Exam 4 - Restrictive Flashcards
What is the hallmark of restrictive lung disease?
the inability to increase lung volume in proportion to an increase in alveolar pressure
RLD affects lung expansion and compliance!
2
What factors can cause RLD?
- connective tissue disease
- environmental
- pulm fibrosis
- increase fluid in alveoli or interstitial space
- diseases that limit excursion of diaphgram/ chest
2
RLD leads to reduced surface area for gas diffusion, causing what 2 complications?
V/Q mismatch and hypoxia
2
As lung elasticity worsens, what symptoms manifest in the patients?
hypoxia, inability to clear secretions and hypoventilation
2
In RLD, what changes do you see in FEV/FVC testing and diffusing capacity tests?
What changes in lung volumes?
- reduced FEV1, low FVC= normal or increased ratio!
- reduced diffusing capacity for for CO
- all lung volumes are decreased, especially TLC
2
What is the principal feature of RLD?
decreased TLC!
4
TLC is used to classify Restrictive Lung disease. What is the predicted value of:
mild disease
moderate
severe
mild 65-80%
moderate 50-65%
severe: <50%!
4
What causes pulmonary edema?
intravascular fluid leakage into the interstitium and alveolar space!
6
Acute pulmonary edema can be caused by what 2 changes in the capillary?
increased capillary pressure or increased capillary permeability
Both of these lead to “capillary stress failure”
6
What does pulm edema look like on CXR?
What pattern is seen w/ increased cap pressure?
bilateral, symmetric perihelar opacities!
Butterfly pattern seen w/ increased capillary pressure vs permeability
6
Pulm edema caused by increased capillary permeability is characterized by what 2 factors in edema fluid?
a high concentration of protein and secretory products in edema fluid
6
In increased permeability pulm edema, what happens to the alveoli?
You get diffuse alveolar damage associated with ARDS
6
What are the clinical manifestations of cardiogenic pulmonary edema
cardiogenic pulm edema is seen in decompensated HF
dyspnea
tachypnea
elevated cardiac pressures
SNS activation
7
Cardiopulmonary edema should be suspected if pt has what changes in cardiac pressures?
a decreased systolic or diastolic pressure!
7
Risk for cardiogenic pulm edema is increased w/ conditions that increase preload.
What 2 valve dysfunctions cause this?
aortic and mitral valve regurg!
7
Risk for cardiogenic pulm edema is also increased w/ conditions that increase afterload or SVR?
What 3 diseases do this?
LV outflow tract obstruction
mitral stenosis
reno vascular HTN
7
Negative pressure pulm edema results after the relief of upper airway obstruction.
What are common causes?
aka post obstructive pulm edema
laryngospasm, epiglotttis, tumors, obesity, hiccups, OSA
8
When is the onset of pulm edema after the relief of obstruction?
What are the s/s ?
up to 2 hours post obstruction!
s/s: tachypnea, cough, SpO2 below 95%
may be confused w aspiration or PE!
8
Describe the changes in pressures that occur that cause increased transcapillary pressure gradient leading up to pulm edema
The development of negative intrapleural pressure decrease the interstitial hydrostatic pressure, this increases VR and LV afterload
-this leads to SNS activation, HTN and central displacement of blood
8
What is the treatment of negative pressure pulm edema?
How long does it take to resolve
supplemental O2 and maintence of patent airway!
Mechanival ventilation may be needed
Might resolve in 12-24 hr
9
What is an intrapulmonary shunt?
Right-to-left pulmonary shunting: perfusion of nonventilated alveoli
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Neurogenic Pulmonary Edema:
- Develops in a ______ fraction of acute brain injury pts.
- occurs ________ - ________ after CNS injury and may manifest during the periop period.
- A massive outpouring of _____ impulses from the injured CNS causesgeneralized ____________ and blood volume shifting into the _________ circulation.
- the increased pulmonary capillary pressure c/b translocation of blood volume leads to the transfer of fluid into the _________ _________.
- Pulmonary _______ & hypervolemia can also injure blood vessels in the lungs.
- small
- minutes - hours
- SNS
- vasoconstriction
- pulmonary circulation
- interstitium
- alveoli
- HTN
10
What condition can be seen in pts using e-cigarettes and vaping?
EVALI (E-Cigarette Vaping Associated Lung Injury)
S17
EVALI is associated with what 5 other conditions?
- pneumonia
- diffuse alveolar damage
- acute fibrinous pneumonitis
- bronchiolitis
- interstitial lung disease (ILD)
S17
What 5 additives are associated with EVALI?
- THC
- Vit E acetate
- Nicotine
- CBD
- other oils
S17
What are the sx of EVALI?
- dyspnea
- cough
- N/V/D
- abd pain
- chest pain
Pt may be febrile, tachycardia, tachypnea, and hypoxic
S17
Radiologic findings of EVALI are similar to what condition?
ARDS
S17
What are the treatments of EVALI
- ABX
- Steroids
- Supportive care
S17
What do survivors of severe COVID can have persistently?
inflammatory interstitial lung disease
S18
What are the sx of COVID 19 Induced restrictive lung disease?
dyspnea to ventilator dependance and pulmonary fibrosis
S18
What PFT result is the most commonly reported finding COVID 19 Induced restrictive lung disease?
drop in diffusion capacity
S18
Who are are at the highest risk for long term pulmonary complications with COVID 19 Induced restrictive lung disease?
Pts who need mechanical ventilation
S18
What negative pulmonary changes do survivors of COVID-19 have?
- decreased exercise capacity
- hypoxia
- opacities on CT
S18
What is the PaO2 of ARF despite02 supplementation and in the absence of a right-to-left intracardiac shunt?
