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E4 Flashcards

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1
Q

Cons to use of immunomodulators, drug example and administration

A

Cons:
Associated w/ anaphylaxis

Drug:
Omalizumab

Admin:
SQ q2-4 wks

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2
Q

What are 3 causes of increased airway resistance in the GETA pt

A

Reduced FRC
ET tube insertion
Circuitry

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3
Q

Fremitus differences in PNA vs pleural effusion

A

PNA
Fremitus over PNA will be pronounced

Effusion
Fremitus over effusion will be decreased

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4
Q

In trendelenburg position, what are some other factors that decrease pul compliance

A
  • Increased pulmonary blood volume

* gravitational force on the mediastinal structures are FRC

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5
Q

What is kyphosis

A

• Both are most commonly present in combination

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6
Q

Which induction medications bronchodilate

A

Propofol
Ketamine
Methohexital

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7
Q

How to perform sigh maneuver

A

Double Vt

Airway pressure 20 cmH2O

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8
Q

How does pneumoperitoneum affect ventilation (4)

A

Can cause respiratory changes when IAP > 15 mmHg

1) Lowers FRC and VC
2) promotes atelectasis formation
3) DEC respiratory compliance
4) INC peak airway pressure

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9
Q

What contributes to hypoxemia the. most?

A

Decreased FRC

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10
Q

What is the drug of choice for semtra’s triad?

A

Leukotriene inhibitors

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11
Q

When is respiratory failure most likely to occur in a pt with kyphoscoliosis

A
  • Associated w/ a VC <45% of predicted

- Scoliotic angle&raquo_space; 110 degree

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12
Q 
O2 tank
color-
pressure-
capacity-
pin position-
A 
O2 tank
color- green
pressure-1,900 psi
capacity- 660 L
pin position- 2-5
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13
Q

RV definition and volume

A

Volume of gas that remains in the lungs after complete forced expiration

CANNOT be exhanled from the lungs

Volume of alveolar gas that acts as reservoir

1200 mL

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14
Q

Primary use of corticosteroids in asthma

A

Usually inhaled
To limit systemic effects
To provide potent anti-inflammatory effects on airways

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15
Q

When N2O PSI is <745, how full is the tank?

A

25% full

397.5 L??

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16
Q

Atelectasis and MR

A

Atelectasis will ALWAYS appear

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17
Q

Surgery implications when an adult pt has just had an URI?

A

infections increase airway responsiveness for 2 weeks

Increases risk of respiratory complications post-op

May need to wait up to 8 weeks to perform elective procedures

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18
Q

MOA, example meds, and benefits/drawback of anticholinergics.

A

MOA:
antimuscarinic properties, decrease secretions

examples:
iptratropium bromide (atrovent)

benefit:
works longer
Better for larger conducting airways

drawback:
longer onset

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19
Q

How does induction of anesthesia affect pulm volumes

A

• there is a loss of inspiratory tone

Diaphragm is even more cephalad

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20
Q

MOA of leukotriene antagonists, and drug example

A

Inhibits constrictor effects of leukotrienes
leading to bronchodilation
For moderate to severe asthma

Drugs: montelukast (singulair)

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21
Q

Purpose of recruitment maneuvers?

A

open alveoli

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22
Q

What should also be considered if evidence of bronchospasm shows up intraop?

A

Consider if the pt is too light

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23
Q

What is asthma

A

 Chronic inflammatory disease

 hyper-irritability of the airways

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24
Q

CV effects of nicotine

A

stimulates adrenal medulla secretion of adrenaline
SNS stimulation (INC HR, BP, PVR)
IN myocardial contractility and O2 demand

