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SEE NCE Boards CoreConcepts > APEX Resp. WB : KEY > Flashcards

APEX Resp. WB : KEY Flashcards

1
Q

The primary synthesis of bicarbonate occurs where?

A

Erythrocytes within peripheral tissue beds through

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2
Q

The primary synthesis of bicarbonate occurs through what reaction?

A

CO2+ H2O—————————> H2CO3 —->H{+} +HCO3-

First reaction catalyzed by Carbonic Anhydrase

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3
Q

CO2 transported in what 3 forms

A
  1. Bicarbonate
  2. Bound to Hemoglobin
  3. Dissolved in plasma
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4
Q

What % of CO2 in transported in the form of Plasma?

A

70%

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5
Q

What % of CO2 in transported in form of “bound to hemoglobin” ?

A

23%

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6
Q

What % of CO2 in transported in form of “Dissolved in plasma’?

A

7%

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7
Q

Vocal cords attachment anteriorly is the

A

Thyroid (AT)

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8
Q

Vocal cords attachment posteriorly is the

A

Arytenoid (PA)

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9
Q

Muscle that elongates (tenses vocal cords)

A

CricoThyroid

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10
Q

Muscle that relaxes vocal cords , 2 names

A

ThyRoarythenoids and Vocalis

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11
Q

Muscle that pull cords apart

A

Posterior CricoArytenoids (Please Come Apart)

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12
Q

Muscle that pull cords together

A

Lateral CricoArytenoids ( Let’s Close Airway)

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13
Q

What innervates anterior 2/3 of the tongue?

A

Trigeminal nerve V3 (mandibular /lingual branch)

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14
Q

What are the 3 branches of the trigeminal nerve?

A

V1: Ophtalmic
V2: Maxillary
V3: Mandibular

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15
Q

Other name for trigeminal V1 Ophtalmic

A

Anterior Ethmoidal

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16
Q

Other name for trigeminal V2 Maxillary

A

Sphenopalatine

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17
Q

Other name for trigeminal V3 Mandibular

A

Lingual

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18
Q

Vagus nerve division

A

Right and Left Vagus nerve

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19
Q

Division of Right Vagus nerve

A

Superior Laryngeal nerve: External and internal nerve

Recurrent Laryngeal Nerve

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20
Q

Division of Left vagus nerve

A

Left Recurrent Laryngeal nerve

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21
Q

3 muscles that depresses the larynx

A

Sternohyoid,
sternothyroid
Omohyoid

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22
Q

3 Key airway Blocks (GST)

A

Glossopharyngeal
Superior Laryngeal
Transtracheal

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23
Q

Glossopharyngeal Block , needle is inserted where

A

BASE of the PALATOGLOSSAL ARCH 0.25 to 0.5cm

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24
Q

Where does the SLN divides into internal and external branches?

A

At the hyoid bone

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25
Q

Where does the Internal branch penetrates thyroid membrane?

A

Between the GREATER CORNU OF THE HYOID BONE

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26
Q

When you performing the Glossopharyngeal nerve block, how much LA is inserted?

A

1-2 ml on both sides.

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27
Q

Which strucuteCloser to epiglottis side (anterior or posterior commissure)

A

Aterior

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28
Q

Which strucuteCloser to epiglottis side (anterior or posterior commissure)

A

Anterior

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29
Q

2 commonly mistaken for the arytenoids

A

Cuneiform and corniculate

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30
Q

Motor innervation of Laryngospasm (ME)

A

Efferent of the SLN internal Branch

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31
Q

Which is thought to be the TUNING FORK of the voice? Which is innervated by the?

A

CRICOTHYROID MUSCLE

External Branch of the Superior Laryngeal nerve

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32
Q

Injury to the trunk of SLN or external branch causess

A

Hoarseness

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33
Q

Injury to the trunk of SLN or external branch causes

A

Hoarseness

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34
Q

The left RLN loops under what structures?

A

Aortic arch

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35
Q

Which is more susceptible to injury the left RLN or the RIGHT RLN?

A

The left due to its location within the thorax

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36
Q

RLN Injury: Left side Only

A

PDA ligation
Left Atrial Enlargement (mitral stenosis)
Aortic Arch aneurysm
Thoracic tumor.

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37
Q

When there is acute bilateral injury what does it lead to ?

