Exam 4 Obstructive lung disease Part II

Question 1

What 3 things may improve reversible componenets of asthma pre-operatively?

Answer 1

chest physiotherapy, antibiotics, and a bronchodilator

Slide 22

Question 2

What is indicated when we are concerned about the adequacy of ventilation or oxygenation?

Answer 2

ABG

Slide 2w

Question 3

____ and ____ therapy should be continued until induction.

Answer 3

Anti-inflammatory and bronchodilator

Slide 22

Question 4

T/F
Patients on systemic steroids within the last 6 months may need a stress dose of hydrocortisone or methylprednisolone

Answer 4

True

Slide 22

Question 5

Asthma patients should be ____ and have a PEFR ____% of predicted or their personal best value before surgery

Answer 5

free of wheezing
>80%

Slide 22

Question 6

Which characteristics of asthma should be evaluated pre-op?

Answer 6

Slide 23

Question 7

COPD is a disease of ____ ____ ____

Answer 7

chronic airflow obstruction

Slide 24

Question 8

COPD Sx include:
____ characterized by lung parenchymal destruction
____ chracterized by cough and sputum production and ____

Answer 8

emphysema, chronic bronchitis, and small airway obstruction

Slide 24

Question 9

Pulmonary elastic recoil is lost d/t ____ destruction

Answer 9

bronchio-alveolar

Slide 24

Question 10

COPD has a worldwide prevalence of ____ and is the ____ leading cause of death

Answer 10

10%
3rd

Slide 24

Question 11

Risk factors for COPD

LONNNGGGG list… just know what you can here

Answer 11

Although cigarette smoking contributes to COPD, multiple other risks exist, including occupational exposure to dust & chemicals (esp coal mining), gold mining, textile industry, biomass fuel, air pollution, genetic factors ( s/a α1-antitrypsin deficiency), age, female sex, poor lung development during gestation such as from maternal smoking, low birth weight, recurrent childhood respiratory infections, low socioeconomic class, and asthma

Slide 24

Question 12

CODP leads to 5 common things

Answer 12

1) pathologic deterioration in elasticity or recoil within the lung parenchyma, which normally keeps the airways in an open position
2) pathologic changes that decrease bronchiolar wall structure, thus allowing them to collapse during exhalation
3) an increase in gas flow velocity in narrowed bronchioli, which lowers the pressure inside the bronchioli and further favors airway collapse
4) active bronchospasm and obstruction resulting from increased pulmonary secretions
5) destruction of lung parenchyma, enlargement of air sacs, and development of emphysema

Slide 25

Question 13

3 common Sx of COPD

Answer 13

dyspnea at rest or exertion
chronic cough
chronic sputum production

Slide 26

Question 14

T/F
COPD exacerbations are c/b chronic worsening in airflow obstruction.

Answer 14

FALSE!
it is an acute worsening in airflow obstruction

Slide 26

Question 15

as expiratory airflow obstruction increases, ____ and ____ ____ ____ become evident

Answer 15

tachypnea
prolonged expiratory times

Slide 26

Question 16

As COPD progresses, ____ become more frequent and are often triggered by ____

Answer 16

Bacterial respiratory infections

Slide 26

Question 17

in COPD breath sounds are ____ and a ____ wheeze is common

Answer 17

decreased
expiratory

Slide 26

Question 18

providers should have a high degree of suspicion and low threshold to test for COPD in pts with ____ and ____ or ____

Answer 18

dyspnea
chronic cough
environmental exposures

Slide 27

Question 19

What test gives us a definitive diagnosis of COPD?

Answer 19

Spirometry

Slide 27

Question 20

PFTs in COPD show a ____ in FEV1:FVC ratio and an even greater ____ in the FEF 25-75% of VC.
FEV1:FVC is usually ____%, FRC and TLC are ____, and the DLCO (diffusing capacity for CO is ____

Answer 20

Decrease
Decrease
<70%
increased
reduced

Slide 27

Question 21

What is responsible for the increase in RV in COPD? (2 things)

Answer 21

slowing of expiratory airflow and gas trapping behind prematurely closed airways

Slide 27

Question 22

What is the advantage of an increased RV and FRC in pts with COPD related to?
What is the cost?

Answer 22

enlarged airway diameter
Cost is a greater work of breathing at higher lung volumes

Slide 27

Question 23

what does spirometry look like with COPD in comparison to normal?

Flip the card to find out!

Answer 23

Slide 28

Question 24

GOLD spirometric criteria for COPD severity is based on ____ measurement.
What are the stages and characteristics at each stage?

Answer 24

FEV1

Slide 29

Question 25

What does a Chest X-ray look like in COPD patients? What suggests emphysema? What confirms it?

