

210
Q

What are the 4 criteria for diagnosing a patient with ARDS?

A

Acute onset, bilateral infiltrates on chest X ray, PaO2/FiO2 less than 200, pcwp less than 18

211
Q

What is the purpose of the ARDSNet Ventilatory Protocol?

A

Avoids volutrauma and barotrauma in patients with ARDS

212
Q 
List the appropriate values set by the ARDSNet Ventilatory Protocol for each of the following:
Tidal Volume:
PEEP:
SpO2:
PaO2:
Plateau pressures:
Peak pressures:
A 
TV: 6cc/kg
PEEP: 5mmHg
SpO2: 88-95%
PaO2: 55-80
Plateau pressures: Below 30mmhg
Peak pressures: below 35mmhg
213
Q

Why do with optimize FiO2/PEEP in patients with ARDS?

A

To reduce O2 toxicity

214
Q

To maintain pH in patients with ARDS, we employ _______ ________

A

Permissive hypercapnia

215
Q

What is the goal pH during permissive hypercapnia of patients with ARDS, and what is the lowest allowable pH?

A

Goal is 7.3-7.45, lowest pH is 7.15

216
Q

What diseases are categorized as Chronic Intrinsic RLD?

A

Interstitial lung diseases

217
Q

What are the characteristics of interstitial lung diseases?

A

Insidious onset, chronic inflammation of alveolar walls and tissue, progressive pulmonary fibrosis

218
Q

In ILDs, what does the chronic interstitial inflammation lead to?

A

Fibroblast activation –> pulmonary fibrosis –> decreased elasticity

219
Q

What are the symptoms of patients with ILDs?

A

Dyspnea, dry cough, tachypnea

220
Q

What appears on a chest x ray of a patient with an ILD?

A

“Ground glass” appearance, prominent reticulonodular markings, honeycomb appearance

221
Q

What is a typical arterial blood gas in a patient with an ILD?

A

Hypoxemia, normocarbia

222
Q

What is found on a physical exam that is consistent with ILD?

A

Dry crackles at lung base, clubbing, signs of RV failure such as ascites, hepatomegaly, anasarca

223
Q

What is characteristic of pulmonary function tests of patients with an ILD?

A

Decreased FVC, normal FEV1/FVC, decreased DLCO

224
Q

What kinds of treatments are available for patients with an interstitial lung disease?

A

Glucocorticoid, immunosuppressive, or supplemental oxygen therapy

225
Q

What is Sarcoidosis?

A

Systemic granulomatous disease that involves many tissues but has predilection for lung fibrosis and thoracic lymph nodes

226
Q

What anatomy is affected in patients with acute extrinsic RLD?

A

Pleura or mediastinum

227
Q

What are some examples of acute extrinsic RLDs?

A

Pleural effusion, pneumothorax, pneumomediastinum

228
Q

What causes chronic extrinsic RLDs?

A

Restriction of lung expansion by chest wall, diaphragm, abdominal contents, or neuromuscular disorders

229
Q

What are the 3 main causes of reduced lung expansion in patients with chronic extrinsic RLDs?

A

Obesity, pregnancy, ascites

230
Q

What airway problems occur in obese patients?

A

Difficult mask ventilation, difficult intubation

231
Q

What chest wall abnormalities can cause reduced lung expansion in patients with chronic extrinsic RLDs?

A

Kyphoscoliosis, sternal deformities, ankylosing spondylitis, flail chest

232
Q

A Cobb angle greater than ___ degrees is usually associated with respiratory failure

A

100 degrees

233
Q

What is scoliosis

A

Lateral curvature of the spine

234
Q

What is kyphosis

A

Anterior flexion of the spine

235
Q

What neuromuscular disorders cause reduced lung expansion in patients with chronic extrinsic RLDs?

A

Spinal cord transection, Guillain-Barr, disorders of neuromuscular transmission (myasthenia gravis, ALS), muscular dystrophy

236
Q

Patients with chronic extrinsic RLDs due to a neuromuscular disorder have the inability to generate what?

A

Normal respiratory pressures - they have weak cough, difficulty clearing secretions, aspiration

237
Q

What medicines are patients with chronic extrinsic RLDs due to neuromuscular disorders sensitive to?

A

Respiratory depressants and paralytics

238
Q

What lung capacity is an important indicator of the severity of RLD? What volume is considered severe?

