APEX Resp. WB : KEY Flashcards
1
Q
The primary synthesis of bicarbonate occurs where?
A
Erythrocytes within peripheral tissue beds through
2
Q
The primary synthesis of bicarbonate occurs through what reaction?
A
CO2+ H2O—————————> H2CO3 —->H{+} +HCO3-
First reaction catalyzed by Carbonic Anhydrase
3
Q
CO2 transported in what 3 forms
A
- Bicarbonate
- Bound to Hemoglobin
- Dissolved in plasma
4
Q
What % of CO2 in transported in the form of Plasma?
A
70%
5
Q
What % of CO2 in transported in form of “bound to hemoglobin” ?
A
23%
6
Q
What % of CO2 in transported in form of “Dissolved in plasma’?
A
7%
7
Q
Vocal cords attachment anteriorly is the
A
Thyroid (AT)
8
Q
Vocal cords attachment posteriorly is the
A
Arytenoid (PA)
9
Q
Muscle that elongates (tenses vocal cords)
A
CricoThyroid
10
Q
Muscle that relaxes vocal cords , 2 names
A
ThyRoarythenoids and Vocalis
11
Q
Muscle that pull cords apart
A
Posterior CricoArytenoids (Please Come Apart)
12
Q
Muscle that pull cords together
A
Lateral CricoArytenoids ( Let’s Close Airway)
13
Q
What innervates anterior 2/3 of the tongue?
A
Trigeminal nerve V3 (mandibular /lingual branch)
14
Q
What are the 3 branches of the trigeminal nerve?
A
V1: Ophtalmic
V2: Maxillary
V3: Mandibular
15
Q
Other name for trigeminal V1 Ophtalmic
A
Anterior Ethmoidal
16
Q
Other name for trigeminal V2 Maxillary
A
Sphenopalatine
17
Q
Other name for trigeminal V3 Mandibular
A
Lingual
18
Q
Vagus nerve division
A
Right and Left Vagus nerve
19
Q
Division of Right Vagus nerve
A
Superior Laryngeal nerve: External and internal nerve
Recurrent Laryngeal Nerve
20
Q
Division of Left vagus nerve
A
Left Recurrent Laryngeal nerve
21
Q
3 muscles that depresses the larynx
A
Sternohyoid,
sternothyroid
Omohyoid
22
Q
3 Key airway Blocks (GST)
A
Glossopharyngeal
Superior Laryngeal
Transtracheal
23
Q
Glossopharyngeal Block , needle is inserted where
A
BASE of the PALATOGLOSSAL ARCH 0.25 to 0.5cm
24
Q
Where does the SLN divides into internal and external branches?
A
At the hyoid bone
25
Where does the Internal branch penetrates thyroid membrane?
Between the GREATER CORNU OF THE HYOID BONE
26
When you performing the Glossopharyngeal nerve block, how much LA is inserted?
1-2 ml on both sides.
27
Which strucuteCloser to epiglottis side (anterior or posterior commissure)
Aterior
28
Which strucuteCloser to epiglottis side (anterior or posterior commissure)
Anterior
29
2 commonly mistaken for the arytenoids
Cuneiform and corniculate
30
Motor innervation of Laryngospasm (ME)
Efferent of the SLN internal Branch
31
Which is thought to be the TUNING FORK of the voice? Which is innervated by the?
CRICOTHYROID MUSCLE
| External Branch of the Superior Laryngeal nerve
32
Injury to the trunk of SLN or external branch causess
Hoarseness
33
Injury to the trunk of SLN or external branch causes
Hoarseness
34
The left RLN loops under what structures?
Aortic arch
35
Which is more susceptible to injury the left RLN or the RIGHT RLN?
The left due to its location within the thorax
36
RLN Injury: Left side Only
PDA ligation
Left Atrial Enlargement (mitral stenosis)
Aortic Arch aneurysm
Thoracic tumor.
37
When there is acute bilateral injury what does it lead to ?
Bilateral paralysis of the vocal cord ABDUCTORS, where the tension action of the CRICOTHYROID muscles act unopposed.
38
Bilateral RLN injury lead to
Stridor AND respiratory distress
39
Bilateral RLN injury lead to
Stridor AND respiratory distress
40
Unilateral RLN injury lead to
Paralysis of IPSILATERAL CORD ABDUCTOR, DOES NOT CAUSE RESPIRATORY DISTRESS>
41
SLN external branch causes_______But RLN unilateral injury causes
Hoarseness: NO respiratory distress
42
SLN injury presents with
Hoarseness
43
RLN injury bilateral presents with
Stridor and respiratory distress
44
RLN Unilateral injury presents with
NO PRESENTATION
45
During a glossopharangeal block if the Aspirate air what does that mean?
