Exam 4 Restrictive Lung Disease Flashcards
What is restrictive lung disease?
- Decreased lung compliance and lung expansion
- Inability to increase lung volume in proportion to an increase in alveoli pressure
- Reduction in surface area for gas diffusion
- All lung volumes are decreased
- Preservation of expiratory flow rates
__________ will result from the inability to clear lung secretions, and hypoventilation
- Hypoxia
Restrictive Lung Disease Dx
* Mild:
* Moderate:
* Severe
Dr. E pretty much told us this will be a test question.
- Mild - TLC 65%–80% of the predicted value
- Moderate- TLC 50%–65% of the predicted value
- Severe - TLC < 50% of the predicted value
Acute Pulmonary Edema is caused by
- Increased capillary pressure OR
- Increased capillary permeability
What will you see on a CXR for someone with acute pulmonary edema?
- Bilateral symmetrical perihilar opacities on CXR
- Butterfly appearance d/t increased capillary pressure
Cardiogenic pulmonary edema signs and symptoms
- Dyspnea
- Tachypnea
- SNS activation
What valvular disorder can cause cardiogenic pulmonary edema?
- Acute aortic regurgitation
- Mitral regurgitation
- Mitral valve stenosis
- Left ventricular outflow tract. obstruction
- Renovascular HTN (renal artery stenosis)
What is the are possible results of aspiration of gastric fluids?
- Destruction of surfactant-producing cells
- Damages pulmonary capillary endothelium
- Atelectasis and leakage of intravascular fluid
- Capillary permeability pulmonary edema
What do patients present with during aspiration?
What will the CXR show with aspiration?
- Arterial hypoxemia
- Tachypnea
- Bronchospasm
- Acute pulmonary HTN
- CXR will show aspiration pneumonitis usually in the superior segment of the RLL (right bronchi is a straight shot)
Aspiration Treatment
- Supplemental oxygen and PEEP
- Bronchodilation
- Antibiotics (controversial- hit or miss)
- Steroids (controversial- hit or miss)
Pulmonary EdemaAnesthesia Considerations
- Optimize patient before Elective surgery
- Make sure large pleural effusions are drained
- Persistent hypoxemia biggest problem consider post op ventilation and PEEP
- Post-op vent management
What is Acute Respiratory Failure
- Inability to provide adequate arterial oxygenation and/or elimination of CO2
With ARF, PaO2< _______ mm Hg despite oxygen supplementation and in the absence of a right-to-left intracardiac shunt.
- < 60 mmHg
PaCO2 during Acute Respiratory Failure
PaCO2can increased, unchanged, or decreased
A PaCO2 above 50 mm Hg in the absence of respiratory compensation for __________is consistent with the diagnosis of acute respiratory failure.
- metabolic alkalosis
Acute RF will result in:
_________ PaCO2
_________ Arterial pH
- ↑ PaCO2
- ↓ Arterial pH
Chronic RF
_______ pH
What organ will compensate for Chronic Renal Failure?
- Arterial pH between 7.35 and 7.45, despite an increased PaCO2
- Renal compensation: ↑ HCO3-
Acute Respiratory Failure
________ FRC and lung compliance
________ PVR and pulmonary HTN
- Decreased FRC and lung compliance
- Increased PVR and pulmonary HTN
Acute Respiratory Failure Treatment
- Establish patent and open upper airway
- Correction of hypoxemia
- Removal of excess CO2
Acute Respiratory Distress Syndrome (ARDS)
- Inflammatory injury to the lung manifested an acute hypoxemic respiratory failure
Acute Respiratory Distress Syndrome (ARDS) Causes
- Direct or indirect lung injury causes
- Sepsis
Acute Respiratory Distress Syndrome (ARDS) Signs/Sx
ARDS Chest CXR is indistinguishable from what condition?
- Rapid-onset respiratory failure
- Refractory arterial hypoxemia
- CXR - indistinguishable from cardiogenic pulmonary edema
Proinflammatory cytokines released in ARDS will lead to capillary membrane permeability in alveoli.
What are direct and indirect lung injuries for ARDS?
What is the biggest indirect lung injury?
- Sepsis is the biggest indirect injury for ARDS
Classification (PaO2/FIO2ratio) for ARDS
Mild-
Moderate -
Severe-
Mild- 201 mm Hg - 300 mm Hg
Moderate - 101 mm Hg - 200 mm Hg
Severe- ≤ 100 mm Hg
To diagnose ARD, what needs to be present in the patient’s CXR?
- Bilateral findings in at least 3 lung quadrants not explained by pleural effusion or atelectasis
What does an ECHO rule out for ARDS?
R/O cardiogenic cause of pulmonary edema
An ECHO is used bc a CXR can distinguish between ARDS and Cardiogenic Pulmonary Edema.