A

Vital capacity, Less than 15cc/kg is considered severe (normal is 70cc/kg)

239
Q

If the bulbar muscles are affected by a patient’s neuromuscular disease, what are they at high risk for?

A

Aspiration

240
Q

What anesthetic consideration is key in managing your patient with a RLD?

A

Preoperative evaluation

241
Q

What parts of a patient’s medical history should be targeted to assess severity of their RLD?

A

Exercise tolerance, nature of disease, recent infections, comorbidities, smoking hx

242
Q

What is important in the physical exam of a patient with RLD to assess the severity?

A

Baseline pO2, breathing pattern, RR, auscultate lungs, cyanosis, body habitus

243
Q

What ABG results are signs of respiratory failure/end stage disease?

A

Hypoxia, hypercapnia

244
Q

What EKG manifestations help evaluate the severity of a patient with RLD

A

Right axis deviation, P pulmonate (waves higher than 2.5mm in lead 2), RVH, RBBB

245
Q

What patient-related factors put them at high pulmonary risk?

A

Old age, ASA greater than 2, CHF, functional dependency, COPD, serum albumin less than 35g/L

246
Q

What procedure-related factors put patients at high pulmonary risk?

A

Surgery greater than 3 hours, thoracic/abdominal/neuro surgery, head/neck surgery, aortic aneurysm repair, emergency surgery, general anesthesia

247
Q

For preoperative risk reduction, encourage cessation of smoking for at least _ weeks

A

6

248
Q

What are the benefits of general anesthesia in patients with a RLD?

A

Able to control oxygenation/ventilation, ability to suction airway, recruitment maneuvers

249
Q

What can be expected after induction in patients with RLD?

A

Rapid desaturation due to their decreased FRC

250
Q

What is the calculation for ideal body weight

A

Height in cm - 100 +/- 10%

251
Q

What is the shortcut for calculating IBW for females

A

100 lbs + 5 lbs for every inch over 5 ft

252
Q

What is the shortcut for calculating IBW for males

A

110 lbs + 5 lbs for every inch over 5 ft

253
Q

What is the calculation for BMI

A

Weight in kg / height in meters squared

254
Q

BMI over __ is defined as overweight

A

24

255
Q

A BMI of 28-35 is defined as what?

A

Obese

256
Q

People who are __% over their IBW are defined as obese

A

20%

257
Q

Waist size greater than __ in males and __ in females is defined as obese

A

40, 25

258
Q

People who are __ times their ideal body weight are defined as morbidly obese

A

2x

259
Q

A BMI over __ is classified as morbid obesity

A

40

260
Q

Give some examples of diseases linked to obesity

A

Diabetes, CHD, hypertension, stroke, arthritis, GERD, cancer

261
Q

Obese individuals are at greater risk of developing what 3 cardiovascular disorders

A

Hypertension, stroke, CAD

262
Q

What are the 2 forms of stroke

A

Ischemic and hemorrhagic

263
Q

When does an ischemic stroke occur

A

When an artery to the brain is blocked

264
Q

What body characteristics increase the risk for ischemic strokes in men and women

A

Overweight and obesity

265
Q

The risk of ischemic strokes are doubled in those with a BMI over __

A

30

266
Q

When do hemorrhagic strokes occur

A

When a blood vessel in the brain erupts

267
Q

Are hemorrhagic strokes affected by body weight?

A

No

268
Q

What is coronary artery disease?

A

A type of atherosclerosis that occurs when the arteries supplying blood to the heart become hardened and narrowed due to plaque buildup

269
Q

What is the most common bariatric procedure in the U.S?

A

Gastric restriction with bypass

270
Q

Obese individuals are at greater risk of developing what 2 gastrointestinal disorders?

A

Colon cancer, gall stones

271
Q

What is the second leading cause of cancer-related deaths in the US?

A

Colorectal cancer

272
Q

What is the primary hepatobiliary pathology associated with overweight?

A

Cholelithiasis - presence of gallstones

273
Q

Obese individuals are at greater risk of developing what 3 metabolic disorders?

A

Diabetes Mellitus, dyslipidemia, liver disease

274
Q

What 3 things make up the triad of metabolic syndromes?