A

Bilateral paralysis of the vocal cord ABDUCTORS, where the tension action of the CRICOTHYROID muscles act unopposed.

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38
Q

Bilateral RLN injury lead to

A

Stridor AND respiratory distress

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39
Q

Bilateral RLN injury lead to

A

Stridor AND respiratory distress

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40
Q

Unilateral RLN injury lead to

A

Paralysis of IPSILATERAL CORD ABDUCTOR, DOES NOT CAUSE RESPIRATORY DISTRESS>

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41
Q

SLN external branch causes_______But RLN unilateral injury causes

A

Hoarseness: NO respiratory distress

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42
Q

SLN injury presents with

A

Hoarseness

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43
Q

RLN injury bilateral presents with

A

Stridor and respiratory distress

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44
Q

RLN Unilateral injury presents with

A

NO PRESENTATION

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45
Q

During a glossopharangeal block if the Aspirate air what does that mean?

A

Needle is too deep

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46
Q

During a Glossopharyngeal Block if BLOOD is aspirated

A

Withdraw needle and redirect MEDIALLY (carotid is close)

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47
Q

Glossopharyngeal nerve block block what 5 structures

A 
Posterior 1/3 of the tongue
Soft palate
Vallecular
Oropharynx 
Gag reflex.
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48
Q

When performing a SUPERIOR LARYNGEAL BLOCK where is the anesthetic injected?

A

Inferior border of the greater Cornu

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49
Q

During both glossopharangeal block and SLN if Aspirate air what does that mean?

A

Needle is too deep

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50
Q

What structure does the SLN block blocks?

A

Cricothyroid muscle

Sensation of the supraglottic region

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51
Q

Transtracheal block penetrate which membrane and in what direction?

A

Cricothyroid membrane in a caudal direction

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52
Q

Nerve block that Block the vocal cords

A

Transtracheal

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53
Q

Adult larynx level

A

C3-C6

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54
Q

Laryngeal structures

A

bone, 3 paired and 3 unpaired cartilages + LIGAMENTS

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55
Q

What is the only bone in body not to articulate with another bone?

A

Hyoid

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56
Q

2 that Provide structure to aryepiglottic folds

A

Corniculate and cuneiform

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57
Q

2 structures that appear as bumps on aryepiglottic folds

A

Corniculate and Cuneiform

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58
Q

Movement of arytenoid can be restricted by 2 conditions

A

Rheumatoid Arthritis and SLE

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59
Q

Largest cartilage of the larynx is the

A

Thyroid

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60
Q

What provides mechanical barrier between pharynx and Larynx opening?

A

Epiglottis

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61
Q

What is the space between the tongue and anterior side of the epiglottis?

A

Vallecula

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62
Q

The only complete cartilaginous ring to the airway

A

Cricoid cartilage

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63
Q

Adult airway shape is ______and pediatric airway shape is ______

A

Cylinder; Funnel

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64
Q

Adult airway narrowest region is ________and the pediatric airway narrowest region for dynamic ______and fixed ______

A

Vocal Cords
Dynamic –> Vocal cords
Fixed –> Cricoid

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65
Q

How is laryngospasm diagnosed?

A

Inspiratory Stridor

Suprasternal & Supraclavicular RETRACTION during inspirattion

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66
Q

Laryngospasm chest appearance

A

Rocking horse appearance of the chest wall.

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67
Q

Pre-anesthetic Risk factors for laryngospasm: AGREA

A 
Active or recent URI
GERD
Reactive airway disease
Exposure to 2nd hand smoke
Age < 1 year
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68
Q

Preventing Laryngospasm: Basic to know

A

Avoid airway manipulation during light anesthesia
CPAP 5-10 during inhalation induction AND after extubation
Remove pharyngeal secretion and blood prior to extubation

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69
Q

Preventing laryngospasm other way: mainly during extubation

A

Extubate deep or fully awake and not in between
IV lidocaine prior ot extubation
Hypercapnia/ Hypoventialtion
PaO2 < 50 mmHg

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70
Q

Treat laryngospams steps: FRD C (for real deep sux)

A

FIO2 100%
Remove noxious stimulation
Deepen anesthesia (VA, propofol or lidocaine)
CPAP 15-20 cm H2O while doing head extension, chin left, Larson’s maneuver
Succinylcholine

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71
Q

Succinylcholine dose IV and IM for CHILD/ adults?