< 60 mmHg
S19
What happens to PaC02 d/o the relationship of alveolar ventilation to C02 production?
increased
unchanged
decreased
S19
What is the PaCO2 in the absence of respiratory-compensated metabolic alkalosis of ARF diagnosis?
PaCO2 > 50 mmHg
How is ARF characterized?
- abrupt increased PaC02
- decreasedpH
S19
What is increased and what is normal in Chronic Respiratory failure?
PaCO2 increased
pH is normal
normal pH reflects renal compensation for respiratory acidosis
S19
What are the 3 tx goals for ARF?
1) a patent airway
2) hypoxemia correction
3) removal of excess C02
S19
What kind of devices can O2 be provided?
And when are they only helpful?
- NC
- venturi mask
- nonrebreather
- T-piece
only helpful in mild to moderate V/Q mismatching
S20
What is initiated when methods fail to maintain Pa02 >60 mmHg?
continuous positive airway pressure (CPAP)
S20
What is the benefit of CPAP?
What is the risk if CPAP?
**benefit: increase lung volumes **
(opening collapsed alveoli and decreasing right-to-left intrapulmonary shunting)
**risk: aspiration **
(via face mask esp pts with N/V)
S20
What is the SpO2 % when PaO2 is > 60 mmHg?
Sp02 is **>90% **
S20
What kind of ventilation is fixed TV w/inflation pressure as dependent variable
Volume-cycled ventilation
S21
What can the pressure relief valve do?
- prevents further gas flow → preventing high airway pressures
- triggers an alarm to alert the provider of a change in pulmonary compliance
S21
What are worsening pulmonary edema, pneumothorax, kinked ETT, or a mucous plug reflecting on the ventilator?
Significant increases in PAP
S21
What is maintained on the vent despite small changes in PAP?
consistent Tidal volume
S21
What is a disadvantage of volume-cycled ventilation regarding leaks in the delivery system?
inability to compensate for leak
S21
High- Altitude Pulmonary Edema (HAPE):
- HAPE may occur at heights ranging from _____ - ______m and is influenced by the rate of ________ to that altitude.
- Onset is often _______ but typically occurs within 48-72 hours at high altitude.
- less severe symptoms of “_______ __________” may preceed pulmonary edema.
- 2500-5000
- ascent
- gradual
- mountain sickness
13
What are the 2 primary modes of volume-cycled ventilation?
- AC (assisted/controlledventilation)
- SIMV (synchronized intermittent mandatory ventilation)
S21
The net effect of an intrapulmonary shunt is a decrease in _____.
Why does this occur?
decrease in Pa02,
Occurs from dilution of oxygenated blood with hypo-oxygenated blood containing coming from unventilated alveoli
s30
Re-Expansion Pulmonary Edema:
- The rapid expansion of a __________ lung may lead to REPE.
- The risk of REPE after relief of pneumothorax or pleural effusion is related to:
1. Amount of air/liquid that was in the ________ space (>1 L increases the risk)
2. The ________ of collapse (>24 hours increases the risk
3. ________ of re-expansion
- Collapsed
- pleural
- duration
- speed
11
A physiologic shunt typically comprises what percentage of COP?
2-5%
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Re-expansion Pulmonary Edema:
- The high ________ content of pulmonary edema fluid suggests that enhanced capillary membrane __________ is a factor in its development.
- Treatment is ___________ care.
- protein
- permeability
- Supportive
11
What is a physiologic shunt?
right-to-left pulmonary shunting but this one is from:
passage of pulmonary arterial blood directly to the left side of the circulation through the bronchial and thebesian veins
s30
Drug Induced Pulmonary Edema:
- can occur after the administration of certain drugs, especially opioids ( _______ ) and _________.
- the high _________ concentration in the pulmonary edema fluid suggests it is a high-___________ pulmonary edema.
- heroine
- cocaine
- protein
- permeability
12
- What does the shunt fraction tell us in pts breathing <100% O2?
- What does the shunt fraction tell us in pts breathing 100% O2?
- shunt fraction tell us the contribution of V/Q mismatching as well as right-to-left intrapulmonary shunting
- shunt fraction eliminates the contribution of V/Q mismatching and only tells us right-to-left intrapulmonary shunting
s30
Drug-Induced Pulmonary Edema:
- ________ causes pulmonary vasoconstriction, acute myocardial ischemia, and myocardial infarction.
- _________does not reverse opioid-induced pulmonary edema.
- Treatment of drug-induced pulmonary edema is __________.
- may include __________ and mechanical ventilation.
- Cocaine
- Naloxone
- Supportive
- Intubation
12
What must be considered when determining whether the pt can tolerate extubation?
pt is alert and cooperative and can tolerate a trial of SV without tachypnea, tachycardia, or respiratory distress
s31
Drug-Induced Pulonary Edema:
- ________ __________ __________ (___) is another condition with similarsx.
- Ifpulmonary edema does not respond to _________, DAH islikely.
- Diffuse Alveolar Hemorrhage (DAH)
- diuretics
12
what are the 7 guidelines for discontinuing mechanical ventilation?
- Vital capacity of >15 mL/kg
- Alveolar-arterial oxygen difference of <350 cmH2O while breathing 100% 02
- Pa02 of >60 mm Hg with an Fi02 of <0.5
- Negative inspiratory pressure of more than −20 cmH2O
- Normal pHa
- RR <20
- VD:VT of < 0.6
s31
What 3 options are considered when a pt is ready for a trial of vent withdrawal?