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25
8 Clinical features of asthma
```  Dyspnea and tachypnea  Chest tightness and tachycardia  Wheezing  Dyspnea  Coughing  Pulsus paradoxus  Visible use of accessory muscles  pursed lip breathing ```
26
Why is post-nasal drip a consideration in asthma pts
Its a risk factor and is worse in the morning causing airway irritability
27
Airway inflammation of airway is mediated by
Increase in IgE causing swelling
28
What are common causes of equipment malfunction
Mechanical failure of O2 delivery system, or disconnection | Improper ET position
29
What are the two types of costovertebral skeletal deformity
scoliosis | kyphosis
30
Considerations for induction of asthmatic patients
- Block airway reflexes before DL and intubation - Prevent SNS response - Relax smooth muscle - Prevent release of mediators
31
What should be done if pt needs awake extubation (neuro sx)
BLUNT reactive airways | Use lido and opioids
32
How does induction of anesthesia affect lung volumes
Supine: FRC is reduced by 0.5 to 1.0 L Induction: Decreases by 0.4-0.5 L Paralysis: Even more reduction of vol
33
7 risk factors for asthma
``` RSV GERD inhaled irritatns post-nasal drip Environmental Secondhand smoke Samter's triad ```
34
When leukotrienes are antagonized what pulmonary action occurs
bronchodilation
35
Vt definition and volume
Amount of gas that enters and exits the lungs during tidal breathing 500 mL
36
Use of ketorolac in asthmatic pts
Ketorolac increases airway resistance | avoided in ASA intolerant asthma (semtra's triad)
37
Monitors used for smoking and pts with pulmonary problems
Routine A-line, CVP, PA? EtCO2
38
Alterations following smoking cessation at 2 to 4 weeks
DEC secretions | DEC airway reactivity
39
Reversibility of asthma and copd
``` athma = reverisble COPD = non-reversible ```
40
What is the mainstay of asthma treatment
beta-2 agnoist
41
MOA of beta-2 agonist | Purpose in asthma use
moa: INC cAMP causing smooth muscle relaxation and BRONCHIOLE dilation Purpose: Bronchodilate the MEDIUM/SMALL airways Quick onset
42
Most commonly used physical exam by CRNAs
Inspection | Auscultation
43
Obese patients desat quickly during induction because why? | How is this countered?
They do not have FRC Increase ERV and denitrogenate
44
What does CO2 retention in the asthmatic pt indicate
* Elevated PaCO2 suggests * air trapping * respiratory fatigue * impending respiratory failure * Late sign
45
FVL fixed obstruction obstruction example, physiology and loop characteristics
Example: large goiter Physiology: • causes obstruction in the upper airway FVL characteristics: •produce plateaus in both inspiratory and expiratory section
46
How does low Vt affect lung volume ventilation
- Decreases drive to breathe spontaneously during GA | - Low depth
47
4 alterations to thoracic shape
Pectus excavatum Barrel Chest Kyphosis Scoliosis
48
Pulmonary problems r/t reduced Vt
- INCREASED airway resistance d/t DEC FRC, ETT, and ventilator - DECREASED lung compliance d/t DEC FRC - DECREASED drive to breathe
49
What is restrictive lung disease
 Characterized by reduced lung compliance and lung volumes
50
Which medications and dosages can be given to blunt airway reactivity on extubation for an asthmatic pt
Lidocaine 1-1.5 mg/kg | Nebulized beta-2 agonist
51
What should be avoided in a patient w/ a highly reactive airway
Avoid intubation | Try to perform regional as much as possible
52
Why are inhaled irritants a contribution to asthma events? Causes and treatments preoperatively?
* Dust mites, animal dander, mold, and dust * can be primarily ablated by * use of β2-adrenergic agonists immediately preoperatively
53
PFT interpretation pearls...
 Less than 80% predicted is abnormal
54
Anesthetic induction corresponds to around 20% of awake FRC contributes to what pulmonary complications?
Altered distribution of ventilation | Impaired blood O2
55
What are some extrnsic causes restrictive lung disease (5)
``` Pregnancy Liver failure w/ ascites Mediastinal mass Kyphoscoliosis Morbid obesity ```
56
1 L NC FiO2 is
24-25%
57
3 altered lab features that occur during an asthma attack
Hypoxemia (PaO2 <80 mmHg) Hyperventilation CO2 retention
58
Ideal extubation technique for asthmatic pts