A

IV 1mg/kg

IM 4mg/kg

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72
Q

Succinylcholine dose IV and IM for neonate/infants?

A

IV 2mg/kg

IM 5 mg/kg

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73
Q

Valsava Maneuver is

A

Exhalation against a closed glottic or obstruction

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74
Q

Risks of valsava Maneuver include (TAB)

A

Increase pressure in thorax, abdomen and Brain

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75
Q

What is Muller’s Maneuver? Risk of Muller’s Maneuver is ?

A

Inhalation against closed glottis or obstruction.

risk: Sub-atmospheric pressure in the thorax leading to NEGATIVE PRESSURE PULMONARY EDEMA.

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76
Q

In the AWAKE states, what muscles prevents airway obstruction ?

A

Tensor Palatine
Genioglossus
Hyoid Muscle

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77
Q

What is the role of the Tensor Palatine?

A

Opens the Nasopharynx

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78
Q

What is the role of the Genioglossus?

A

Opens the Oropharynx

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79
Q

What is the role of the Hyoid Muscles?

A

Opens the hypo-pharynx

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80
Q

Where does the trachea begins?

A

C6

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81
Q

Where does the trachea ends?

A

T4-T5

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82
Q

Width of trachea_______; Length of trachea ____

A

2.5cm ; 10-13 cm long

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83
Q

Sensory innervation trachea –>

A

Vagus

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84
Q

Tissue of the tracheal

A

Ciliated Columnar Epithelium

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85
Q

What are the blood supply of Larynx ( BISts BITA)

A

Inferior Thyroid Artery
Superior Thyroid Artery
Bronchial Artery
Internal Thoracic Artery

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86
Q

Carina level_____and corresponds to what structure?______

A

T4-T5; angle of Louis

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87
Q

Carina is made up of what kind of tissue

A

Ciliated Columnar Epithelium.

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88
Q

of alveoli in a human_____and by what age_____

A

300 million by age 9

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89
Q

What is the substance that allow AIR movement between alveoli?

A

Pores of Kohn

90
Q

What type of Pneumocytes are there?

A

Type I
Type II
Type III

91
Q

Roles of type I pneumocyte?

A

Cover 80% of alveolar surface

FORM TIGHT JUNCTIONS

92
Q

Roles of Type II pneumocyte?

A

Produce Surfactant

93
Q

Pneumocytes capable of cell division?

A

Type II cells

94
Q

Pneumocytes that can produces type I cells?

A

Type II cells.

95
Q

2 Roles of Type III pneumocytes?

A

Fight Lung infection and produce Inflammatory response.

96
Q

Neutrophils presence in

A

Alveolus in smokers and with acute lung injury

97
Q

Type I pneumocytes are made up of what tissues?

A

Flat squamous

98
Q

Which type of Pneumocytes are structuraL?

A

Type I cells

99
Q

From top to bottom pharynx (NOL)

A

Nasopharynx
Oropharynx
Laryngopharynx

100
Q

Structure that is right on top of our turbinates is

A

CRIBIFORM PLATE

101
Q

What are the 3 functional divisions of the airway?

A

Conducting zones
Respiratory zones
Transition zones

102
Q

What increases as airway bifurcates?

A

Number of airways
Cross sectional areas
Muscular layers

103
Q

What decreases as airway bifurcates?

A

Airflow velocity
Amount of cartilage
Globlet cells and ciliated

104
Q

Right mainstem bronchus take off____how long is it___?

A

25 degrees take off; 2.5 cm Long

105
Q

Left mainstem bronchus take off ______how long is it?

A

45 degrees take off ; 5 cm long

106
Q

Distance from incisors to larynx is _____; Larynx to carina is ________and Incisors to carina is ________

A

13 cm; 13cm; 26 cm

107
Q

Neck ________ make distance from incisors to carina shorter

A

Flexion

108
Q

In kids up to _______both bronchi take off at ____degrees

A

3 years; 55 degrees from the long axis of the trachea.

109
Q

Conduction zone spans from

A

Mouth to TERMINAL BRONCHIOLES

110
Q

Conduction zone gas exchange

A

No gas exchange it is anatomic dead space

111
Q

What are the last structures to be perfused by bronchial circulation?