- SIMV, which allows progressively fewer mandatory breaths until pt breathing on their own
- Intermittent trials of total removal of mechanical support and breathing through a T-piece
- Use of decreasing levels of pressure support ventilation
s32
High-Altitude Pulmonary Edema (HAPE)
- Cause of this high-permeability pulmonary edema is presumed to be ________ pulmonary vasoconstriction, which _______ pulmonary vascular pressure.
- Treatment includes 02 administration and quick _______ from the high altitude.
- Inhalation of _______ ________may improve oxygenation
- hypoxic
- increases
- descent
- nitric oxide
13
What tell us the pt won’t be able to tolerate extubation?
Breathing at rapid rates with low tidal volumes
s32
Anesthesia Implications for Pulmonary Edema:
__________ surgery should be delayed in pts with pulmonary edema, and every effort must be made to optimize cardiorespiratory function before surgery.
Elective
14
Chemical Pneumonitis (Aspiration Pneumonitis):
- If aspiration noted, the ________ should be suctioned and the pt turned to the ______.
- _________ position will not stop reflux, but can prevent aspiration once gastric contents are in the _________.
- oropharynx
- side
- Trendelenburg
- pharynx
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The Pa02 should remain ___ mmHg with Fi02 ____.
PaO2 Greater than 60 mmHg w/ FiO2 <0.5
s33
Anesthesia Implications for Pulmonary Edema:
- Large ______ _______ may need to be drained.
- Persistent _________ may require mechanical ventilation and positive end-expiratory pressure (PEEP).
- ___________ monitoring useful in the assessment and treatment of pulmonary edema.
- Pleural Effusions
- Hypoxemia
- Hemodynamic
14
The PaC02 should remain ____ and the pHa ____.
PaCO2 less than 50 mmHg and pHa >7.30
s33
Anesthesia Implications for Pulmonary Edema:
- Current evidence shows benefit from ventilation using low ___ & a RR of 14-18 while keeping end-inspiratory plateau pressures < ____ cm H2O.
- careful titration of ______ along with inspiratory _______ is recommended to optimize lung compliance.
- TV
- 30
- PEEP
- Pause
14
What is commonly needed after extubation d/t V/Q mismatching?
Supplemental O2
s33
Anesthesia Implications for Pulmonary Edema:
- Pts with Restrictive Lung Disease typically have _______, _________ breathing.
- ___________ should not be used as the sole criteria for delaying ____________ if gas exchange and other assessments are satisfactory.
- rapid
- shallow
- Tachypnea
- extubation
14
O2 weaning is accomplished by:
gradually decreasing the FiO2
guided by measurements of PaO2 and/or monitoring of Sp02
s33
Chemical Pneumonitis (Aspiration Pneumonitis):
- Pts w/ _________ airway reflexes are at risk for aspiration.
- __________ the HOB during intubation & extubation decrease aspiration risk
- decreased
- Elevating
15
Along with being awake and alert, what else should the patient have for possible vent weaning?
active laryngeal reflexes and the ability to generate an effective cough and clear secretions
s33
Chemical Pneumonitis (Aspiration Pneumonitis)
- Chemical pneumonitis sx: _______ onset dyspnea, tachycardia, and __________.
- When _________ fluid is aspirated, it distributes throughout the lungs and destroys ________ -producing cells and pulmonary capillary endothelium.
- As a result, there is ________ and leakage of intravascular fluid into the lungs, producing capillary-__________ pulmonary edema.
- abrupt
- desaturation
- gastric
- surfactant
- atelectasis
- permeable
15
WHat is assoc with the highest risk of ARDS?
Sepsis
s34
Chemical Pneumonitis (Aspiration Pneumonitis)
- This acute lung injury might present with tachypnea, bronchospasm, _______ pulmonary HTN, and ________ hypoxemia.
- CXR may not demonstrate evidence of ________ pneumonitis for ___ - ____ hrs.
- if the ptaspirated in _______ position, radiographic evidence of aspiration is most likely in the superior segment of the ______.
- acute
- arterial
- aspiration
- 6-12
- supine
- RLL
15
What is ARDS caused by and how does it manifest?
caused by inflammatory injury to the lungs
and manifests as acute hypoxemic respiratory failure
s34
What are the 3 hallmarks of ARDS?
- Rapid-onset respiratory failure
- arterial hypoxemia
- CXR findings similar to cardiogenic pulmonary edema
s34
Chemical Pneumonitis (Aspiration Pneumonitis):
- Measurement of gastric fluid ____ is useful, since it reflects the pH of the aspirated fluid.
- The aspirated gastric fluid is rapidly redistributed to _________ lung regions, so ________ is not useful.
- pH
- peripheral
- lavage
16
In ARDS, what causes the increased alveolar-capillary membrane permeability and alveolar edema?
Proinflammatory cytokines
s34
Chemical Pneumonitis (Aspiration Pneumonitis):
- ____________ pneumonitis is best treated w/ supplemental 02 & _______.
- There is no evidence that _____ decrease the incidence of pulmonary infection or alter outcomes.
- Abx may be considered if a pt symptomatic after _____ hrs and ____ culture results.
- aspiration
- PEEP
- antibiotics
- 48 hours
- positive (+)
16
What can ARDS progress to if it doesn’t resolve completely?
fibrosing alveolitis with persistent arterial hypoxemia and decreased pulmonary compliance
s34
Why is proning helpful for ARDS?
recruits lung units and improve V/Q matching by exploting gravity
s35
Who is considered for ECMO?
pts with severe hypoxemic and/or hypercapnic respiratory failure
s35
Why is ECMO helpful?
rests the lungs until severe hypoxemia, and respiratory acidosis has resolved
s35
What are additional supportive therapies for ARDS besides proning and ECMO?