A

Obesity, hypertension, type II diabetes

275
Q

A weight gain of __-__ pounds increases the risk of developing Type 2 diabetes

A

11-18 pounds

276
Q

Over __% of people with Type 2 DM are overweight or obese

A

80%

277
Q

What is dyslipidemia

A

An abnormal concentration of lipids or lipoproteins in the blood

278
Q

What is the term given to describe a collection of liver abnormalities that are associate with obesity?

A

Nonalcoholic fatty liver disease (NAFLD)

279
Q

What is steatosis

A

A pathological finding that means “fatty liver”

280
Q

How is cortisol production changed in obese people?

A

Increased cortisol production

281
Q

How are progesterone, testosterone, and growth hormone levels affected in obese people?

A

All are decreased

282
Q

What should you assess for in a cardiac evaluation of your obese patient?

A

Prior MI, hypertension, angina, PVD

283
Q

What are some indications of left ventricular dysfunction?

A

Limited exercise tolerance, history of orthopnea, paroxysmal nocturnal dyspnea

284
Q

Severely obese total body water is __%, compared to normal body water percentage of __%

A

40%, 60-65%

285
Q

Estimated blood volume in obese patients is __-__ mL/kg, compared to __mL/kg for the non-obese

A

45-55 ml/kg; 70ml/kg

286
Q

What is the recommended volume of Hetastarch (Hespan) to administer?

A

20mL/kg

287
Q

What should you use to replaced blood loss in obese patients?

A

Crystalloid 3:1 ratio

288
Q

What should you avoid during volume replacement of obese patients?

A

Rapid rehydration

289
Q

What can you use during volume replacement in obese patients to support circulatory volume and oncotic pressure?

A

Albumin 5% or 25%

290
Q

What physiologic changes can be seen in obese patients with OHS?

A

Hypersomnolence, arterial hypoxemia, polycythemia, hypercarbia, respiratory acidosis, pulmonary htn, RV failure

291
Q

What positions accentuate restrictive lung disease symptoms in obese patients?

A

Supine and trendelenberg

292
Q

What occurs if a patients FRC falls below closing capacity

A

Alveolar collapse, V/Q mismatch

293
Q

What 3 statements make up the Desaturation Theory

A
  1. FRC is reduced by 1.5L by positioning and general anesthesia
  2. FRC is usually 2-2.5L
  3. Under general anesthesia, FRC is about 1 L
294
Q

How fast will a patient with a BMI over 43 desaturate

A

Less than 130 seconds

295
Q

How are lung volumes (TV, IRV, and ERV) affected by obesity

A

TV normal or decreased, IRV decreased, ERV greatly decreased

296
Q

Even after an 8 hour fast, most morbidly obese patients have gastric volumes over __ mL and gastric pH below ___

A

25mL, 2.5

297
Q

What is the best treatment to prevent aspiration during surgeries on morbidly obese patients?

A

H2 blockers the night before surgery

298
Q

What inhalation agent is the most resistant to hepatic degradation?

A

Desflurane

299
Q

Why is desflurane the preferred inhalation agent in obese patients?

A

Low solubility, rapid washout, absence of hepatic/renal toxicity, supports blood pressure

300
Q

What drugs can be given preoperatively to obese patients to decrease risk of aspiration pneumonitis

A

Metoclopramide, H2 antagonist

301
Q

What labs should be assessed preoperatively for obese patients?

A

Cardiopulmonary reserve, ABG, EKG, PFT

302
Q

What are patient risk factors for difficult bag/mask ventilation

A

Age over 55, beard, snoring history, edentulous, BMI over 26

303
Q

What are the 6 Ds of physical signs of a difficult airway?

A
  1. Disproportion (tongue size)
  2. Distortion (neck mass)
  3. Decreased thyromental distance
  4. Decreased inter incisor gap
  5. Decreased range of motion
  6. Dental overbite
304
Q

What is a simple clinical sign to assess jaw function and addresses D3 and D6 of the 6 Ds?

A

The bite test - ask patient to touch upper lip with lower teeth, protrudes the mandible and assesses thyromental distance and overbite

305
Q

What is the “HELP” position

A

Head elevated laryngoscopy position - helps improve view during a DL of an obese patient, increases the time to desat, and facilitates rescue ventilation techniques

306
Q

What is the best position for obese patients to optimize pulmonary function

A

Reverse trendelenberg

307
Q

What does pleuritic chest pain indicate in patients coming in for thoracic surgery

A

The disease has spread to the pleura

308
Q

What are the symptoms of Horner’s syndrome

A

Ptosis, miosis, anhidrosis, conjuctiva, flushing

309
Q

What causes Horner’s syndrome

A

Apical lung tumor or venous congestion

310
Q

A ppo FEV1 result under what percentage is assc. with increased morbidity/mortality

A

40%

311
Q

A pop FEV1 result under what percentage is assc. with post-op ventilatory support

A

30%

312
Q

What position are VATS and thoracotomy procedures typically done under?