A

Terminal bronchioles

112
Q

Part of the Conducting zone

A 
Trachea
Mainstem Bronchi
Lobar Bronchi
Small bronchi
Bronchioles
Terminal bronchioles
113
Q

Where does the Respiratory zone starts?

A

At respiratory bronchioles

114
Q

Gas exchange occurs at _____Zone

A

respiratory zone

115
Q

Part of the Respiratory zones are

A

Respiratory bronchioles
Alveolar ducts
Alveolar facts

116
Q

What occurs at the transitional zone?

A

Air conduction and gas exchange

117
Q

Breathing 2 critical function

A

O2 delivered to Hgb

CO2 eliminated from blood

118
Q

For air movement to occur what pressure gradient must exist?

A

The pressure inside the airway must be GREATER than the pressure outside of the airway (transpulmonary pressure)

119
Q

Alveolar pressure is the

A

Pressure inside of the lung

120
Q

Intrapleural pressure is the

A

Pressure outside of the lung.

121
Q

Transpulmonary pressure formula (TPP)

A

Alveolar pressure (bubble) - Intrapleural pressure (triangle)

122
Q

During tidal breathing, Transpulmonary pressure of (TPP) is always:

A

Positive (keeps airways open)

123
Q

During tidal breathing, intrapleural pressure is always:

A

negative (Keep the lungs inflated)

124
Q

Alveolar pressure during inspiration become

A

Slightly negative

125
Q

Intrapleural pressure is always

A

Negative

126
Q

Alveolar pressure during expiration become

A

Slightly positive

127
Q

Aside from a pathologic state of_______, the only time that intrapleural pressure becomes positive is during

A

FORCED EXPIRATION

128
Q

Contraction of the inspiratory muscles effect of thoracic pressure and thoracic volume

A

Decrease thoracic pressure; Increases thoracic volume

129
Q

Muscles of inspiration

A

Diaphragm and External Intercostals

130
Q

Accessory muscles of inspiration

A

Sternocleidomastoid muscles

Scalene muscles

131
Q

Muscles that increase the AP diameter

A

External Intercostals

132
Q

Exhalation process is ____ What is it driven by?

A

Passive ; recoil of the chest wall.

133
Q

Active Exhalation is carried out by what muscles of the abdomen?

A

Rectus abdominus
Transverse Abdominus
Internal and External obliques

134
Q

When does exhalation become an ACTIVE process?

A

When minute ventilation increases OR

in patients with lung disease such as COPD

135
Q

What vital capacity in needed for an effective cough?

A

15 ml/kg

136
Q

Gas that does not participate in gas exchange?

A

Dead space (Vd)

137
Q

Vd is normally _____ml/kg

A

2ml/kg

138
Q

What effect does an increase Vd has on the PaCO2 - EtCo2 gradient?

A

Widens the gradient

139
Q

Alveolar ventilation only measures what

A

The fraction of minute ventilation available for gas exchange , it REMOVES anatomic dead space (Vd) from the VE equation.

140
Q

What is the formula for alveolar ventilation?

A

VA = (Tidal volume - Anatomic dead space) x RR

= (Vt - Vd) x RR

141
Q

Alveolar Ventilation relationship to CO2 Production

A

directly proportional

142
Q

Alveolar Ventilation relationship to PaCO2 Production

A

Inversely proportional

143
Q

Alveolar ventilation is ____production /

A

CO2 production or VA or VCO2 / PaCO2

144
Q

Types of dead space (AAPA)

A

Anatomic
Alveolar
Physiologic
Apparatus

145
Q

Air confined to the conducting zone, what type of Vd

A

Anatomic Vd

146
Q

Alveoli ventilated not perfused

A

Alveolar Vd

147
Q

Physiologic Vd include

A

Anatomic Vd + Alveolar Vd

148
Q

Vd added by equipment is

A

Apparatus Vd

149
Q

Apparatus Vd examples include

A

Face Mask and HMEs

150
Q

Dead space to Vt ratio for a 70kg

A

For example: 70kg, Vd/Vt = 150/450ml = 0.33

151
Q

Conditions that alter Vd –>

A

Anything that Increase the Vd/Vt ratio increase Vd & by extension reduces

152
Q

What is the most common cause of increased Vd/Vt under GA is

A

a reduction in CO.