Optimal fluid mgmt, NMB, inhaled nitric oxide, prostacyclins (PGI2), recruitment maneuvers, surfactant replacement, glucocorticoids, and ketoconazole
s35
What is Interstitial Lung Disease (ILD)?
group of diseases w/ similar presentation and radiographic findings, leading to restrictive physiology d/t diffuse parenchymal disease
s36
What 5 things are a part of the (primary) supportive care for ARDS?
ventilation, antibiotics, stress ulcer prophylaxis, DVT prophylaxis, and early enteral feeding
s34
What are the 5 examples of Interstitial Lung Disease from lecture?
- Sarcoidosis
- Hypersensitivity Pneumonia
- Pulmonary Langerhans Cell Histiocytosis
- Pulmonary Alveolar Proteinosis
- Lymphangioleiomyomatosis
s36
How do pts usually present with ILD?
dyspnea & nonproductive cough, ultimately leading to chronic restrictive lung disease
s36
Progressive pulmonary fibrosis causes loss of pulmonary vasculature which can lead to what?
pulmonaryhtn&corpulmonale
s36
What is sarcoidosis? How is it identified?
Systemic granulomatous disorder that involves many tissues, most commonly in the lungs and intrathoracic lymph nodes.
Identified incidentally on CXR. Often asymptomatic.
S38
What is the most common form of neurological sarcoidosis?
unilateral facial nerve palsy
S38
What type of sarcoidosis occurs in up to 5% of pts and may interfere with intubation?
Laryngeal sarcoidosis
S38
What is a classic electrolyte abnormality that occurs in <10% of pts with sarcoidosis?
Hypercalcemia
S38
What enzyme activity is increased w/ sarcoidosis?
Angiotensin-converting enzyme, likely d/t its production by granuloma cells
S39
What test is used to detect sarcoidosis and is similar to a tuberculin test?
Kveim test
S39
What procedures may be necessary to provide tissue or bronchoalveolar lavage for dx of sarcoidosis?
mediastinoscopy, endobronchial/transbronchial ultrasound, and bronchoscopy
S39
What is used to suppress sx of sarcoidosis and treat hypercalcemia?
Corticosteroids
S39
Hypersensitivity Pneumonitis
Characterized by diffuse interstitial granulomatous in the lungs after inhalation of dust containing fungi, spores, animal or plant material
may present as acute, subacute, or chronic
S40
What are the signs of Hypersensitivity Pneumonitis?
dyspnea & cough 4-6 hrs after inhailing the antigen, followed by leukocytosis, eosinophilia, and often arterial hypoxemia
S40
What is the term used for a group of diseases with similar presentation and CXR findings, leading to restrictive physiology d/t diffuse parenchymal disease?
Interstitial lung disease (ILD)
S37
In what disorders does the digit clubbing is most common?
asbestosis & idiopathic pulmonary fibrosis
S37
Which 2 diseases develop as progressive pulmonary fibrosis causing loss of pulmonary vasculature?
Pulmonary HTN & cor pulmonale
S37
What are the examples of Interstitial lung disease (ILD)?
- Sarcoidosis
- Hypersensitivity Pneumonia
- Pulmonary Langerhans Cell
- Histiocytosis
- Pulmonary Alveolar Proteinosis
- Lymphangioleiomyomatosis
S37
How does the patient w/ ILD present?
dyspnea & nonproductive cough
S37
What may repeated episodes of hypersensitivity pneumonitis lead to?
pulmonary fibrosis
S40
What is the treatment for Hypersensitivity Pneumonitis?
antigen avoidance, glucocorticoids, and lung transplant
S40
What are the most common procedures you would expect patients with Hypersensitivity Pneumonitis have?
bronchoscopy, transtracheal or transbronchial biopsy, and cryobiopsy
S40
What is Pulmonary LangerhansCell Histiocytosis?
Pulmonary fibrosis accompanies the disease process previously known as eosinophilic granuloma (histiocytosis X)
S41
Where would you see the inflammation to be in Pulmonary LangerhansCell Histiocytosis?
Around smaller bronchioles, causing destruction of the bronchiolar wall and surrounding lung parenchyma
S41
What is Pulmonary LangerhansCell Histiocytosis most associated with?
Smoking tobacco
S41
What zones does the Pulmonary LangerhansCell Histiocytosis usually affect?
upper and middle zones of the lung
S41
What is the treatment for Pulmonary LangerhansCell Histiocytosis?
smoking cessation, systemic glucocorticoids, and symptomatic support
S41
What would CT and lung biopsy show in someone w/ Pulmonary LangerhansCell Histiocytosis?
CT can be diagnostic, showing cysts or honeycombing in upper zones with costophrenic sparing
Lung biopsy shows inflammatory lesions around the bronchioles containing Langerhans cells, eosinophils, lymphocytes, and neutrophils
S41
What is Pulmonary Alveolar Proteinosis (PAP)?
Disease characterized by lipid-rich proteinaceous materials in the alveoli
*It usually presents in the fourth or fifth decade of life w/ sx of dyspnea and hypoxemia *
S42
What is Pulmonary Alveolar Proteinosis (PAP) associated with?
chemotherapy, AIDS, or inhalation of mineral dust
*May occur independently *
S42
What would CXR show in someone w/ Pulmonary Alveolar Proteinosis (PAP)?
batwing distribution of alveolar opacities in middle and lower lung zones
S42
What is the treatment of Pulmonary Alveolar Proteinosis (PAP)?
severe cases requires whole-lung lavage under GA to remove the alveolar material and improve macrophage function
S42
What would airway management include during anesthesia for someone w/ Pulmonary Alveolar Proteinosis (PAP)?
