exam 2 chap. 1-11 Flashcards
Tool used to assess for sleep apnea STOP BANG, what does it stand for?
The acronym STOP stands for Snoring, Tired (daytime sleepiness), Observed apnea, and high Pressure; and the acronym BANG stands for BMI 35 or greater, Age 50 years or older, Neck circumference 40 cm (17 inches) or larger, and male Gender.
What neurotransmitters are involved in wakefulness?
acetylcholine, dopamine, norepinephrine, histamine, and 5-hydroxytryptamine (serotonin)
Which neuronal pathway is responsible for wakefulness?
ascending reticular activating system (ARAS)
How is sleep maintained?
inhibition of the ARAS via a hypothalamic nucleus known as the ventrolateral preoptic (VLPO)
What neurotransmitters are involved in sleep?
γ-aminobutyric acid (GABA) and galanin
also adenosine
How does adenosine promote sleep?
inhibiting cholinergic ARAS neurons and activating VLPO neurons
What is the hallmark of OSA?
sleep-induced hypoxia and arousal-relieved upper airway obstruction
conditions associated with increased prevalence of OSA include?
hypertension, CAD, MI, CHF, afib, stroke, type 2 DM, nonalcoholic steatohepatitis (NASH), polycystic ovarian syndrome, Graves’s disease, hypothyroidism, and acromegaly
PREdisposing factors for OSA include?
o genetic inheritance o non-Caucasian race o upper airway narrowing o obesity o male gender o menopause o use of sedative drugs and alcohol o cigarette smoking
Tell me about obesity and OSA?
Obesity is a risk factor for OSA in all age groups.
A 10% increase in body weight is associated with a 6-fold increase in the odds of having OSA and a 32% increase in the apnea-hypopnea index
A 10% weight loss is associated with a 26% decrease in the apnea-hypopnea index
What is the most reliable stimulator of arousal? (talking about respiratory-related arousal response being stimulated by)
the work of breathing
hypercapnia, hypoxia, and upper airway obstruction also
s/s of OSA?
daytime sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, observed apnea
Children with an acute URI are more likely to have?
Hypoxemia and laryngospasm
Factors that put children at an increased risk for respiratory complications?
o History of copious secretions o Prematurity o Parental smoking o Nasal congestion o Reactive airway disease o Endotracheal intubation o Airway surgery o Clear systemic signs of infection (fever, purulent drainage, productive cough, and rhonchi) are at CONSIDERABLE risk for adverse events in the peri-op period
Is asthma a reversible or irreversible airflow obstruction?
REVERSIBLE
Asthma is REVERSIBLE airflow obstruction characterized by? (3)
o Bronchial hyperreactivity
o Bronchoconstriction
o Chronic airway inflammation
s/s of asthma?
Characterized by acute exacerbations mixed with periods of no symptoms
Wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia
diagnosis of asthma?
FEV1, FEV1/FVC ratio, and FEF25-75% all reduced but improve with bronchodilators
how does the flow volume loop look for someone with asthma?
Downward scooping of the expiratory limb
Flow-volume loops where the inspiratory or expiratory portion is flat suggest wheezing that is caused by what?
upper airway obstruction
foreign body, tracheal stenosis, or mediastinal tumor
If asthma is suspected based on s/s what test will provide supporting evidence?
bronchodilator responsiveness
what do ABGs look like with mild asthma?
normal PaO2 and PaCO2
what is the most common ABG finding in asthma ?
Hypocarbia and respiratory alkalosis
what does it mean when the PaCO2 is increased in asthma?
when the FEV1 is <25% of the predicted value
This usually indicates skeletal muscle fatigue and impending respiratory failure → intubate!
name some short acting bronchodilators used for asthma relief?
albuterol, levalbuterol which are both B2- agonists (stimulates B2 receptors in tracheobronchial tree)
name some long acting bronchodilators that are B2 agonists?
Arformoterol (Brovana), Formoterol, Salmeterol
name some inhaled corticosteroids for asthma?
Beclomethasone, Budenoside, Ciclesonide, Flunisolide, Fluticasone (Flovent), Mometasone, Triamcinolone
long acting bronchodilators should always be used with what other drug and why?
Using long-acting bronchodilators ALONE can cause airway inflammation and increase asthma exacerbations.
ALWAYS use with inhaled corticosteroid
Name some combined inhaled corticosteroids + long acting bronchodilators?
Budesonide + Formoterol (Symbicort), Fluticasone + Salmeterol (Advair)
Cromolyn is?
mast cell stabilizer
name some leukotrine modifiers?
Montelukast (Singulair), Zafirlukast (Accolate), Zileuton (Zyflo)
how does theophylline / aminophylline work?
increases cAMP by inhibiting phosphodiesterase
- Blocks adenosine receptors
- Releases endogenous catecholamines
what opioid do you avoid if someone has asthma?
morphine due to histamine release
what is status asthmatics?
life threatening bronchospasm that persists despite treatment
during an asthma attack of any kind, hypercarbia requires what?
tracheal intubation and mechanical ventilation
how should the ventilator be adjusted for asthma?
prolonged expiratory phase to allow for complete exhalation.
what reductions in PFTs are considered a risk factor for perioperative respiratory complications?
reduction in FEV1 or FVC to less than 70% of predicted.
FEV1:FVC ration that is less than 65% of predicted.