153
Q

If the EtCo2 acutely decreases, you should first rule out

A

Hypotension

154
Q

LMA and Vd (increases or decrease Vd and why?)

A

It reduces Vd because it bypass much of the anatomic VD such as the mouth and the glottis

155
Q

Atropine and Vd (increases or decrease Vd and why?)

A

Increases VD because its bronchodilator action increase the volume of the conducting airways

156
Q

Neck extension and Vd (increases or decrease Vd and why?)

A

Increase Vd because it opens up the HYPOPHARYNX and increase its volume

157
Q

Neck Flexion and Vd

A

Decrease Vd

158
Q

What equation helps calculate the Physiologic Vd?

A

Bohr Equation

159
Q

When Vd increase, what must increase to maintain a constant PaCO2?

A

VE (RR,Vt or both)

160
Q

In the circle system , Vd begins at the

A

y-piece

161
Q

Anything that is proximal to the y-piece, does it influence vd? what is the only exception?

A

Does not influence

Exception is an INCOMPETENT VALVE. The entire limb with the bad valve becomes apparatus Vd

162
Q

Causes of increased Vd: airway wise

A

FM, HMEs, PPV, and filter

163
Q

Drugs that can increase Vd:

A

Anticholinergics because they Bronchodilate

164
Q

Age and Vd

A

Old age increased Vd

165
Q

Pathophysiologic causes of increased (dead space)Vd

A

Decreased CO, PBF, COPD, PE (air, bone, fat, amniotic fluid)

166
Q

What posture cause an increased in Vd?

A

Sitting

167
Q

What posture cause a decrease in Vd?

A

Supine, head down position

168
Q

Alveolar complicance curve: Ventilation is _____L/min and Perfusion ______L/min

A

4L/min ; 5L/min.– V/Q is 4/5 = 0.8

169
Q

Compliance formula

A

Change in Volume / Change in pressure

170
Q

The most compliant alveoli are the _______; the least compliant alveoli are the _______

A

best ventilated; poorest ventilated

171
Q

In the sitting position the dependent region of the lung is the _____-and the nondependent region of the lung is

A

Base ; Apex

172
Q

In the supine position the dependent region of the lung is the _____-and the nondependent region of the lung is

A

Posterior; anterior

173
Q

In the LEFT LATERAL DECUBITUS position the dependent region of the lung is the _____-and the nondependent region of the lung is

A

Left lung; right lung

174
Q

In the RIGHT LATERAL DECUBITUS the dependent region of the lung is the _____-and the nondependent region of the lung is

A

Right lung; left lung

175
Q

Parameter that is same in both non-dependent and dependent lung

A

PAN2

176
Q

In the nondependent lung: VA, Q, V/Q, PAO2, PACO2

A 
VA is low
Q is Low
V/Q is HIGH
PAO2 is HIGH
PACO2 is LOW
177
Q

In the Dependent lung: VA, Q, V/Q, PAO2, PACO2

A 
VA is HIGH
Q is HIGH
V/Q is LOW
PAO2 is LOW
PACO2 is HIGH
178
Q

Perfusion is greatest where? why?

A

At the lung base due to gravity

179
Q

Ventilation is greatest where ? why?

A

At the lung base due to HIGHER ALVEOLAR COMPLIANCE

180
Q

Base is the most ______region and the apex is the

A

dependent; least

181
Q

What is the most common cause of hypoxia in the PACU is ?

A

V/Q mismatch (ATELECTASIS)

182
Q

How does anesthesia affect FRC and V/Q mismatch?

A

FRC becomes smaller so there is less radial traction to actually hold airways open

183
Q

Ultimate results of decrease FRC when under GA VRAH

A

Atelectasis
Right to Left snunt
V/Q mismatch
Hypoxemia

184
Q

Treatment of atelectasis in the PACU

A

Humidified O2 maneuvers that can open airway such as mobility, coughing, deep breathing and incentive spirometry.

185
Q

How does the body compensate for V/Q mismatch ?

A

First obviously will attempt to correct to combat Vd (zone 1, bronchioles constrict), to combat shunt (zone 3), HPV reduces Blood flow.

186
Q

What are the consequences of V/Q mismatch with underventilated alveoli?

A

Underventilated alveoli : that blood tend to retain CO2 and is unable to take in enough O2

187
Q

What are the consequences of V/Q mismatch with Overventilated alveoli?