DLT to lavage of each lung separately and optimize oxygenation during the procedure
S42
What is Lymphangioleiomyomatosis?
Rare multisystem disease that results in proliferation of smooth muscle in airways, lymphatics, and blood vessels mostly in women of reproductive age.
S43
What would PFTs show in someone w/ Lymphangioleiomyomatosis? What are the signs of Lymphangioleiomyomatosis?
PFTs show restrictive and obstructive disease with a decrease in diffusing capacity
Sx: progressive dyspnea, hemoptysis, recurrent pneumothorax, & pleural effusions
S43
____________is associated with physiologic lung changes, ________________ chest wall compliance, and ________________ elastic recoil
This leads to increased ____________ volume and decreased ____________capacity
Geriatric pts breathe at a higher lung volume with an increased ________.
Aging is associated with physiologic lung changes, decreased chest wall compliance, and decreased elastic recoil
This leads to increased **residual **volume and decreased vital capacity
Geriatric pts breathe at a higher lung volume with an increased FRC
Age-related Restrictive Physiology
44
In Age-related Restrictive Physiology…
________________ and the anteroposterior (AP) diameter of the chest increase with aging, thus decreasing the ________________ of the diaphragm
There seems to be a rapid decline in ________and ____________with age and an even more rapid decline in pts with increased airway reactivity
Kyphosis and the anteroposterior (AP) diameter of the chest increase with aging, thus decreasing the efficiency of the diaphragm
There seems to be a rapid decline in FEV1 and FVC with age and an even more rapid decline in pts with increased airway reactivity
Age-related Restrictive Physiology
44
____________ ____________ ____________ lung disease is often d/t disorders of the thoracic cage (chest wall) that interfere with lung expansion
Chronic extrinsic restrictive lung disease is often d/t disorders of the thoracic cage (chest wall) that interfere with lung expansion
Chronic Extrinsic Restrictive Lung Disease
45
In Chronic Extrinsic Restrictive Lung Disease…
Deformities of the sternum, ribs, vertebrae, & costovertebral structures include these four disorder…..
Deformities of the sternum, ribs, vertebrae, & costovertebral structures include:
1. ankylosing spondylitis
2. flail chest
3. scoliosis
4. kyphosis
Chronic Extrinsic Restrictive Lung Disease
45
In Chronic Extrinsic Restrictive Lung Disease….
Work of breathing is increased d/t abnormal mechanics and increased ____________ ____________that results from decreased lung volumes
Any thoracic deformity may cause ________________ of the pulmonary vasculature and lead to________ ventricular dysfunction
Poor ability to cough leads to ____________ pulmonary infections
Work of breathing is increased d/t abnormal mechanics and increased **airway resistance **that results from decreased lung volumes
Any thoracic deformity may cause compression of the pulmonary vasculature and lead to **right **ventricular dysfunction
Poor ability to cough leads to recurrent pulmonary infections
Chronic Extrinsic Restrictive Lung Disease
45
Chronic Extrinsic Restrictive Lung Disease.
What are the 2 types of costovertebral skeletal deformities?
a. scoliosis and kyphosis
b. ankylosing spondylitis and kyphosis
c. ankylosing spondylitis and scoliosis
d. flail chest and scoliosis
a. scoliosis, and kyphosis
46
Chronic Extrinsic Restrictive Lung Disease.
In costovertebral skeletal deformities, they may present in combination as ________________, which leads to severe restrictive impaired lung function
This combination may be idiopathic (________% cases), r/t a ________________ disorder, or r/t congential vertebral malformations
They may present in combination as kyphoscoliosis, which leads to severe restrictive impaired lung function
Kyphoscoliosis may be idiopathic (80% cases), r/t a neuromuscular disorder, or r/t congenital vertebral malformations
46
Kyphoscoliosis commonly begins in late childhood/early adolescence and may progress during periods of rapid _________ ___________.
Pts w/ kyphoscoliosis r/t a neuromuscular disorder have ____________ respiratory compromise than those with idiopathic kyphoscoliosis, which results in a decreased ________________ capacity & increased work of breathing
Commonly begins in late childhood/early adolescence and may progress during periods of rapid skeletal growth
Pts w/ kyphoscoliosis r/t a neuromuscular disorder have more respiratory compromise than those with idiopathic kyphoscoliosis, which results in a decreased ventilatory capacity & increased work of breathing
46
T/F
The severity of respiratory compromise d/t kyphoscoliosis, correlates with the degree of spinal curvature.
True
The severity of respiratory compromise correlates with the degree of spinal curvature
46
Pectus ____________, aka “pigeon chest:” deformity of sternum characterized by the ____________ projection of the sternum & ribs.
The cause is ____________, run in families and is
usually more of a cosmetic concern, but may cause respiratory symptoms or __________
Pectus carinatum, aka “pigeon chest:” deformity of sternum characterized by the outward projection of the sternum & ribs
The cause is unknown, does run in families and is usually more of a cosmetic concern, but may cause respiratory symptoms or **asthma **
47
Multiple rib fractures, especially when in a ____________ ____________ orientation, can produce a ____________ ____________ w/paradoxic inward movement of the unstable portion of the thoracic rib cage
Sx: pain, increased work of breathing, inability to ____________, and atelectasis
If the lung has a contusion, it may result in low compliance & low___________
Tx of flail chest includes ____________ pressure ventilation until stabilization
Multiple rib fractures, especially when in a parallel vertical orientation, can produce a flail chest w/paradoxic inward movement of the unstable portion of the thoracic rib cage
Sx: pain, increased work of breathing, inability to cough, and atelectasis
lung contusion results in low compliance & lowFRC
Tx of flail chest includes **positive **pressure ventilation until stabilization
47
Matching!!