Needle is too deep
46
During a Glossopharyngeal Block if BLOOD is aspirated
Withdraw needle and redirect MEDIALLY (carotid is close)
47
Glossopharyngeal nerve block block what 5 structures
```
Posterior 1/3 of the tongue
Soft palate
Vallecular
Oropharynx
Gag reflex.
```
48
When performing a SUPERIOR LARYNGEAL BLOCK where is the anesthetic injected?
Inferior border of the greater Cornu
49
During both glossopharangeal block and SLN if Aspirate air what does that mean?
Needle is too deep
50
What structure does the SLN block blocks?
Cricothyroid muscle
| Sensation of the supraglottic region
51
Transtracheal block penetrate which membrane and in what direction?
Cricothyroid membrane in a caudal direction
52
Nerve block that Block the vocal cords
Transtracheal
53
Adult larynx level
C3-C6
54
Laryngeal structures
bone, 3 paired and 3 unpaired cartilages + LIGAMENTS
55
What is the only bone in body not to articulate with another bone?
Hyoid
56
2 that Provide structure to aryepiglottic folds
Corniculate and cuneiform
57
2 structures that appear as bumps on aryepiglottic folds
Corniculate and Cuneiform
58
Movement of arytenoid can be restricted by 2 conditions
Rheumatoid Arthritis and SLE
59
Largest cartilage of the larynx is the
Thyroid
60
What provides mechanical barrier between pharynx and Larynx opening?
Epiglottis
61
What is the space between the tongue and anterior side of the epiglottis?
Vallecula
62
The only complete cartilaginous ring to the airway
Cricoid cartilage
63
Adult airway shape is ______and pediatric airway shape is ______
Cylinder; Funnel
64
Adult airway narrowest region is ________and the pediatric airway narrowest region for dynamic ______and fixed ______
Vocal Cords
Dynamic --> Vocal cords
Fixed --> Cricoid
65
How is laryngospasm diagnosed?
Inspiratory Stridor
| Suprasternal & Supraclavicular RETRACTION during inspirattion
66
Laryngospasm chest appearance
Rocking horse appearance of the chest wall.
67
Pre-anesthetic Risk factors for laryngospasm: AGREA
```
Active or recent URI
GERD
Reactive airway disease
Exposure to 2nd hand smoke
Age < 1 year
```
68
Preventing Laryngospasm: Basic to know
Avoid airway manipulation during light anesthesia
CPAP 5-10 during inhalation induction AND after extubation
Remove pharyngeal secretion and blood prior to extubation
69
Preventing laryngospasm other way: mainly during extubation
Extubate deep or fully awake and not in between
IV lidocaine prior ot extubation
Hypercapnia/ Hypoventialtion
PaO2 < 50 mmHg
70
Treat laryngospams steps: FRD C (for real deep sux)
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
71
Succinylcholine dose IV and IM for CHILD/ adults?
IV 1mg/kg
| IM 4mg/kg
72
Succinylcholine dose IV and IM for neonate/infants?
IV 2mg/kg
| IM 5 mg/kg
73
Valsava Maneuver is
Exhalation against a closed glottic or obstruction
74
Risks of valsava Maneuver include (TAB)
Increase pressure in thorax, abdomen and Brain
75
What is Muller's Maneuver? Risk of Muller's Maneuver is ?
Inhalation against closed glottis or obstruction.
| risk: Sub-atmospheric pressure in the thorax leading to NEGATIVE PRESSURE PULMONARY EDEMA.
76
In the AWAKE states, what muscles prevents airway obstruction ?
Tensor Palatine
Genioglossus
Hyoid Muscle
77
What is the role of the Tensor Palatine?
Opens the Nasopharynx
78
What is the role of the Genioglossus?
Opens the Oropharynx
79
What is the role of the Hyoid Muscles?
Opens the hypo-pharynx
80
Where does the trachea begins?
C6
81
Where does the trachea ends?
T4-T5
82
Width of trachea_______; Length of trachea ____
2.5cm ; 10-13 cm long
83
Sensory innervation trachea -->
Vagus
84
Tissue of the tracheal
Ciliated Columnar Epithelium
85
What are the blood supply of Larynx ( BISts BITA)
Inferior Thyroid Artery
Superior Thyroid Artery
Bronchial Artery
Internal Thoracic Artery
86
Carina level_____and corresponds to what structure?______
T4-T5; angle of Louis
87
Carina is made up of what kind of tissue
Ciliated Columnar Epithelium.