A

Decubitus

313
Q

What component of the ventilator could you use to limit V/Q mismatch in an anesthetized patient undergoing thoracic surgery

A

Add PEEP

314
Q

What are 3 absolute indications for one lung ventilation

A

Contamination (i.e. pneumonia), control distribution of ventilation (fistula), bronchoalveolar lavage

315
Q

What are the relative indications for one lung ventilation

A

Thoracic aneurysm, pneumonectomy, upper lobe procedures, esophagectomy, transplant

316
Q

Why can one lung ventilation lead to hypoxemia?

A

V/Q mismatch, shunt, decreased fio2, inadequate ventilation, anemia, impaired diffusion

317
Q

Patients usually tolerate which sided surgery requiring one lung ventilation

A

Left side because the right lung is bigger

318
Q

How does hypoxic pulmonary vasoconstriction help in one lung ventilation

A

Decreases blood flow to the bad lung, reduces shunt fraction and improves oxygenation

319
Q

What are some factors that can inhibit HPV

A

Vasodilators, PEEP, Ca2+ channel blockers, hypocapnia, hypercarbia/hypoxemia, hypothermia

320
Q

Why is it more challenging to place a right sided double lumen tube?

A

The right upper lobe take off is much shorter than the left, have a small margin of error

321
Q

When would a right sided double lumen tube be indicated

A

Patients with tumor in mainstream, left sided single lung transplant, anastomosis

322
Q

What size ETT do we use with bronchial blockers?

A

Usually 8.0 or 8.5

323
Q

What tidal volumes should you deliver to the ventilated lung during one lung ventilation

A

6-8ml/kg

324
Q

What should you keep your peak pressures under during one lung ventilation

A

25cmH2O

325
Q

What is the most common vent mode for one lung ventilation

A

Pressure support

326
Q

Why should you cation CPAP to non ventilated lung

A

It can impair surgical exposure

327
Q

Why should you caution PEEP in the ventilated lung during OLV

A

Could distort surgical field, also caution in patients w/ COPD, emphysema - could cause bullae to rupture or autoPEEP

328
Q

Which lung resection procedure has the most morbidity and incidence of arrhythmias

A

Pneumonectomy (whole lung)

329
Q

What is post-pneumonectomy syndrome

A

Mediastinal shift which causes stretching and compression of the tracheobronchial tree and esophagus

330
Q

What is the main symptom of post-pneumonectomy syndrome

A

Shortness of breath

331
Q

In which lung is post-pneumonectomy syndrome most common

A

Left pneumonectomy

332
Q

What is the treatment for post-pneumonectomy syndrome

A

Saline filled implants in vacant hemithorax

333
Q

Which lung has the highest incidence for post-pneumonectomy pulmonary edema

A

Right

334
Q

What are the main etiologies of tracheal disease

A

Prolonged intubation, extrinsic airway compression, mass/tumor

335
Q

Tracheal resections may need what types of special ventilation

A

Jet ventilation (low volume, high pressure), cross table ventilation

336
Q

Which anesthetic method is best for a tracheal resection

A

TIVA

337
Q

What should you consider for emergency/extubation in a tracheal resection

A

Deep extubation, using dexmetetomidine

338
Q

What is LVRS

A

Lung volume reduction surgery

339
Q

How should you manage ventilation/oxygenation in patients having a LVRS

A

No peep, long expiratory time to avoid breath stacking and ruptured bullae

340
Q

What side should a pulse ox be placed for mediastinoscopy

A

Right side to monitor for nominate artery compression

341
Q

What diseases indicate a lung transplant

A

End stage lung disease - COPD, cystic fibrosis, a1 antitrypsin deficiency, pulmonary HTN, pulmonary fibrosis

342
Q

When are epidurals for thoracic surgeries indicated

A

Thoracotomies, patients with chronic pain

343
Q

When should a paravertebral block be considered in thoracic surgery

A

In patients with contraindications to neuraxial methods

Anesthesia Practice (9 decks)

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