Pleural effusion – C. fluid (blood, serous fluid, pus, lipids) in pleural space
Pneumothorax – A. gas in the pleural space c/b disruption the parietal pleura or visceral pleura. May be spontaneous or secondary to pathology
Idiopathic spontaneous PTX – **D. **occurs most often in tall, thin men age 20-40 and is c/b rupture of apical subpleural blebs
Secondary PTX - B. may occur as a complication ofCOPD, pulmonary malignancies, cystic fibrosis, or lung abscesses
48
How is a Pleural effusion diagnosed? What is the most preferred method?
Dx made with CXR, CT, or bedside US (preferred)
48
What type of pneumothorax is considered a medical emergency??
Tensionptx= medical emergency
49
Tension pnx and develops when gas enters the pleural spaceduring ________________ andcan’tescape during _____________.
Tension ptx develops when gas enters the pleural space during inspiration and can’t escape during exhalation
49
Symptoms of a Tension pneumothorax is vast:
respiratory distress, tachypnea, SOB, hypoxia, ________ chest pain, tachycardia,________-tension
tracheamay be deviated ________ from PTX
breathsounds are decreased/absent on the side of PTX
Sx: respiratory distress, tachypnea, SOB, hypoxia, pleuritic chest pain, tachycardia,Hypo-tension
tracheamay be deviated away from PTX
breathsounds are decreased/absent on the side of PTX
49
If the patient with a Tension Pneumothorax is on a ventilator what airway pressures will you be able to observe?
a. increased airway pressures and increased Tidal Volume
b. decreased airway pressures and decreased Tidal Volume
c. increased airway pressures and decreased Tidal Volume
d. decreased airway pressures and increased Tidal Volume
C. increased airway pressures and decreased TV can be observed
49
What is the immediate treatment for Tension Pneumothorax?
Immediate evacuation through a needle or small-bore catheter placed into the secondanterior intercostal space can be lifesaving
49
________fibrosis may follow hemothorax, empyema, or surgical pleurodesis
Functional restrictive lung abnormalities are usually ________.
Surgical ____________ to remove thick fibrous pleura is considered if the restrictive lung disease is very symptomatic.
Pleural fibrosis may follow hemothorax, empyema, or surgical pleurodesis
Functional restrictive lung abnormalities are usually minor.
Surgical **decortication **to remove thick fibrous pleura is considered if the restrictive lung disease is very symptomatic.
50
Acute ____________: c/b bacterial contamination after esophageal perforation
Symptoms include chest pain & fever. It is treated with ____________-____________ abx & surgical drainage
Acute mediastinitis: c/b bacterial contamination after esophageal perforation
Symptoms include chest pain & fever. It is treated with broad-spectrum abx & surgical drainage
50
Mediastinal masses:
- Anterior mediastinal masses: ____________ (20%, most common), ________ cell tumors, lymphomas, ________thoracic thyroid tissue, & ________thyroid lesions
- Middle mediastinal masses
- Posterior mediastinal masses
- Anterior mediastinal masses: thymomas (20%, most common), germ cell tumors, lymphomas, intrathoracic thyroid tissue, & parathyroid lesions
50
Mediastinal masses:
- Anterior mediastinal masses
- Middle mediastinal masses: ____________ masses, bronchogenic and ____________ cysts, enlarged lymph nodes, and proximal ________ disease (i.e., aneurysm or dissection)
- Posterior mediastinal masses
Mediastinal masses
2
Middle mediastinal masses: tracheal masses, bronchogenic and pericardial cysts, enlarged lymph nodes, and proximal aortic disease (i.e., aneurysm or dissection)
50
Mediastinal masses:
- Anterior mediastinal masses
- Middle mediastinal masses
- Posterior mediastinal masses: ____________ tumors and cysts, meningoceles, lymphomas, ____________ aortic aneurysms, and esophageal disorders such as ____________ and neoplasms
Mediastinal masses:
3
Posterior mediastinal masses: neurogenic tumors and cysts, meningoceles, lymphomas, descending aortic aneurysms, and esophageal disorders such as diverticula and neoplasms
50
Treatment of a mediastinal mass d/o underlying _____________.
Many require surgery, radiation, chemotherapy, or careful ____________over time
Preop evaluation includes measurement of a _____-_______ __________, chest imaging, and clinical evaluation for evidence of airway ___________
Treatment of a mediastinal mass d/o underlying pathology
Many require surgery, radiation, chemotherapy, or careful surveillance over time
Preop radiation of a malignant mass to decrease its size should be considered whenever possible
Preop evaluation includes measurement of a flow-volume loop, chest imaging, and clinical evaluation for evidence of airway compression
51
Which diagnostic test is best to determine the size of the mediastinal mass?
What diagnostic test is best for evaluating degree of obstruction from mediastinal mass?
The size of the mediastinal mass and degree of tracheal compression can be established by CT scan
Flexible fiberoptic bronchoscopy under topical anesthesia can be useful for evaluating the degree of airway obstruction
51
What kind of anesthesia should be used for flexible fiberoptic bronchoscopy?
What kind of anesthesia should be used for symptomatic pt’s that need a diagnostic tissue biopsy?
Flexible fiberoptic bronchoscopy under topical **anesthesia **can be useful for evaluating the degree of airway obstruction
**Local Anesthetic **technique is best for symptomatic pts requiring a diagnostic tissue biopsy
51
T/F
Fortunately, the severity of preop pulmonary symptoms can give you some idea of the degree of respiratory compromise that can be encountered during anesthesia planning.