88
of alveoli in a human_____and by what age_____
300 million by age 9
89
What is the substance that allow AIR movement between alveoli?
Pores of Kohn
90
What type of Pneumocytes are there?
Type I
Type II
Type III
91
Roles of type I pneumocyte?
Cover 80% of alveolar surface
| FORM TIGHT JUNCTIONS
92
Roles of Type II pneumocyte?
Produce Surfactant
93
Pneumocytes capable of cell division?
Type II cells
94
Pneumocytes that can produces type I cells?
Type II cells.
95
2 Roles of Type III pneumocytes?
Fight Lung infection and produce Inflammatory response.
96
Neutrophils presence in
Alveolus in smokers and with acute lung injury
97
Type I pneumocytes are made up of what tissues?
Flat squamous
98
Which type of Pneumocytes are structuraL?
Type I cells
99
From top to bottom pharynx (NOL)
Nasopharynx
Oropharynx
Laryngopharynx
100
Structure that is right on top of our turbinates is
CRIBIFORM PLATE
101
What are the 3 functional divisions of the airway?
Conducting zones
Respiratory zones
Transition zones
102
What increases as airway bifurcates?
Number of airways
Cross sectional areas
Muscular layers
103
What decreases as airway bifurcates?
Airflow velocity
Amount of cartilage
Globlet cells and ciliated
104
Right mainstem bronchus take off____how long is it___?
25 degrees take off; 2.5 cm Long
105
Left mainstem bronchus take off ______how long is it?
45 degrees take off ; 5 cm long
106
Distance from incisors to larynx is _____; Larynx to carina is ________and Incisors to carina is ________
13 cm; 13cm; 26 cm
107
Neck ________ make distance from incisors to carina shorter
Flexion
108
In kids up to _______both bronchi take off at ____degrees
3 years; 55 degrees from the long axis of the trachea.
109
Conduction zone spans from
Mouth to TERMINAL BRONCHIOLES
110
Conduction zone gas exchange
No gas exchange it is anatomic dead space
111
What are the last structures to be perfused by bronchial circulation?
Terminal bronchioles
112
Part of the Conducting zone
```
Trachea
Mainstem Bronchi
Lobar Bronchi
Small bronchi
Bronchioles
Terminal bronchioles
```
113
Where does the Respiratory zone starts?
At respiratory bronchioles
114
Gas exchange occurs at _____Zone
respiratory zone
115
Part of the Respiratory zones are
Respiratory bronchioles
Alveolar ducts
Alveolar facts
116
What occurs at the transitional zone?
Air conduction and gas exchange
117
Breathing 2 critical function
O2 delivered to Hgb
| CO2 eliminated from blood
118
For air movement to occur what pressure gradient must exist?
The pressure inside the airway must be GREATER than the pressure outside of the airway (transpulmonary pressure)
119
Alveolar pressure is the
Pressure inside of the lung
120
Intrapleural pressure is the
Pressure outside of the lung.
121
Transpulmonary pressure formula (TPP)
Alveolar pressure (bubble) - Intrapleural pressure (triangle)
122
During tidal breathing, Transpulmonary pressure of (TPP) is always:
Positive (keeps airways open)
123
During tidal breathing, intrapleural pressure is always:
negative (Keep the lungs inflated)
124
Alveolar pressure during inspiration become
Slightly negative
125
Intrapleural pressure is always
Negative
126
Alveolar pressure during expiration become
Slightly positive
127
Aside from a pathologic state of_______, the only time that intrapleural pressure becomes positive is during
FORCED EXPIRATION
128
Contraction of the inspiratory muscles effect of thoracic pressure and thoracic volume
Decrease thoracic pressure; Increases thoracic volume
129
Muscles of inspiration
Diaphragm and External Intercostals
130
Accessory muscles of inspiration
Sternocleidomastoid muscles
| Scalene muscles
131
Muscles that increase the AP diameter
External Intercostals
132
Exhalation process is ____ What is it driven by?
Passive ; recoil of the chest wall.
133
Active Exhalation is carried out by what muscles of the abdomen?
Rectus abdominus
Transverse Abdominus
Internal and External obliques
134
When does exhalation become an ACTIVE process?
When minute ventilation increases OR
| in patients with lung disease such as COPD
135
What vital capacity in needed for an effective cough?