Deep extubation if signs of bronchospasm
59
7 Preop considerations for asthma pts
``` Routine labs PFT Baseline ABG Abstinence from smoking Presence of URI? Stress dose steroids Prophylactic inhaler ```
60
Prevalence of atelectasis in surgical pts
Appearas in 90% of all anesthetized pts
61
Common auscultation errors
- listening through a gown - Auscultating in noisy room - Interpreting chest hair sounds as adventitious lung sounds - auscultating only convenient areas
62
Closing capacity definition and volume
Volume above RV when small airways begin to close Variable
63
Anesthesia considerations for pts with restrictive lung disease
-consider poor pulmonary compliance -OPTIMIZE -Don't give too much meds can cause depression -Regional anesthesia concerns
64
``` Air tank color- psi- capacity- pin position- ```
``` Air tank color- yellow psi- 1,900 psi capacity- 625 L pin position- 1-5 ```
65
How does paralysis affect pulm volumes? What are some components that contribute to the changes?
* Furthers the DEC FRC * The pressure on the diaphragm HIGH * caused by weight of abd contents during paralysis * The magnitude of these changes * in FRC r/t paralysis depends on body habitus
66
What is the position for one lung ventilation and important considerations
Lateral decubitus position PADDING high pressure areas to prevent pressure injury or nerve damade (head, neck, shoulder, arms, legs scrotum)
67
What is the action of leukotrienes
1000 times more potent bronchial constriction than histamine
68
What should be done following every position change of an intubated patient?
Check ETT connections
69
How does anesthetic depth affect respiratory pattern
Inadequate (<1 MAC): hyperventilation Vocalization breath-holding At 1 MAC Breathing patterns are regular w/ normal Vt RR slower
70
What is scoliosis
scoliosis • lateral curvature • rotation of the vertebral column
71
PEEP use and extubation
Turn off PEEP p/t extubation | To determine if pt will oxygenate well w/o it
72
2 maneuvers to prevent atelectasis
Recruitment/Sigh maneuver | VC maneuver
73
With routine use of corticosteroids, what airway effects occur (3)
decrease airway reactivity decreased inflammation results in improved control and lung function
74
Airway and breathing complications to consider for a pt who is a smoker? (6)
``` reintubation laryngospasm bronchospasm aspiration hypoventilation hypoxemia ```
75
PFT results for FEV1, FEV1/FVC ratio and FVC
FEV1 is LOW FVC is LOW FEV1/FVC ratio is LOW
76
Side effects of beta-2 agonist
tachycardia
77
What occurs to PVR during asthma attack
PVR INCREASES | which increase workload of the RH
78
Effects of lower respiratory viral infections on asthma
RSV infection provokes hyperreactivity for up to 6 weeks
79
What interventions are appropriate for asthmatic pt intraop w/ bronchospasms?
Give MR INC MAC give beta-2 agonist
80
FVL variable intrathoracic obstruction example, physiology, and loop characteristics
Examples: Endobronchial tumors, tracheomalacia Physiology: Airway obstruction during expiration Due to positive intrathoracic pressure that narrows airways FVL characteristics: Expiratory plateau
81
What are some mechanisms of hypoxemia
Equipment malfunction Hypoventilation Decreased FRC
82
How is closing capacity affect by age and weight
Closing capacity is closer to RV in younger people | It is close to or above FRC in older adults and the obese
83
Surgical considerations for ped pts w/ respiratory infections
Complications INC 11-fold w/ URI and GETA | HIGH risk for laryngospasm and brochospasm
84
At 24 hours post smoking cessation, what is the most important consideration when intubation
More secretions will still be increased | This cause a more reactive airway and will contribute to coughing
85
If pt has dyspnea what should you ask next
how bad severe w/ exertion? Will they require postop ventilation
86
Process of pathogenesis of asthma (4)
``` • Contraction of the smooth muscle • Airway edema • Increased capillary permeability • Mucous secretions (contraction, edema, permeability, secretions) ```
87
Different phases of EtCO2
Upstroke - initiation of expiration plateau - last half of expiration Tallest point of plateau - END TIDAL reading
88
Vital capacity (VC) and volume
IRV + Vt + ERV | 4500 mL
89
