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Concepts 2 > Diseased and Failing Lung > Flashcards

Diseased and Failing Lung Flashcards

1
Q

What is bronchoconstriction mediated by?

A

1: PNS & immune response (IgE)
2: Mast cells
•Histamine
•Prostaglandin D2 and F2
•Leukotrienes C4, E4, and D4
•Platelet activating factor•Bradykinin
3: Non-cholinergic c-fibers
•Substance P
•Neurokinin A
•Calcitonin

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2
Q

What is the process of bronchoconstriction?

A

Vagas nerve (X) innervates smooth muscle → cholinergic nerve endings release AcH to muscarinic receptors → G protein coupling → IP3 (2nd messenger) → stimulates iCa from sarcoplasmic reticulum → increased calcium activates myosin light chain kinase

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3
Q

What is bronchodilation mediated by?

A

–Mediated by circulating catecholamines and NO

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4
Q

Three mechanisms of airway obstruction:

A
  1. partial occulusion
  2. wall thickening
  3. outside of airway disease
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5
Q

CHRONIC OBSTRUCTIVE AIRWAY DISEASE (COPD) - diseases

A
  • Chronic bronchitis
  • Emphysema
  • Cystic fibrosis
  • Asthma
  • Bronchiectasis = Repeated infection/inflammation - - Permanent dilation of bronchi/oles destroying muscle elastin supporting tissue
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6
Q

Types of Chronic Obstructive Pulmonary Disease

A
  1. Centriacinar: destruction confined to the terminal and respiratory bronchioles
  2. Panacinar: the terminal and respiratory bronchioles & peripheral alveoli are involved
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7
Q

Two types of Pulmonary Emphysema

A

Type A and Type B

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8
Q

CHARACTERISTICS OF TYPE A PULMONARY EMPHYSEMA

A

“PINK PUFFER”
•Smoking history
•Age of onset: 40 – 50 years
•Often dramatic barrel chest
•Weight loss
•Decreased breath sounds
•Normal blood gases until late in disease process
•Cor pulmonale only in advanced cases
•Slowly debilitating disease

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9
Q

CHARACTERISTICS OF
TYPE B CHRONIC BRONCHITIS

A

“BLUE BLOATER”
•Smoking history
•Age of onset 30–40 years
•+/- Barrel chest may be p
•Shortness of breath predominant early s/s
•Sputum frequent early manifestation
•Rhonchi often present
•Often dramatic cyanosis
•Hypercapnia and hypoxemia may be present
•Frequent Cor pulmonale (RIGHT CHF) and polycythemia
•Numerous life-threatening episodes due to acute exacerbations

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10
Q

Changes w/ COPD

A
  • Reductions of FEV1, FVC, and the ratio of FEV1/FVC are the hallmark of airflow limitation
  • Flow-volume loops show a concave pattern in the expiratory tracing

CXR: flat diaphragm, lungs are hyperinflated d/t air trapping, heart size increased

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11
Q

COPD Overview

A

Causes: tobacco and air pollution → continual bronchial irritation and inflammation → chronic bronchitis: bronchial edema, productive cough, bronchospasm

OR → alpha-1 antitrypsin deficiency → breakdown of elastin in connective tissue of lungs → emphysema: destruction of alveolar walls, lung fibrosis, and air trapping

→ airway obstruction/air trapping, dyspnea, frequent infections → abnormal V/Q, hypoxemia and hypoventilation

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12
Q

Cystic Fibrosis

A

Mutation of CFTR gene = cystic fibrosis transmembrane conduction receptor regulator

  • regulates sweat, digestive juices, and mucous → lung congestion and infection, + malabsorption of nutrients by the pancreas
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13
Q

Cystic Fibrosis Changes

A
  • ABG – hypoxemia
  • FVC decreased
  • FEV1 decreased
  • FEV1/FVC decreased
  • FEF25-75 decreased
  • RV - INCREASED
  • RV/TLC - INCREASED
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14
Q