FALSE
Unfortunately, the severity of preop pulmonary sx has no relationship to the degree of respiratory compromise that can be encountered during anesthesia
several asymptomatic pts have developed severe airway obstruction during anesthesia
51
Define A/C mode on a ventilator
a set RR ensures the set number of breaths even if there are no inspiratory effort.
If negative pressure is sensed, a tidal volume will be delivered
Slide 22
What is unique about SIMV mode on the ventilator
- allows SV, while providing a predefined minute ventilation.
- The circuit provides sufficient gas flow
- periodic mandatory breaths that are synchronous with the pt’s inspiratory efforts
Slide 22
What are the theortical advanges of SIMV over AC mode on the ventilator
- continuous use of respiratory muscles
- lower mean airway
- lower mean intrathoracic pressure
- prevention of respiratory alkalosis
- improved pt–ventilator coordination
Slide 22
What type of ventilator mode provides gas flow to the lungs until a preset airway pressure is reached.
Pressure-cycled ventilation
*Tidal volume is the dependent variable and varies with changes in compliance and airway resistance *
Slide 22
What type of mechanical ventilation complication can cause a patient to have an acute respiratory failure, which can be the predisposing factor for developing nosocomial pneumonia (ventilator-associated pneumonia)?
infection
Slide 23
What is the primary cause of micro- aspiration?
contaminated secretions around the ETT cuff
Slide 23
What mechanical ventilted complication is strongly related to the presence of a nasotracheal tube?
Nosocomial sinusitis
Slide 23
What are the treatments for Nosocomial sinusitis ?
antibiotics
replacement of nasal tubes with oral tubes
decongestants
head elevation to facilitate sinus drainage
Slide 23
Barotrauma may be present in which mechanical ventilation complication
- subcutaneous emphysema
- pneumomediastinum
- pneumoperitoneum
- pneumopericardium
- pulmonary interstitial emphysema
- arterial gas embolism
- tension pneumothorax
Slide 23
These examples of _____ -_____ air almost always reflect passage of air from ____ alveoli
extra-alveolar
ruptured
Slide 23
How does an infection effects the risk of barotruma
weakening the pulmonary tissue
Slide 23
What is the common cause of hypoxemia during mechanical ventilation
Atelectasis
Slide 24
What do a CRNA need to check in an acute desaturation?
- ETT migration
- kinks
- mucous plugs
Slide 24
True of false: hypoxemia due to atelectasis is reponseive to an increase in FiO2.
False: Hypoxemia due to atelectasis is not responsive to an increase in Fi02
Slide 24
What are other causes of sudden hypoxemia?
- tension PTX
- PE,
(which are usually accompanied by HoTN)
Slide 24
What can be use to remove a muocus plug?
Bronchoscopy
Slide 24
True or False: Atelectasis may be identified on bedside lung ultrasound (LUS) by presence of static air bronchograms.
True
Slide 24
How do a CRNA monitor the progress of the patient when managing a complication of a mechanical ventialtor.
evaluating pulmonary gas exchange and cardiac function
Slide 25
PaO2 correlates to what regarding gas exchange
the adequacy of 02 exchange across alveolar capillary membranes
Slide 25
The efficacy of this exchange is measured by the____ between the alveolar Pa02 and the measured arterial Pa02
difference
Slide 25
What is useful for evaluating gas exchange lung function and distinguishing the cause of arterial hypoxemia?
Alveolar Pa02
Slide 25
What is the PaO2, PaCO2, PaO2-PaO2 and response to supplemental oxygen to low inspired oxygen concentration (altitude)
- PaO2: decrease
- PaCO2: normal to decrease
- PaO2-PaO2: normal
- response to supplemental oxygen: improve
Slide 25
What is the PaO2, PaCO2, PaO2-PaO2 and response to supplemental oxygen to hypoventilation (drug overdose)?
- PaO2: Decrease
- PaCO2: Increase
- PaO2-PaO2: normal
- response to supplemental oxygen: improve
What is the PaO2, PaCO2, PaO2-PaO2 and response to supplemental oxygen to ventilation/ perfusion mismatching (chronic obstrucvtive pulmonary disease, pneumonia)
- PaO2: decrease
- PaCO2: increase
- PaO2-PaO2: normal
- response to supplemental oxygen to: improve
Slide 25
What is the PaO2, PaCO2, PaO2-PaO2 and response to supplemental oxygen to right - to - left intrapulmonary shut ( pulmonary edema)
- PaO2: decrease
- PaCO2: normal to decrease
- PaO2-PaO2: increase
- response to supplemental oxygen to: poor to none
Slide 25
What is the PaO2, PaCO2, PaO2-PaO2 and response to supplemental oxygen to diffusion impairment (pulmonary fibrosis)?
- PaO2: decrease
- PaCO2: normal to decrease
- PaO2-PaO2: increase
- response to supplemental oxygen to: improve
Slide 25
When does significant desaturation of arterial blood occurs ?
only when the Pa02 is <60 mmHg
Slide 26
What are the 3 main causes of arterial hypoxemia?
- V/Q mismatch
- right-to-left pulmonary shunting
- hypoventilation
Slide 26
Increasing the Fi02 improves the Pa02 in all of these conditions except?
right-to-left pulmonary shunting
Slide 26
- Compensatory responses are stimulated by an acute decrease in Pa02 <____ mmHg
- In chronic hypoxemia, these responses are occur when Pa02 is <____mmHg
- <60
- <50
Slide 26
What are the 3 main compensatory responses
- Carotid body–induced increase in alveolar ventilation
- Hypoxic pulmonary vasoconstriction to divert pulmonary blood flow away from hypoxic alveoli
- Increased SNS activity to increase COP and enhance tissue oxygen delivery
Slide 26
Chronic hypoxemia leads to what in regards to improving oxygen-carrying capacity?
increase in RBC mass
Slide 27
The ____ reflects the adequacy of alveolar ventilation relative to C02 production
PaCO2
Slide 27
What is the term use to define the tidal volume ratio (VD:VT) reflection on the efficacy of C02 transfer across alveolar capillary membranes ?
dead space
slide 27
Whatratio indicates areas in the lungs that receive adequate ventilation but inadequate or no pulmonary blood flow?