What is hyper-irritability of tracheobronchial tree attributed to in asthm
local inflammation | provoked by exposure to irritating stimulus
90
What are the two types of restrictive lung disease
 Intrinsic • Inflammation or scarring of the lung parenchyma  Extrinsic • Disorders of the pleura, diaphragm, or chest wall that limit lung expansion
91
ERV definition and volume
Volume in the lungs after normal end tidal expiration | 1100 mL
92
Minute ventilation =
RR x tidal volume
93
Alterations following smoking cessation at 12-24 hrs
DECREASED carboxyhgb down from 15% and DEC CV nicotine effects INCREASED tissue O2 INC secretions and reactive airway
94
Useful treatment for pt with kyphoscoliosis
Supplemental O2 | Augment nocturnal ventilatory support
95
Percussion of normal, vs PTX, vs PNA lung
Normal- resonance PTX- Hyperresonance PNA- Tactile fremitus
96
Goal of RSI for asthmatic intubation
prevent aspiration and asthmatic attack
97
Inspiratory capacity (IC) and volumes
IRV + Vt | 3500 mL
98
Progression of asthma treatment
1. SABA (Tachycardia) 2. 1 + ICS (low dose) 3. 2 + LABA 4. 3 + Leukotriene inhibitors 5. 4 + Immunomodulator (IgE) 6. 5 + Oral corticorticosteroid
99
4 Effects of GA on smokers
 Atelectasis  ↓ compliance  ↓ FRC  Impaired O2 exchange
100
How do pts w/ restrictive lung disease compensate for reduced compliance
INC WOB | Hyperventilation which keeps the PaCO2 at normal levels
101
Most common double-lumen tube and what is it for
Left | for one-lung ventilation
102
Questions to consider for preop assessment
``` ask about dyspnea cough smoking exercise tolerance risk factors for acute lung injury ```
103
What is fremitus, how is it performed, when is it present on palpation?
Fremitus - indication of consolidation -Generates audible sounds and vibrations--Determines underlying tissue filled with air or fluid Performed- hands firmly held against side of chest -have pt say "ninety-nine" Present- pronounced in PNA
104
How to blunt airway reflexes
Lidocaine 1mg/kg (2%) -- LTA inhaled agent -- (not opioids) Opioids
105
How does supine position affect lungs
* FRC decreases by 0.5 L to 1.0 L | * d/t a 4-cm cephalad (upward) displacement of diaphragm by abdominal viscera
106
Effects of lateral decubitus position on pulmonary ventilation
``` dependent lung: • experiences a moderate DEC FRC and • is predisposed to atelectasis, nondependent lung: • may have INC FRC ```
107
When PaCO2 has increased in restrictive lung disease, what is occurring in the disease process
It is very severe and advanced
108
If pt has cough preop considerations should include
Is it product hemoptysis or sputum Is there need for Abx Coughing increase airway irritability
109
Effects of using PEEP
``` INC intrathoracic pressure: DEC VR (impedes) DEC CO ``` Rapid recollapse when PEEP d/c'd
110
Important consideration when preping pt for one-lung surgery
positioning and padding
111
What is the pathophysiology of restrictive lung disease
reduced compliance of lung, pleura, diaphragm or chest wall Which INC WOB
112
Problem with high FiO2
Results in rapid reappearance of atelectasis | GETA usually just uses FiO2 0.3-0.4 and increased if PaO2 is low
113
Cheyne-Stokes respirations characteristics causes
Cheyne-stokes respirations characteristics: Periodic breathing Gradual hyperpnea/hypopnea then apnea causes: Sleep, hypoxemia, drugs **Hypoperfusion of the brain**
114
What are causes of mechanical failure of O2 delivery to patient
-ETT elbow connector disconnection- Problem at diameter index safety system (DISS)-rare -Empty O2 tank -Use of nonO2 yoke for O2 take (not correct PISS positioning) -PISS for O2 is 2-5
115
Preop considerations for PFT in asthma pts
PFT results before and including response to bronchodilator
116
What occurs with hyperventilation in the asthmatic patient
d/t asthma attack | • Hypocarbia and respiratory alkalosis
117
Features on the EKG and CXR for acutely asthmatic pt
EKG and CXR = RHF EKG = RV strain w/ RIGHT axis deviation during SEVERE attack PVC d/t ventricular irritability CXR = hyperinflation of the lungs
118
Asthma mediators
Mast cell eosinophil macrophages other mediators
119
How does trendelenburg positioning affect lung volumes