What causes pulmonary HTN?
- Pulmonary artery vasoconstriction and pulmonary capillary bed destruction
- Acute right-sided HF
ARDS Treatment
Prone positioning
* Lung recruitment
* Improves ventilation/perfusion matching
ECMO
* Severe hypoxemic
* Hypercapnic respiratory failure
Conservative fluid therapy
Neuromuscular blockers
* Less barotrauma
* Less secretion of both pulmonary and systemic proinflammatory mediators
What is Sarcoidosis
Systemic granulomatous disorder primarily involving intrathoracic lymph nodes and the lungs
What are the different types of sarcoidosis
- Ocular sarcoidosis - uveitis (eye redness)
- Myocardial sarcoidosis - conduction defects and dysrhythmias
- Endobronchial sarcoid- c/o chest tightness
- Laryngeal sarcoidosis - occurs in 5% of pts
Sarcoidosis signs, symptoms, and manifestations?
- No symptoms at the time of presentation
- CXR - abnormal findings
- Wheezing, dyspnea, and cough
- Cor pulmonale
- Hypercalcemia (classic manifestation) ↑Ca2+
- Increase ACE activity
How is Sarcoidosis diagnosed?
Mediastinoscopy
ACE activity is ____________ with sarcoidosis
increased
How do steroids treat sarcoidosis?
- Corticosteroids suppress the manifestations of sarcoidosis
- Treat the hypercalcemia
Anesthesia Considerations for Sarcoidosis
- Avoid prolonged apneic periods -Small FRC and low oxygen stores
- Pt will have decreased FRC
- GA- supine position and controlled ventilation
- Faster Uptake of inhaled anesthetics
- ↑ Risk of hypoxia (biggest consideration)
What is the cause of Chronic Restrictive Lung Disease?
- Often due to disorders of the thoracic cage that interfere with lung expansion
- Deformities of the sternum, ribs, vertebrae, and costovertebral structures
- Ankylosing spondylitis, flail chest, scoliosis, and kyphosis
- Compressed lungs and reduced lung volumes
- ↑ WOB
- Compression of the pulmonary vasculature
- Recurrent pulmonary infection
Define Scoliosis
lateral curvature with rotation of the vertebral column
Define Kyphosis
anterior flexion of the vertebral column
Kyphoscoliosis leads to severe restrictive impairment of lung function. What are the causes of Kyphoscoliosis?
- Idiopathic (80%)
- Neuromuscular disorder
- Associated with congenital vertebral malformations
Kyphoscoliosis will result in:
_______ventilatory capacity of the lung
________ work of breathing
________ hemidiaphragm on the side of the concavity
- Decreased ventilatory capacity of the lung
- Increased work of breathing
- Raised hemidiaphragm on the side of the concavity
How is the severity of kyphoscoliosis measured?
Severity measured by the degree of spinal curvature (Cobb angle)
- Mild to moderate kyphoscoliosis
- (scoliotic angle < 60 degrees)
- > 70 degrees - increased risk of respiratory dysfunction
What are the results of Severe Kyphoscoliosis deformities (scoliotic angle > 100 degrees)?
- Chronic alveolar hypoventilation
- Hypoxemia
- Secondary erythrocytosis
- Pulmonary HTN
- Cor pulmonale
- Respiratory failure
- Vital capacity < 45% of the predicted value
What is Pleural Effusion?
What are the possible causes of Pleural Effusion?
- Accumulation of fluid in the pleural space
- Hemothorax (blood)
- Empyema (pus)
- Chylothorax (lipids)
- Hydrothorax (serous liquid)
How is a pleural effusion diagnosed?
- CXR
- CT scan of the chest
- Bedside US
What will you see with pleural effusion on a CXR?
- Blunting of the costophrenic angle
- Homogeneous opacity
- Concave meniscus with the chest wall
- CXR has decreased sensitivity
How many mL needs to be considered for pleural effusion to be diagnosed on a CXR?
- 250 cc
Ultrasound has increased sensitivity and is better at diagnosing pleural effusion.
Where is the pleural effusion
Notice the blunting on the patient’s right lung. That is the pleural effusion.
What is a Pneumothorax?
Differentiate a parietal and visceral pleura pneumothorax.
- Presence of gas in the pleural space with disruption of the Parietal pleura or Visceral pleura
- There will be pleural separation where air can be seen between the visceral pleural lining and rib cage
- Parietal pleura pneumo is from an external penetrating injury
- Visceral pleura pneumo from a tear or rupture in the parenchyma
Secondary pneumothorax
Known parenchymal lung pathology
COPD, Lung CA, CF - something that is known and diagnosed that is causing the pathology.
Idiopathic spontaneous pneumothorax
Rupture of apical subpleural blebs
This usually occurs with tall thin men b/w the ages of 20 to 40. Think basketball players.