15 ml/kg
136
Gas that does not participate in gas exchange?
Dead space (Vd)
137
Vd is normally _____ml/kg
2ml/kg
138
What effect does an increase Vd has on the PaCO2 - EtCo2 gradient?
Widens the gradient
139
Alveolar ventilation only measures what
The fraction of minute ventilation available for gas exchange , it REMOVES anatomic dead space (Vd) from the VE equation.
140
What is the formula for alveolar ventilation?
VA = (Tidal volume - Anatomic dead space) x RR
| = (Vt - Vd) x RR
141
Alveolar Ventilation relationship to CO2 Production
directly proportional
142
Alveolar Ventilation relationship to PaCO2 Production
Inversely proportional
143
Alveolar ventilation is ____production /
CO2 production or VA or VCO2 / PaCO2
144
Types of dead space (AAPA)
Anatomic
Alveolar
Physiologic
Apparatus
145
Air confined to the conducting zone, what type of Vd
Anatomic Vd
146
Alveoli ventilated not perfused
Alveolar Vd
147
Physiologic Vd include
Anatomic Vd + Alveolar Vd
148
Vd added by equipment is
Apparatus Vd
149
Apparatus Vd examples include
Face Mask and HMEs
150
Dead space to Vt ratio for a 70kg
For example: 70kg, Vd/Vt = 150/450ml = 0.33
151
Conditions that alter Vd -->
Anything that Increase the Vd/Vt ratio increase Vd & by extension reduces
152
What is the most common cause of increased Vd/Vt under GA is
a reduction in CO.
153
If the EtCo2 acutely decreases, you should first rule out
Hypotension
154
LMA and Vd (increases or decrease Vd and why?)
It reduces Vd because it bypass much of the anatomic VD such as the mouth and the glottis
155
Atropine and Vd (increases or decrease Vd and why?)
Increases VD because its bronchodilator action increase the volume of the conducting airways
156
Neck extension and Vd (increases or decrease Vd and why?)
Increase Vd because it opens up the HYPOPHARYNX and increase its volume
157
Neck Flexion and Vd
Decrease Vd
158
What equation helps calculate the Physiologic Vd?
Bohr Equation
159
When Vd increase, what must increase to maintain a constant PaCO2?
VE (RR,Vt or both)
160
In the circle system , Vd begins at the
y-piece
161
Anything that is proximal to the y-piece, does it influence vd? what is the only exception?
Does not influence
| Exception is an INCOMPETENT VALVE. The entire limb with the bad valve becomes apparatus Vd
162
Causes of increased Vd: airway wise
FM, HMEs, PPV, and filter
163
Drugs that can increase Vd:
Anticholinergics because they Bronchodilate
164
Age and Vd
Old age increased Vd
165
Pathophysiologic causes of increased (dead space)Vd
Decreased CO, PBF, COPD, PE (air, bone, fat, amniotic fluid)
166
What posture cause an increased in Vd?
Sitting
167
What posture cause a decrease in Vd?
Supine, head down position
168
Alveolar complicance curve: Ventilation is _____L/min and Perfusion ______L/min
4L/min ; 5L/min.-- V/Q is 4/5 = 0.8
169
Compliance formula
Change in Volume / Change in pressure
170
The most compliant alveoli are the _______; the least compliant alveoli are the _______
best ventilated; poorest ventilated
171
In the sitting position the dependent region of the lung is the _____-and the nondependent region of the lung is
Base ; Apex
172
In the supine position the dependent region of the lung is the _____-and the nondependent region of the lung is
Posterior; anterior
173
In the LEFT LATERAL DECUBITUS position the dependent region of the lung is the _____-and the nondependent region of the lung is
Left lung; right lung
174
In the RIGHT LATERAL DECUBITUS the dependent region of the lung is the _____-and the nondependent region of the lung is
Right lung; left lung
175
Parameter that is same in both non-dependent and dependent lung
PAN2
176
In the nondependent lung: VA, Q, V/Q, PAO2, PACO2
```
VA is low
Q is Low
V/Q is HIGH
PAO2 is HIGH
PACO2 is LOW
```
177
In the Dependent lung: VA, Q, V/Q, PAO2, PACO2
```
VA is HIGH
Q is HIGH
V/Q is LOW
PAO2 is LOW
PACO2 is HIGH
```
178
Perfusion is greatest where? why?
At the lung base due to gravity
179
Ventilation is greatest where ? why?