Asthma Characteristics

A
  1. Airway Hyperreactivity:
    •Various noxious stimuli: cold air, allergens, chemicals, exercise, drugs (aspirin, NSAIDs, sulfites), instrumentation of the airway
    •Bronchial smooth muscle constricts in response to irritants
    •Asymptomatic asthmatic patients also possess airway hyperreactivity
  2. Airway Wall Inflammation:
    •Presence of mucus, edema and inflammatory cells leads to reduction of airway size or obstruction of the airway.
  3. Reversible Expiratory Airflow:
    •Bronchodilator therapy can cause a 15% or greater increase in airflow
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15
Q

Asthma Process diagragm

A
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16
Q

Asthma Attack w/ Spirometry

A

Residual volume = NORMAL

RV, ERV, IRV air trapping = ?

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17
Q

Asthma PFTs

A

–FEV1: direct reflection of the severity of expiratory airflow obstruction
•Little or no sx with FEV1 > 50%
–FEF 25-75%: also measures severity of expiratory airflow obstruction
–FRC increases by 1-2L as expiratory obstruction retains air in lungs, but overall lung capacity remains within normal limits

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18
Q

Asthma Flow Volume Loops

A

–Expiratory loop is smaller

–with a “scooped-out” appearance

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19
Q

Asthma: Diffusing Capacity & Blood Gases

A

•Diffusing Capacity–Not decreased in asthmatics

•Blood Gases
–PaO2: normal in mild to moderate asthma
•Decreases with marked asthma and severe asthma (i.e. status asthmatics)
–PaCO2: normal in mild asthma
•Increases slightly in moderate asthma and more substantially in marked and severe asthma

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20
Q

Interventions for intraop bronchospasm

A
  • 100% O2
  • Deepen anesthetic (volatile agent or propofol)
  • Ketamine
  • Lidocaine
  • Short acting inhaled Beta-2 agonist (albuterol)
  • Inhaled ipratropium (atrovent)
  • Epinephrine 1 mcg/kg
  • Hydrocortisone 2-4 mg/kg•(not acute symptoms)
  • Aminophylline
  • Heliox
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21
Q

Bronchospasm vs. Laryngospasm

A

If you have secured your airway, then have a sudden loss of TV, its likely bronchospasm. don’t automatically assume it is laryngospasm and do NOT remove your airway. try all other interventions before adjusting the airway

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22
Q

Mechanical Ventilation Targets

A
  • Respiratory rate 7-8 breaths per minute
  • Slow inspiratory flow helps gas redistribute from high compliance areas to those with longer time constants –Maximizes V/Q matching
  • FiO2 adjusted to prevent hypoxemia•Smaller Vt (6 – 8 mL/kg)
  • PEEP maintains patency in alveoli: 2-5 normal
  • Increased expiratory times to minimize air trapping
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23
Q

Different Restrictive Lung Diseases

A

•Lung Parenchyma
–Pulmonary Fibrosis
–Sarcoidosis
–Pneumonitis

•Pleura
–Pneumothorax
–Pleural Effusion

•Chest Wall
–Scoliosis
–Ankylosing Spondylitis

  • Neuromuscular Disorders
  • *Obesity
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24
Q

Restrictive Lung Disease Characteristics

A

–VC = decreased
–Resting lung volume = decreased
–Normal Airway Resistance

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25
Q

Structure Of Alveolar Wall

A

–Type 1 Epithelial Cells
•Chief Structure Cells
•Gas Exchange

–Type 2 Epithelial Cells
•Functional Cells
•Secrete Surfactant
•Replenish Type 1

–Alveolar Macrophage
–Fibroblast
–Interstitium (Space)

26
Q

DIFFUSE INTERSTITIAL PULMONARY FIBROSIS

A
  • Thickening of the alveolar wall interstitium
  • Infiltration with lymphocytes and plasma cells
  • Fibroblast: Construct collagen bundles
  • Desquamation - Macrophages and mononuclear cells
  • Pathogenesis – unknown (Immunologic Reactions)
27
Q

INTERSTITIAL PULMONARY FIBROSIS - Changes

A
  • FVC decreased
  • FEV1 decreased
  • FEV1/FVC normal
  • FEF25-75 is normal or increased
  • All lung volumes decrased
  • PaO2 & PaCO2 decreased
  • pH normal: compensated
  • DLCO decreased (diffusion Capacity)
  • Va/Q inequality
28
Q