Answer 25

abnormalities minimal even w/ severe COPD -hyperlucency in the lung periphery suggests emphysema -bullae confirms emphysema, although only a small percentage of pts with emphysema have bullae | Slide 30

Question 26

____ is much more sensitive at diagnosing COPD than ____

Answer 26

CT, CXR | Slide 30

Question 27

what symptoms are suggestive of multi-organ loss of tissue (MOLT) COPD phenotype? What is it associated with?

Answer 27

airspace enalrgement and alveolar destruction loss of bone, muscle and fat associated with higher rates of lung cancer | Slide 30

Question 28

what symptoms indicate bronchitic phenotype? What is it usually accompanied by?

Answer 28

bronchiolar narrowing and wall thickening metabolic syndrome and high rates of cardiac disease | Slide 30

Question 29

Is CT usually used for COPD diagnosis? What has prompted interest in expanding the protocol for all COPD cases?

Answer 29

No, but the wealth of information it provides has prompted interest in expanding the protocol for all COPD cases | Slide 30

Question 30

what factors does the BODE index look at?

Answer 30

BMI, degree of obstruction, level of dyspnea, exercise tolerance all used to assess prognosis | Slide 31

Question 31

Higher BODE scores indicate greater risk of what?

Answer 31

COPD exacerbations, hospitalizations, and death c/b pulmonary complications | Slide 31

Question 32

____ deficiency is an inherited disorder associated w/ premature development of COPD in blood testing, a low level indicates ____ and need for lifelong replacement therapy

Answer 32

alpha1-antitrypsin genetic disease | Slide 31

Question 33

Which lab should be measured in pts w/ uncontrolled COPD despite adequate bronchodilator treatment? What do high levels indicate? Low levels are associated with?

Answer 33

eosinophils high: need for inhaled glucocorticoids low: poor response and increased risk of pneumonia | Slide 31

Question 34

____ often remains normal until COPD is severe. ____ doesnt usually decrease until FEV1 is ____ and PaCO2 may not increase until the FEV1 is ____

Answer 34

ABG PaO2, <50% PaCO2, even lower | Slide 31

Question 35

COPD treatment is designed to worsen symptoms and speed up progression. T/F

Answer 35

False, haha should alleviate symptoms and slow progression | Slide 32

Question 36

what is the 1st step in treating COPD?

Answer 36

reduce exposure to smoking and environmental pollutants | Slide 32

Question 37

smoking cessation can decrease disease progression and lower mortality by up to ____ What else may diminish or disappear as well?

Answer 37

18% chronic bronchitis and lung degeneration | Slide 32

Question 38

Pharmacologic Treatment of COPD often begins with ____. What is added if dyspnea persists? the 3rd treatment, ____, is most effective with associated ____, ____, ____ and ____

Answer 38

long acting muscarinic antagonist inhaler long acting beta 2 agonist glucocorticoids, asthma, rhinitis, elevated eosinophils, and history of exacerbations | slide 32

Question 39

inhaled treatements improve symptoms & FEV1, and reduce exacerbations T/F

Answer 39

True | Slide 33

Question 40

What are some other treatments for COPD not including the inhaled medications?

Answer 40

flu and pneumonia vaccines diuretics (when RHF or CHF has developed) | Slide 33

Question 41

During exacerbations of COPD, what 3 types of medications may be necessary?

Answer 41

abx, corticosteroids, and theophylline | Slide 33

Question 42

What kind of COPD treatment can increase exercise capacity?

Answer 42

pulmonary rehab progreams | Slide 33

Question 43

long term home ____ is recommended when the ____ is < 55mmHg, ____ is >55%, or ther is evidence of ____ in order to decrease the risk of death

Answer 43

O2 PaO2 Hct Cor pulmonale | Slide 34

Question 44

what is the goal of supplemental O2 in COPD patients? What is usually needed to accomplish this?

Answer 44

PaO2>60mmHg NC @2L/min | Slide 34

Question 45

How is the O2 flow rate titrated in COPD patients?

Answer 45

ABG or SpO2 | Slide 34

Question 46

The relief of hypoxemia with ____ ____ is more effective than any drug therapy in decreasing pulmonary vascular resistance and pulmonary hypertension and in preventing erythrocytosis

Answer 46

supplemental O2 | Slide 34

Question 47

Pts should be advised to do ____ or ____ to improve respiratory function post-operatively

Answer 47

deep breathing exercises incentive spirometry | Slide 34

Question 48

COPD treatment chart

Answer 48

| Slide 35

Question 49

what kind of surgery may be indicated in pts w/severe COPD, unresponsive to medical therapy who have overdistended, poorly functioning lung tissue

Answer 49

lung volume reduction surgery | Slide 36

Question 50

What does surgical removal of overdistended areas of the lung allow for?