At the lung base due to HIGHER ALVEOLAR COMPLIANCE
180
Base is the most ______region and the apex is the
dependent; least
181
What is the most common cause of hypoxia in the PACU is ?
V/Q mismatch (ATELECTASIS)
182
How does anesthesia affect FRC and V/Q mismatch?
FRC becomes smaller so there is less radial traction to actually hold airways open
183
Ultimate results of decrease FRC when under GA VRAH
Atelectasis
Right to Left snunt
V/Q mismatch
Hypoxemia
184
Treatment of atelectasis in the PACU
Humidified O2 maneuvers that can open airway such as mobility, coughing, deep breathing and incentive spirometry.
185
How does the body compensate for V/Q mismatch ?
First obviously will attempt to correct to combat Vd (zone 1, bronchioles constrict), to combat shunt (zone 3), HPV reduces Blood flow.
186
What are the consequences of V/Q mismatch with underventilated alveoli?
Underventilated alveoli : that blood tend to retain CO2 and is unable to take in enough O2
187
What are the consequences of V/Q mismatch with Overventilated alveoli?
blood passing through overventilated places tend to give off TOO MUCH CO2.
188
CO2 vs diffusion of O2
CO2 diffuses 20X faster than O2
189
Once the PaO2 reaches 100mmHg, Hgb is
Fully saturated and any additional O2 that enters blood must be dissolved in the blood.
190
A lung with V/Q mismatch does what to compensate?
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
Alveolar Surface tension for CYLINDER SHAPE Equation?
Tension = Pressure x Radius
192
Cylinder Shape examples
Vessels and Cylindral Aneurysms
193
Alveolar Surface tension for SPHERICAL SHAPE Equation?
Tension = Pressure x radius /2
194
Examples of Spherical shape (HAS)
Alveoli, heart and SACCULAR Aneurysm
195
What law describes alveolar surface tension?
Laplace
196
What cell type produces surfactant?
TYPE II
197
When does the process of surfactant begin?
22 - 26 weeks
198
How does the surfactant work ?
decreased alveolar surface tension
199
When does the process of surfactant mature
35-36 weeks
200
Large alveoli and amount of surfactant
Small
201
Small alveoli and amount of surfactant
large
202
As the radius changes, what happens to the surface tension ?
It remains constant, which prevents smaller alveoli from collapsing and emptying into the larger alveoli
203
West Zone of the lungs name
Zone I : Dead space
Zone II: Waterfall
Zone III : SHUNT
204
Perfusion follows what kind of pattern?
Central to Peripheral pattern and is also affected by gravity
205
Explain what happens in zone I in terms of ventilation and perfusion? When is it not present?
Ventilation, NO perfusion
| Not present in normal lung
206
What increases Zone I
Hypotension, PE, Excessive Airway pressure,
207
Bronchioles of underperfused alveoli does what?
Bronchioles constrict to decrease Vd
208
Explain what happens in zone II in terms of ventilation and perfusion?
Waterfall. Both ventilation and perfusion occurs in zone II. Blood flow is directly proportional to the difference of Pa-PA
209
What can occurs with zone II ?
Zone II may transition and change to zone I or III
210
Explain what happens in zone III in terms of ventilation and perfusion?
Shunt occurs with blood flow is absence of ventilation (V/Q = 0).
211
Blood flow is a function of
pulmonary arteriovenous pressure difference (Pa-Pv)
212
Most zone III units are
Shunt like (Better perfused than ventilated V< Q))
213
What happens to combat zone III?
HPV reduces pulmonary blood flow to underventilated units. Since the pressure in the capillary > alveolus, the vessel is always open.
214
Where should the tip of the PAC be placed?
Zone III
215
Explain what happens in zone IV ?
Pulmonary Edema
216
Zone 4 pressures
Pa > Pis > Pv > PA
217
What is the classic example of Zone IV? how does it occur?
Pulmonary edema. Occurs when rate of fluid into pulmonary interstitium > rate of fluid removal by lymphatics
218
Pumonary Edema results from 2 things:
1. Fluid is pushed across capillary membranes by a significant INCREASE IN CAPILLARY HYDROSTATIC PRESSURE or PROFOUND REDUCTION in PLEURAL PRESSURE
219
3 things that can cause a SIGNIFICANT INCREASE in capillary hydrostatic pressure?
Fluid overload
Mitral valve Stenosis
Severe pulmonary vasoconstriction
220
3 things that can cause a profound reduction in pleural pressure
Laryngospasm Or INHALATION AGAINST A CLOSED GLOTTIS --> Negative pressure pulmonary edema.