A

blood passing through overventilated places tend to give off TOO MUCH CO2.

188
Q

CO2 vs diffusion of O2

A

CO2 diffuses 20X faster than O2

189
Q

Once the PaO2 reaches 100mmHg, Hgb is

A

Fully saturated and any additional O2 that enters blood must be dissolved in the blood.

190
Q

A lung with V/Q mismatch does what to compensate?

A

Eliminates CO2 from overventilated alveoli to compensate for underventilated alveoli. Keeps the PACO2-PaCO2 small during V/Q mismatch . But the same lung cannot absorb more O2 from overventilated alveoli to compensate for underventilated alveoli. This is why the PAO2-PaO2 gradient is usually LARGE with V/Q mismatch.

191
Q

Alveolar Surface tension for CYLINDER SHAPE Equation?

A

Tension = Pressure x Radius

192
Q

Cylinder Shape examples

A

Vessels and Cylindral Aneurysms

193
Q

Alveolar Surface tension for SPHERICAL SHAPE Equation?

A

Tension = Pressure x radius /2

194
Q

Examples of Spherical shape (HAS)

A

Alveoli, heart and SACCULAR Aneurysm

195
Q

What law describes alveolar surface tension?

A

Laplace

196
Q

What cell type produces surfactant?

A

TYPE II

197
Q

When does the process of surfactant begin?

A

22 - 26 weeks

198
Q

How does the surfactant work ?

A

decreased alveolar surface tension

199
Q

When does the process of surfactant mature

A

35-36 weeks

200
Q

Large alveoli and amount of surfactant

A

Small

201
Q

Small alveoli and amount of surfactant

A

large

202
Q

As the radius changes, what happens to the surface tension ?

A

It remains constant, which prevents smaller alveoli from collapsing and emptying into the larger alveoli

203
Q

West Zone of the lungs name

A

Zone I : Dead space
Zone II: Waterfall
Zone III : SHUNT

204
Q

Perfusion follows what kind of pattern?

A

Central to Peripheral pattern and is also affected by gravity

205
Q

Explain what happens in zone I in terms of ventilation and perfusion? When is it not present?

A

Ventilation, NO perfusion

Not present in normal lung

206
Q

What increases Zone I

A

Hypotension, PE, Excessive Airway pressure,

207
Q

Bronchioles of underperfused alveoli does what?

A

Bronchioles constrict to decrease Vd

208
Q

Explain what happens in zone II in terms of ventilation and perfusion?

A

Waterfall. Both ventilation and perfusion occurs in zone II. Blood flow is directly proportional to the difference of Pa-PA

209
Q

What can occurs with zone II ?

A

Zone II may transition and change to zone I or III

210
Q

Explain what happens in zone III in terms of ventilation and perfusion?

A

Shunt occurs with blood flow is absence of ventilation (V/Q = 0).

211
Q

Blood flow is a function of

A

pulmonary arteriovenous pressure difference (Pa-Pv)

212
Q

Most zone III units are

A

Shunt like (Better perfused than ventilated V< Q))

213
Q

What happens to combat zone III?

A

HPV reduces pulmonary blood flow to underventilated units. Since the pressure in the capillary > alveolus, the vessel is always open.

214
Q

Where should the tip of the PAC be placed?

A

Zone III

215
Q

Explain what happens in zone IV ?

A

Pulmonary Edema

216
Q

Zone 4 pressures

A

Pa > Pis > Pv > PA

217
Q

What is the classic example of Zone IV? how does it occur?

A

Pulmonary edema. Occurs when rate of fluid into pulmonary interstitium > rate of fluid removal by lymphatics

218
Q

Pumonary Edema results from 2 things:

A
  1. Fluid is pushed across capillary membranes by a significant INCREASE IN CAPILLARY HYDROSTATIC PRESSURE or PROFOUND REDUCTION in PLEURAL PRESSURE
219
Q

3 things that can cause a SIGNIFICANT INCREASE in capillary hydrostatic pressure?

A

Fluid overload
Mitral valve Stenosis
Severe pulmonary vasoconstriction

220
Q

3 things that can cause a profound reduction in pleural pressure

A

Laryngospasm Or INHALATION AGAINST A CLOSED GLOTTIS –> Negative pressure pulmonary edema.

SEE NCE Boards CoreConcepts (44 decks)

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