Diseased and Failing Lung

Question 1

What is bronchoconstriction mediated by?

Answer 1

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

Question 2

What is the process of bronchoconstriction?

Answer 2

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

Question 3

What is bronchodilation mediated by?

Answer 3

–Mediated by circulating catecholamines and NO

Question 4

Three mechanisms of airway obstruction:

Answer 4

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

Question 5

CHRONIC OBSTRUCTIVE AIRWAY DISEASE (COPD) - diseases

Answer 5

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

Question 6

Types of Chronic Obstructive Pulmonary Disease

Answer 6

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

Question 7

Two types of Pulmonary Emphysema

Answer 7

Type A and Type B

Question 8

CHARACTERISTICS OF TYPE A PULMONARY EMPHYSEMA

Answer 8

“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

Question 9

CHARACTERISTICS OF
TYPE B CHRONIC BRONCHITIS

Answer 9

“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

Question 10

Changes w/ COPD

Answer 10

• 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

Question 11

COPD Overview

Answer 11

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

Question 12

Cystic Fibrosis

Answer 12

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

Question 13

Cystic Fibrosis Changes

Answer 13

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

Question 14

Asthma Characteristics

Answer 14

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

Question 15

Asthma Process diagragm

Answer 15

Question 16

Asthma Attack w/ Spirometry

Answer 16

Residual volume = NORMAL

RV, ERV, IRV air trapping = ?

Question 17

Asthma PFTs

Answer 17

–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

Question 18

Asthma Flow Volume Loops

Answer 18

–Expiratory loop is smaller

–with a “scooped-out” appearance

Question 19

Asthma: Diffusing Capacity & Blood Gases

Answer 19

•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

Question 20

Interventions for intraop bronchospasm

Answer 20

• 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

Question 21

Bronchospasm vs. Laryngospasm

Answer 21

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

Question 22

Mechanical Ventilation Targets

Answer 22

• 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

Question 23

Different Restrictive Lung Diseases

Answer 23

•Lung Parenchyma
–Pulmonary Fibrosis
–Sarcoidosis
–Pneumonitis

•Pleura
–Pneumothorax
–Pleural Effusion

•Chest Wall
–Scoliosis
–Ankylosing Spondylitis

• Neuromuscular Disorders
• *Obesity

Question 24

Restrictive Lung Disease Characteristics

Answer 24

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

Question 25

Structure Of Alveolar Wall

Answer 25

–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)

Question 26

DIFFUSE INTERSTITIAL PULMONARY FIBROSIS

Answer 26

* 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)

Question 27

INTERSTITIAL PULMONARY FIBROSIS - Changes

Answer 27

* FVC decreased * FEV1 decreased * FEV1/FVC **normal** * FEF_25-75 is normal or increased * All lung volumes decrased * PaO₂ & PaCO₂ decreased * pH normal: compensated * DLCO decreased (diffusion Capacity) * V_a/Q inequality

Question 28

Sarcoidosis

Answer 28

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

Question 29

Sarcoidosis Outcomes

Answer 29

–Pulmonary fibrosis –Severe restricted lung function

Question 30

DISEASES OF THE PLEURA: Pneumothorax

Answer 30

–Spontaneous •Sudden onset pain •Dyspnea •decreased breath sounds •Confirmation by x-ray –#1 = Tension –FEV1 decreased –FVC decreased

Question 31

Pleural Effusion: changes, assessment, and treatment

Answer 31

Changes: –Fluid/Exudates –FEV1 decreased –FVC decreased •Assessment –Dyspnea –Pleuritic pain –Absent Breath Sounds –Dull percussion •Treatment –Underlying cause –Aspiration

Question 32

Scoliosis Changes

Answer 32

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

Question 33

Ankylosing Spondylitis Changes

Answer 33

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

Question 34

Morbid Obesity

Answer 34

Load of outter lungs increased

Question 35

Morbid Obesity Changes

Answer 35

* 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

Question 36

Morbid Obesity Changes: FEV1, FVC, DLCO

Answer 36

FEV1/FVC: Normal FEV1: Normal or decreased FVC: decreased DLCO: decreased

Question 37

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

Answer 37

FEV1/FVC = 70 - 90% FEV1 = 100% FVC = 100% DLCO = 100%

Question 38

Neuromuscular Disorders

Answer 38

* Poliomyelitis * Guillain-Barré syndrome * ALS * MG * MD

Question 39

Neuromuscular Disorder Changes

Answer 39

ALL decreased: FVC, TLC, IC, FEV1

Question 40

Vascular Diseases/ Pulmonary Edema

Answer 40

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

Question 41

Pulmonary Edema Changes in Pressure

Answer 41

**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 = **\>25**mmHg Capillary colloidal osmotic pressure = 25mmHg

Question 42

Mechanisms of Pulmonary Edema

Answer 42

Question 43

Vascular Disease/Pulmonary Embolism Causes and Changes

Answer 43

* 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

Question 44

Clinical features of small emboli (PE)

Answer 44

Frequently unrecognized Repeated PE may result in Pulmonary hypertension

Question 45

Clinical features of medium sized PE

Answer 45

* Pleuritic pain * Dyspnea * Cough * Pleural friction rub * Chest x-ray WNL * Lung scan – areas of under perfusion

Question 46

Massive PE

Answer 46

* CV collapse * Central CP * Hypotension * Weak pulse * Distended neck veins * Death

Question 47

Pulmonary HTN

Answer 47

•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

Question 48

What DECREASES PVR

Answer 48

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

Question 49

What INCREASES PVR?

Answer 49

–Hypoxia –Hypercarbia –Nitrous oxide –Hypothermia –PEEP

Question 50

COVID-19: Acute and Post Symptoms

Answer 50

Question 51

COVID Long-Haulers Symptoms

Answer 51

Question 52

Respiratory Failure

Answer 52

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

Question 53

Ventilatory Failure

Answer 53

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

Question 54

Oxygenation Failure

Answer 54

•**_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).

Question 55

Respiratory Failure: Assessment

Answer 55

•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)

Question 56

Respiratory Failure Interventions

Answer 56

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

Question 57

Intubation and Mechanical ventilation: Indications

Answer 57

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

Question 58

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

Answer 58

•*Benefits*: Patent airway, Controlled ventilation, Lung isolation •*Medications* that may be administered: "NAVEL" –**N**arcan – **a**tropine – **v**asopressin **– e**pinephrine - **l**idocaine

Question 59

Mechanical Ventilation: Types of Ventilators

Answer 59

–Constant-volume ventilators –Constant-pressure ventilators

Question 60

Patterns of Ventilation

Answer 60

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

Question 61

Physiologic Effects of Mechanical Ventilation

Answer 61

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

Question 62

Predictors of postoperative pulmonary complications

Answer 62

•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)