Answer 50

areas of normal lung to expand and and improves lung function | Slide 36

Question 51

How is lung volume reduction surgery most commonly performed?

Answer 51

Median sternotomy or Video-Assisted Thoracoscopic Surgery (VATS) | Slide 36

Question 52

What mechanisms improve lung function in COPD?

Answer 52

1) increased elastic recoil, which increases expiratory airflow 2) decreased hyperinflation, which improves diaphragmatic and chest wall mechanics 3) decreased ventilation/perfusion mismatch, improving alveolar gas exchange  | Slide 36

Question 53

What is included in anesthesia management of a patient have lung volume reduction surgery?

Answer 53

a double-lumen ETT avoidance of nitrous oxide minimizing excessive airway pressure | Slide 36

Question 54

What measurement is an unreliable guide for fluid management in COPD? Why?

Answer 54

CVP d/t surgical alterations that will affect intrathoracic pressures | Slide 36

Question 55

What history should we look into with pro-operative COPD patients?

Answer 55

smoking history current meds (esp recent corticosteroids) exercise tolerance exacerbation frequency need for hospitalizations | Slide 37

Question 56

Any previous need for ____ or ____ should be determined pre-operatively in COPD patients

Answer 56

NIPPV- Noninvasive positive pressure ventilation or Mechanical ventilation | Slide 37

Question 57

Becuase smoking & COPD are associated w/ multiple comorbidities, pts should also be questioned on what>

Answer 57

Presence of other diseases such as DM, HTN, PVD, ischemic heart disease, heart failure, dysrhythmias, and lung cancer | Slide 37

Question 58

If a patient has pulmonary disease, ____ function should be assessed by ____ and ____

Answer 58

RV clinical exam and echocardiogram | Slide 37

Question 59

which therapies should be continued until the morning of the surgery in COPD?

Answer 59

inhalation therapies | Slide 37

Question 60

What pre-operative therapies can reduce post-op pulmonary complications?

Answer 60

chest physiotherapy such as deep breathing, coughing, incentive spirometry, and pulmonary PT | Slide 37

Question 61

What findings are more predictive of pulmonary complications that spirometric tests?

Answer 61

clinical findings such as smoking, wheezing, and productive cough | Slide 37

Question 62

The value of routine pre-op PFT's cannot be overstated...T/F?

Answer 62

False! pre-op PFT value is controversial | Slide 37

Question 63

What are the 9 indications for pre-operative pulmonary evaluation?

Answer 63

1) hypoxemia on room air or the need for home 02 without a known cause 2) a bicarbonate >33 mEq/L or PC02 >50 mmHg w/o diagnosed pulmonary dz   3) a history of respiratory failure d/t an existing problem  4) severe shortness of breath attributed to respiratory disease 5) planned pneumonectomy 6) difficulty assessing pulmonary function by clinical signs 7) the need to distinguish causes of respiratory compromise 8) the need to determine the response to bronchodilators 9) suspected pulmonary HTN He Bikes His Seven Puppies Down Narrow Roads Perfectly | Slide 38

Question 64

Do COPD patients undergoing peripheral surgery require preop PFT's? when in doubt, what is sufficient to assess lung disease?

Answer 64

no spirometry with FEV1 | Slide 38

Question 65

Ventilatory function can also be assessed under ____ by measuring airflow related to lung volume

Answer 65

dynamic conditions | Slide 39

Question 66

Expiratory flow rates can be plotted against ____ to produce ____

Answer 66

lung volumes flow volume curves | Slide 39

Question 67

when flow rates during inspiration are added to flow volume curves, what do you get?

Answer 67

Flow Volume Loops | Slide 39

Question 68

The flow rate is ____ at TLC before the start of expiration. Once forced expiration starts, the ____ ____ ____ is rapidly achieved. The flow rate then falls in a ____ as the volume decreases to ____.

Answer 68

0 peak flow rate linear RV | Slide 39

Question 69

During maximal inspiration from RV to TLC, the inspiratory flow is most rapid at the ____ of inspiration, causing a ____ inspiratory curve

Answer 69

midpoint U-shaped | Slide 39

Question 70

In COPD, there is a ____ expiratory flow rate at any given lung volume

Answer 70

Lower | Slide 39

Question 71

Flow volume loops have a ____ expiratory curve due to ____ emptying ofthe airways

Answer 71

concave uniform | Slide 39

Question 72

Why is the RV increased in COPD?

Answer 72

Air trapping | Slide 39