• allows the abdominal contents to push the diaphragm further cephalad • so the diaphragm does not only ventilate the lungs -also lifts abd contents out of the thorax • causes predisposition DEC FRC and atelectasis
120
PFT influencing variables and rationale
``` Ht: Tall person has larger lung volume. Incr Age: Volumes ↓ w/ age Sex: Lung volumes smaller in females Race: Smaller volumes in Asian, Hispanics & blacks by 12-15% ```
121
Purpose of PFT
 determine & categorize nature & severity of obstructive/ restrictive Evaluation of pre-op, -follow course of dx/ tx
122
Effects of muscarinic innervation
increase secretions
123
Why use 100% FiO2 during induction?
To pre-oxygenate and increase reservoir of O2 for use during apneic period To increase time of safe apnea
124
Examples of beta-2 agonists
short-acting (SABA) = albuterol (ventolin, proventil) long-acting (LABA) = salmeterol (serevent) Terbutaline
125
Principles of O2 cylinder pressure and volume
The pressure in an O2 cylinder is directly proportional to the volume of the O2 in the cylinder
126
Advantage of double-lumen tube compared to bronchial blocker
double lumen has suction capabilities
127
Important intervention prior to intubating a pt who has stopped smoking 12-24 hrs prior to surgery
Blunt reactive airway reflexes very well prior to blade insertion
128
Neuromuscular causes of restrictive lung disease
MD?
129
Intrinsic causes of restrictive lung dissease
Pulmonary fibrosis Aspiration PNA Pulmonary edema Upper airway obstruction
130
Components to a physical exam?
inspection palpation percusion auscultation
131
Evidence of asthma attack intraop resulting in bronchospasm
INC airway pressures UPsloping CO2 Desaturation
132
Functional residual capacity (FRC) makeup and volume
RV + ERV | 2300 mL
133
8 considerations when performing inspeciton
``` Work of breathing Use of O2 adjunct Assess RR Hyperpnia Hyperventilation Cyanosis Clubbing Thoracic shape ```
134
IRV definition and volume
Amount of gas that can be forcefully expired after a tidal inhalation 3000 mL
135
Biot's respirations characteristics causes
``` Biots respirations characteristics: aka ataxic respirations Periodic breathing Hyperpnea and apnea ``` causes: Neuro damage
136
What can affect ET positioning causing hypoxemia
- Esophageal intubation (no ventilation) - Flexion of head (causing caudal/deep ETT migration) - Extension of head (cephalad/upward ETT migration)
137
Immunomodulators use, MOA and benefits
MOA: anti-IgE antibodies Use: reserved for severely asthmatic with high levels of IgE Benefits: May decrease steroid requirements
138
FVL variable extrathoracic obstruction example, physiology, and loop characteristics
Exmples: VC paralysis, vocal cord neoplasms, neoplasm in the neck Physiology: Upper airway obstruction during inspiration -due to generation of negative intrathoracic pressure during inspiration that pulls the extrathoracic airway closed FVL characteristics: Inspiratory limb of FVP plateaus
139
How does depth ultimately affect the lung volumes
Higher the anesthetic depth the greater the pulmonary depression
140
Difference in sigh and VC maneuver
Sigh maneuver is to reopen collapsed tissue VC maneuver is more pressure and longer VC is for complete reopening of all collapsed lung tissue
141
Total lung capacity (TLC) makeup and volume
TLC = IRV + Vt + ERV + RV 5800 mL
142
When would stridorous breath sounds be present? Correlate with surgical procedure and electrolyte imbalance?
D/T partial obstruction Surgical correlation: S/P thyroidectomy w/ accidental removal of PT gland Ca++ imbalance
143
When are oral or parenteral corticosteroids used/
Reserved for acute exacerbations | When asthma is unresponsive to maximal bronchodilator therapy
144
Operative considerations for pts who currently smoke (3)
Do they have cough They will have mucous hypersecretion They may have airflow obstruction
145
Examples of corticosteroids used in asthma
Prednisone (prelone) | Beclemethasone (vanceril)
146
Alterations to FVC, RV and FRC during asthma
FVC = decreased during severe asthma attack RV = markedly increased FRC = increased d/t air trapping
147
Treatments modalities for asthma
Remove cause | Pharmacologic
148
Describe the types of asthma
```  Extrinsic = allergic asthma • Familial • increased levels of IgE in serum  Intrinsic = idiosyncratic asthma • related to PNS abnormality ```