Sarcoidosis

A
  • Granulomatous Widespread interstitial lung disease
  • Lung Volumes decreased
  • FEV1/FVC preserved
  • Lung compliance decreased
  • PaO2 decreased
  • PaCO2 normal or decreased
  • DLCO decreased
  • Pathogenesis unknown
29
Q

Sarcoidosis Outcomes

A

–Pulmonary fibrosis

–Severe restricted lung function

30
Q

DISEASES OF THE PLEURA: Pneumothorax

A

–Spontaneous
•Sudden onset pain
•Dyspnea
•decreased breath sounds
•Confirmation by x-ray

–#1 = Tension
–FEV1 decreased
–FVC decreased

31
Q

Pleural Effusion: changes, assessment, and treatment

A

Changes:
–Fluid/Exudates
–FEV1 decreased
–FVC decreased

•Assessment
–Dyspnea
–Pleuritic pain
–Absent Breath Sounds
–Dull percussion

•Treatment
–Underlying cause
–Aspiration

32
Q

Scoliosis Changes

A

–Lung volumes (TLC) = decreased
– FRC, FEV1 = decreased
–NORMAL FEV1/FVC ratio
–Resistance normal
•Relative to lung volumes

33
Q

Ankylosing Spondylitis Changes

A

–FVC decreasd
–TLC decrased
–FEV1/FVC normal
–Resistance normal

34
Q

Morbid Obesity

A

Load of outter lungs increased

35
Q

Morbid Obesity Changes

A
  • Reduction in lung compliance
  • Reduction in lung volume
  • Reduction in respiratory muscle strength
  • Increase in airway resistance
  • Increase in pulmonary diffusion
  • heterogeneity of ventilation distribution
    • hypercapnic respiratory failure
36
Q

Morbid Obesity Changes: FEV1, FVC, DLCO

A

FEV1/FVC: Normal

FEV1: Normal or decreased

FVC: decreased

DLCO: decreased

37
Q

Normal values for FEV1/FVC, FEV1, FVC, and DLCO

A

FEV1/FVC = 70 - 90%

FEV1 = 100%

FVC = 100%

DLCO = 100%

38
Q

Neuromuscular Disorders

A
  • Poliomyelitis
  • Guillain-Barré syndrome
  • ALS
  • MG
  • MD
39
Q

Neuromuscular Disorder Changes

A

ALL decreased: FVC, TLC, IC, FEV1

40
Q

Vascular Diseases/ Pulmonary Edema

A

•DECREASED Distensibility
•Increased Airway resistance
•Hypoxemia–50% shunt
•PEEP
•J-receptors (stretch receptors)
–Rapid Breathing Pattern

41
Q

Pulmonary Edema Changes in Pressure

A

Normal:
Capillary Filtration Pressure = 10mmHg
Capillary colloidal osmotic pressure = 25mmHg

Pulm Edema: capillary filtration pressure exceeds the capillary colloidal osmotic pressure that pulls fluid back into the capillary
Capillary Filtration Pressure = >25mmHg
Capillary colloidal osmotic pressure = 25mmHg

42
Q

Mechanisms of Pulmonary Edema

A
43
Q

Vascular Disease/Pulmonary Embolism Causes and Changes

A
  • DVT
  • Right heart
  • Non-thrombotic–Fat – air – amniotic fluid
  • Stasis of blood
  • Coagulopathy
  • Vessel wall abnormalities
  • Hypoxemia
  • Shunt/dead space increased
  • High V/Q ratio
44
Q

Clinical features of small emboli (PE)

A

Frequently unrecognized

Repeated PE may result in Pulmonary hypertension

45
Q

Clinical features of medium sized PE

A
  • Pleuritic pain
  • Dyspnea
    • Cough
  • Pleural friction rub
  • Chest x-ray WNL
  • Lung scan – areas of under perfusion
46
Q