VD:VT
Slide 27
Ventilation to these alveoli that receive adequate ventilation but inadequate or no pulmonary blood flowis described as ?
wasted or dead space
Slide 27
- Normally the VD:VT is <____, but it may increase to ≥ ____ when there is an increase in dead space ventilation
- An ___ VD:VT occurs in the presence of ARF, a ___ in cardiac output, and pulmonary embolism
0.3, 0.6
increase, decrease
Slide 27
Hypercarbia is defined as a PaC02 >____mmHg
> 45mmHg
Slide 28
Permissive hypercapnia: strategy of allowing PaC02 to increase to ≥ ____ to delay the need for intubation & ventilation
≥ 55 mmHg
Slide 28
The signs and symptoms of hypercarbia is dependent on?
level and rate of C02 increase
Slide 28
Acute increase in PaCO2 causes is associated with?
increase in CBF
Increase in ICP
Slide 28
Extreme increases in PaC02 to >____ mmHg result in CNS depression
> 80 mmHg
Slide 28
Arterial pH measurments are necessary to detect ?
- acidemia
- alkalemia
Slide 29
- Arterial hypoxemia is associatedwith ____ acidosis
- Acidemia caused by ____ or ____ compromise may lead todysrhythmias and pulmonary hypertension
- Metabolic
- respiratory or metabolic
Slide 29
What is often associated with mechanical hyperventilation and diuretic use, which leads to loss of chloride & potassium ions?
Alkalemia
Slide 29
What kind of heart condition can increase respiratory alkalosis?
dysrhythmia
Slide 29
What are the 2 proposed therapies for the life-threatening refractory hypoxemia in ARDS?
Prone positioning and extracorporeal membrane oxygenation (ECMO)
s35
*____ bronchoscopy used to visualize airways + obtain smaples for cultures, biopsy
* ________ occurs after transbronchial lung biopsy + percutaneous needle biopsy oof peripheral lung lesions
* Major C/I to pleural biopsy is _______
* ___________ is performed under GA through small transverse incision above __________ notch
* Risks of this are ______ , mediastinal hemorrhage, air embolism + _______ injury
* Why does the mediastinoscope cause loss of pulses in R arm + dec R carotid flow?
RLD Diagonsitcs
- Fiberoptic
- Pneumothorax
- Coagulopathy
- Mediastinoscopy ,, suprasternal
- PTX ,, RLN
- bc it exerts pressure on the R innominate artery
58
- AVOID :: drugs with prolonged ______________ depressant effects
- Vigilance for development of ___________ and the need to avoid or discontinue nitrous oxide
- _____________ _______________ facilitates optimal oxygenation
- increased _____________ ________________ may be necessary
- Postoperative __________ ___________ is often needed
RLD - Anesthetic Mgmt
- respiratory
- pneumothorax
- mechanical ventilation
- inspiratory pressures
- mechanical ventilation
57
- Pregnancy can lead to RLD in many ways ::
- Subcostal angle of rib cage ______ ,, circumference of lower chest wall _____ ,, diaphramg moves _____
- increased levels of _____ stretch lower rib cage ligaments
- these changes peak at ____ week of pregnancy
- chest wall normalizes ____ months postpartum
- Except subcostal anlge remains wider by ____%
- enlarging uterus pushes diaphragm up by _____ cm
RLD - Pregnancy
- increase ,, increase ,, cephalad
- relaxin
- 37th
- 6 months
- 20 %
- 4 cm
56
- Obesity causes ______ in FEV1, FVC, FRC , ERV
- BMI > ____ causes ______ RV + TLC
- extreme obesity :: _____ may exceed closing volume + approach RV
- FEV1:FVC ratio is _______
RLD - Obesity
- decrease
- 40 ,, decrease
- FRC
- Preserved
55
- injury higher than ____ causes diaphragmatic paralysis
- ____ is almost totally absent
- solely diaphragmatic breathing causes diminished _____
- Why do quadriplegic pts have bronchial constriction?
- What drug can reverse this?
Spinal Cord Injuries
- T4
- coughing
- Tidal Volume
- PSNS is unopposed by SNS activity from spinal cord
- anticholinergic bronchodilating drug
54
- Guillan Barre :: 20-25% require ______ ____ for avg of _____ months
- MG :: most common causing resp failure + are resistant to _______ + sensitive to ______
- Muscular Dystrophy :: weak swallow muscles lead to _____ _______
- CNS depressand drugs should be _______
- ______ ventialtion devices may be useful
RLD - Neuromuscular Dz
- mechanical ventilation ,, 2 mo
- succinylcholine ,, Non-Depol NMBs
- pulm aspiration
- avoided
- nocturnal
53
- _________ disorders interfere with CNS input and cause RLD
- Inability to generate normal resp pressures can be caused by abnormalities of :: spinal cord , _____ nerves , NMJ , ________ muscles
- Prevent adequate expiratory airflow to provide ________
- Can be dependent on state of ______________ to maintian ventilation
- In sleep ,, hypoxemia + hypercapnia can cause _____ ________________
Extra Thoracic Causes of RLD
- Neuromusclar
- peripheral ,, skeletal
- cough
*wakefulness - cor pulmonale
52