149
What are patients with kyphoscoliosis at risk for
Developing PNA and hypoventilation | Especially when exposed to CNS depressants
150
What is FEV1 and FVC
FEV1 = forced expiratory volume in 1 second FVC = the total volume available that can be exhaled with maximum effort after dep inhalation
151
Description of abnormal lung sounds
Rales/crackles Rhonchi Wheezing Stridor
152
What is pulsus paradoxus | Why does it occur in asthmatic pts
* a fall in SBP > 10 mm Hg * during spontaneous inspiration * when BP should stay the same or slightly increase d/t hyperinflation that decreases afterload to right ventricle
153
How does surgical positioning affect lung volumes.
Trendelenburg >> effect than supine FRC MUCH more reduced Worse
154
``` N2O tank color- psi- capacity- pin position- ```
``` N2O tank color- blue psi- 745 psi capacity- 1,590 L pin position- 1-5 ```
155
Which anesthetic does not impair muscle tone and lead to atelectasis
Ketamine
156
How to perform VC maneuver
Inflation pressure of 40 cmH2O is required for 7-8 seconds
157
Most common presentation of costovertebral skeletal deformity
Kyphoscoliosis
158
Pulmonary effects of nicotine
Narrowing of small airways Higher closing volume Hyper-irritable airways
159
Postop management in pacu
watch for apnea or hypoventilation respiratory depression d/t opioids or gases residual MR blockade
160
Alterations following smoking cessation at 5-8 weeks
DEC incidence of post-op complications Improved: mucociliary clearance airway irritability Closing volume
161
Pitfalls of PFTs
 Testing is effort-dependent  Use of Predicted Values • Age, gender, height, race
162
FiO2 to Liter ratio?
For every 1 L O2 | Increase FiO2 by 2-4%
163
Prevention of atelectasis during anesthesia
Add PEEP = 5-10 cmmHg
164
Effects of beta receptor stimulation
Bronchodilation | via PSNS stimulation
165
How do the kidney/lithotomy and prone position affect lung volumes?
•Kidney/lithotomy: • also cause small DEC FRC Prone: • may INC FRC moderately
166
Effects of GERD on asthma
Treatment of GERD w/ H2 (ranitidine) receptor antagonist or prokinetics decrease morbidity and the need for asthma medications
167
What is the average reduction of lung volumes w/ anesthesia
• corresponds to around 20% of awake FRC
168
Respiratory function complications during anesthesia
anesthetic depth and pattern mechanism of hypoxemia atelectaasis pneumoperitoneum
169
Closing capacity makeup and volume
RV + CV | variable volume
170
In the presence of cyanosis what is the hgb?
Deoxyhgb is 5 gm/dl
171
Possible problems with the use of immunomodulator
caner or lymphoma
172
Kussmaul respirations characteristics causes
Kussmaul respirations characteristics: Deep, rapid breathing Hyperpnea ``` causes: Metabolic acidosis K-etones U-remia S-epsis S-alicylates M-ethanol A-ldehydes L-actic acids ```
173
What causes closing volume to occur
Expiration causing the airways to narrow and deep expiration can cause them to close Usually occurs below Vt, above RV, at the beginning of FRC
174
6 Pharmacologic agent classes for asthma
``` beta2 agonist anticholinergic leukotriene antagonist corticosteroids cromolyn sodium immunomodulators ```
175
Complications with the use of inhaled corticosteroids
osteoporosis PNA fungal infxn of the mouth
176
Smooth muscle contraction is mediated by
beta and muscarinic innervation | PSNS
177
What is a late sign of sever asthma attack
CO2 retention
178
Complications associated w/ kyphoscoliosis
Scoliotic angle >100 may lead to - chronic alveolar hypoventilation - hypoxemia - Pulmonary HTN - cor pulmonale
179
Description of normal breath sounds, I:E and location
Vesicular Insp (low) > Exp (soft) Majority of lung Broncho-vesicular: Insp (med) = Exp (med) Near main stem bronchi Bronchial Exp (high) > Insp (loud) Over trachea
180
Use of cromoly sodium in asthma and MOA
Not for acute use Prophylactic only MOA: Stabilizes mast cells Which decreases IgE mediated release of histamine and leukotrienes
181
How does low FRC affect lung volumes and hypoxemia in obese patients
FRC reduction is more pronounced than normal patients | Restrictive b/c abd is pushing up
182
What is Samter's triad
sensitive to NSAIDs (esp ASA) h/o nasal polyps h/o asthma

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