The prevalence of pneumothorax increases with this risk factor.
A lot of times, when does spontaneous pneumothorax occur?
- Smoking
- Spontaneous pneumothorax occurs at rest
What is a Tension Pneumothorax?
- Gas enters the pleural space during inspiration and can’t escape during exhalation.
- The trapped gas will expand and increase in tension over time.
- Medical Emergency
30% of the time, a tension pneumothorax will occur during ________.
- Mechanical Ventilation
Tension Pneumothorax Signs and Symptoms
- Respiratory distress
- Trachea deviated to the side, away from the pneumothorax
- Decreased/absent breath sounds on the side of the pneumothorax
- Hyperresonance on percussion
- Tachycardia and hypotension
Tension Pneumothorax Treatment
- Evacuation of gas through a needle or a small-bore catheter
- Second anterior intercostal space (hotspot)
- Placement of a chest tube
Needle decompression is for small to moderate-size spontaneous pneumothorax.
Tension Pneumothorax Anesthesia Consideration
- D/C nitrous oxide IMMEDIATELY
- 100% O2
- Needle/catheter decompression
- Chest tube placement
Pneumothorax less than _____% and no symptoms. The intervention will be just to monitor the patient.
This will be a test question.
- 15%
What is a pneumomediastinum?
- Tear in the esophagus/ tracheobronchial tree OR
- Alveolar rupture
Pneumomediastinum cause
No known cause
Pneumomediastinum signs and symptoms
- Retrosternal chest pain and dyspnea
- Subcutaneous emphysema
- Pneumothorax
- Pneumomediastimum occurs after cocaine use.
What is used to diagnose a Pneumomediastinum
- CXR
Pneumomediastinum Treatment
- Spontaneous pneumomediastinum self-resolving
- Surgery (VATS)
What were some common Mediastinal Masses listed in class?
- Tracheal Mass
- Descending aortic aneurysm
- Esophageal disorder
- Thyroid
Mediastinal Mass – Evaluation
- CT w/ contrast to assess vascular structures, soft tissues, calcifications, and Size
- Evaluate Airway obstruction (fiber optics)
- Evaluate Loss of lung volumes
- Evaluate Pulmonary artery compression
- Evaluate Cardiac compression
- Evaulate Superior vena cava obstruction
Mediastinal Mass – Anesthetic Considerations Preop
- Consider Flow-volume loop
- Imaging studies
- Tracheobronchial compression
- Fiberoptic bronchoscopy
- Local anesthetic vs GA - (Prefer LA b/c we need to maintain spontaneous vent)
- External edema - mouth and hypopharynx
- Arterial line - BP
The induction and intubation in the presence of mediastinal tumors depend on the preoperative airway assessment. Visible external edema associated with superior vena cava syndrome is likely accompanied by similar edema inside the ______ and __________.
- Mouth
- Hypopharynx
Symptomatic patients may need to be in a ______ position to breathe adequately. If so, anesthetic induction should proceed in the _____ position until the airway has been secured.
- sitting
- sitting
What does obesity do to chest wall compliance?
- Mildy reduced chest wall compliance
Central obesity effect on lung function?
- Worse lung function and respiratory symptoms
- Increased resting respiratory rate w/ normal Vt
Anterior abdominal wall and viscera adipose tissue:
________Diaphragmatic movement
________Basal lung expansion during inspiration
________Closure of peripheral lung units
- Decrease Diaphragmatic movement
- Decrease Basal lung expansion during inspiration
- Increase Closure of peripheral lung units
Anterior abdominal wall and viscera adipose tissue will lead to
- Ventilation/perfusion abnormalities
- Arterial hypoxemia
- Respiratory compromise
Pregnancy Thorax structural changes
- Increased subcostal angle of the rib cage
- Increased circumference of the lower chest wall
- Diaphragm moves cephalad
Pregnancy:
Increase in ____ level contributes to structural changes in pregnancy
- Relaxin
The subcostal angle widens, _____ to _____ degrees
- 68 to 103
What happens to the anteroposterior diameter and transverse diameter of the chest wall during pregnancy?
- Increase by 2 cm
Where does the uterus move during pregnancy?
- up toward the lungs
When do the structural changes peak during pregnancy?
- 37 weeks
- Chest wall configuration normalizes in about ___ months postpartum
- 6 months
Pregnancy will cause a _____FRC, ERV, and RV
Decrease
During Pregnancy, FRC typically decreases by 15%– 20% or _______ mL
- 200 to 300 mL
Does a pregnant mother prefer a sitting or supine position?
- Sitting, she will have a hard time breathing supine.
_______ lung compliance is unaffected by pregnancy.
- Intrinsic
Lungs still move the same on the inside.