FEV1 means?
forced expiratory volume in 1 second.
volume of air that can be exhaled in 1 sec.
Normal is greater than 80% of predicted value.
FVC means?
forced vital capacity which is the volume of air that can be exhaled after a deep inhalation.
normal for males is 4.8L and females is 3.7 L
reason for bronchospasm during anesthesia that is not asthma?
light on gas, check your MAC
S/S of bronchospasm intra- op?
- High peak airway pressure
- Upsloping of ETCO2 waveform
- Wheezing
- Desaturation
differential diagnosis of intra operative bronchospasm and wheezing includes?
o Kinking o Secretions o overinflation of ETT cuff o light anesthesia o endobronchial intubation o aspiration o pulmonary edema o PE o Pneumo o acute asthma attack
treatment of bronchospasm?
Deepening anesthesia with either volatile agents or IV injections of propofol and administration of a rapid-acting β2-agonist (Albuterol)
If bronchospasm continues, other drugs (IV corticosteroids, Epi, Mag) may be necessary
Restrictive lung dz and the choice of drugs for induction or maintenance?
does not influence
restrictive lung dz is characterized by?
decrease in ALL lung volumes, especially Total Lung Capacity (TLC)
what drugs/ techniques should be avoided with patients who have restrictive lung dz?
drugs with prolonged resp. depression into the post op. period.
regional above T10
what does restrictive lung dz look like on a flow volume loop?
small ice cream cone
what does obstructive lung dz look like on a flow volume loop?
took a bite out of my ice cream cone (baby carriage)
example of fixed lesion dz?
tracheal stenosis
Progressive loss of alveolar tissue and progressive airflow obstruction that is NOT reversible describes?
COPD
Why might emergence be prolonged in someone with COPD?
D/T air trapping
why be cautious with the use of nitrous and a patient with COPD?
may cause enlargement or rupture of bullae leading to tension pneumo
tidal volumes for COPD patient?
low, 6-8mL/kg
peak pressures for COPD patient?
less than 30 cm H2O
I:E ratio for COPD and why?
you want to allow for adequate time for expiration to avoid air trapping. 1:3 ratio
What do you want the RR at for a COPD patient?
lower RR to give more time in the expiratory phase
who is at risk for bronchospasm?
COPD patients
definitive diagnosis for COPD?
SPIROMETRY
tell me about pulmonary fibrosis?
S/S?
What develops because you have pulmonary fibrosis?
• Interstitial lung disease is characterized by changes in the intrinsic properties of the lungs and is most often caused by pulmonary fibrosis that produces chronic restrictive form of lung disease.
Pulmonary hypertension and cor pulmonale develop as progressive pulmonary fibrosis results in the loss of pulmonary vasculature.
Dyspnea is prominent, and breathing is rapid and shallow.
what is sarcoidosis?
what medication is given for sarcoidosis and why?
• Inflammatory disease characterized by growth of benign inflammatory masses. Many present with no symptoms and disease is identified by abnormal findings on chest x-ray. Some may have dyspnea and cough. Corticosteroids are administered to suppress the manifestations of sarcoidosis and to treat hypercalcemia.
Eosinophilic Granuloma leads to? treatment?
• Eosinophilic Granuloma leads to pulmonary fibrosis. No treatment has been shown to be beneficial for this disease.
What is alveolar proteinosis? What may cause it? treatments?
• Unknown etiology. Deposition of lipid-rich proteinaceous material in the alveoli. Present with dyspnea and arterial hypoxemia. May occur independently or in association with chemotherapy, AIDS, or inhalation of mineral dusts. Whole-lung lavage may be needed to remove the alveolar material and improve macrophage function. Double lumen tube needed for lung lavage to separate lungs during lavage to optimize oxygenation during the procedure.
what types of shock fall under hypo dynamic shock?
hypovolemic shock, cardiogenic shock, and obstructive shock
what types of shock / disorders / dz’s fall under hyperdynamic shock?
sepsis, severe trauma, anaphylaxis, specific drug intoxications, neurogenic shock, adrenal insufficiency, and severe pancreatitis
hypodynamic shock, tell me about the hemodynamics?
o Decreased CI and vasoconstriction
o Decreased CO results in increased oxygen extraction and lactic acidosis
o Organ dysfunction from inadequate blood flow
hyperdynamic shock, tell me about the hemodynamics?
o High CI and vasodilation
o Normal or decreased oxygen extraction
o Increased or normal filling pressures depending on volume status and myocardial performance
o Organ dysfunction from maldistribution of blood flow, rather than inadequate blood flow
what causes hypovolemic shock and what is the hallmark sign of hypovolemic shock?
o Hemorrhage, dehydration, and massive capillary leak
o Decreased cardiac filling pressures are the hallmark sign
most common cause of cardiogenic shock?
acute MI involving 40% or more of the left ventricle
tell me about systolic dysfunction?
- Decreased CO and SV
- Systemic perfusion is decreased, which results in compensatory vasoconstriction and fluid retention…further leading to myocardial dysfunction
- Hypotension decreases coronary perfusion pressure and worsens MI
Tell me about diastolic dysfunction?
• Increase LVEDP, pulmonary congestion, and hypoxemia
most common causes of obstructive shock?
o Most common cause is pericardial tamponade, acute PE, and tension pneumothorax