Massive PE

A
  • CV collapse
  • Central CP
  • Hypotension
  • Weak pulse
  • Distended neck veins
  • Death
47
Q

Pulmonary HTN

A

•Increased LA pressure
–MS – LV failure – AS - AI

•Increase in Pulmonary blood flow
–CHD with left-to-right shunts through ASD – PFO - VSD

•Increases in PVR
–Vasoconstriction: Alveolar hypoxia
–Obstructive: Thromboembolism
–Obliterative: Emphysema

  • Primary Pulmonary Hypertension
  • Cor Pulmonale
48
Q

What DECREASES PVR

A

–Hyperventilation
–Nitric Oxide
–Nitroglycerin
–Phosphodiesterase inhibitors
–Prostaglandins (PGE1 and PGI2)

49
Q

What INCREASES PVR?

A

–Hypoxia
–Hypercarbia
–Nitrous oxide
–Hypothermia
–PEEP

50
Q

COVID-19: Acute and Post Symptoms

A
51
Q

COVID Long-Haulers Symptoms

A
52
Q

Respiratory Failure

A

DEFINITION: fails to oxygenate arterial blood adequately &/OR fails to prevent CO2 retention

•Hypoventilation INCREASED PCO2
–NM disease – narcotic OD

•Severe V:Q inequality; INCREASED PCO2
–COPD

•Severe interstitial disease - Normal PCO2
–No CO2 retention
–Diffuse interstitial disease – sarcoidosis

•ARDS - DECREASED PCO2

53
Q

Ventilatory Failure

A

•Ventilatory failure: is the type that effects V/Q mismatching, in which perfusion is normal but ventilation is inadequate (V=¯, Q= Norm).

54
Q

Oxygenation Failure

A

•Oxygenation failure: thoracic pressure changes are normal, and the lungs can move air sufficiently but cannot oxygenate the pulmonary blood system.The V/Q mismatch is based on ventilation is normal but perfusion is inadequate (Q=¯, V= Norm).

55
Q

Respiratory Failure: Assessment

A

•Assessment: Dyspnea scale
–No SOB -> SOB (As Bad As Can Be)
–Changes In Resp. Rate,& Pattern
–Lung Sound Changes
–S/S Of Hypoxemia
–Pulse Oximetry
–ABG’s *(Know Baseline On Room Air)

56
Q

Respiratory Failure Interventions

A

–Oxygen Therapy
–Position Of Comfort (HOB UP)
–Relaxation, DB & C, Diversion, & Minimal Selfcare
–Pulmonary Meds (Metered-dose Inhalers)
–If ETT & Ventilator, Sedation & Pain Management

57
Q

Intubation and Mechanical ventilation: Indications

A

–PaCO2 > 60 mmHg
–Inspiratory force < 25 cm H2O
–Vital capacity < 15 mL/kg
–RR > 40 breaths per minute

58
Q

Intubation and Mechanical ventilation: Benefits & Meds that may be administered

A

•Benefits: Patent airway, Controlled ventilation, Lung isolation

•Medications that may be administered: “NAVEL”
–Narcan
– atropine
– vasopressin
– epinephrine
- lidocaine

59
Q

Mechanical Ventilation: Types of Ventilators

A

–Constant-volume ventilators

–Constant-pressure ventilators

60
Q

Patterns of Ventilation

A

–IPPV: intermittent positive pressure ventilation, vol or pressure
–PEEP: 2-5
–CPAP
–IMV
–High frequency

61
Q

Physiologic Effects of Mechanical Ventilation

A

–Reduction of PaCO2
–Increase in PaO2
–Effects on venous return
–Miscellaneous hazards

62
Q

Predictors of postoperative pulmonary complications

A

•Patient
–Age > 65, worsens as age increases*
–ASA III – V
–CHF
–COPD
–Cigarette smoking, vaping & other inhalational agents

•Procedure
–Aortic > Thoracic > Upper Abdominal = Neuro = Peripheral Vascular > Emergency
–Duration of anesthesia > 2.5 hours
–GA

•Test
–Albumin < 3.5 g/dL (low albumin can increase interstitial lung disease)

Concepts 2 (11 decks)

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