Exam 4 Restrictive Lung diseases Part II Flashcards
1
Q
Intrapulmonary shunt: right to left pulnonary shunting =
A
perfusion of nonventilated alveoli
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2
Q
Net effect of intrapulmonary shunting
A
Decrease in PaO2, reflecting the dilution of oxygenated blood with hypo-oxygenated blood coming from unventilated alveoli
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3
Q
Calculation of the intrapulmonary shunt fraction is useful why?
A physiologic shunt accounts for __ - __% of COP
A
- Calculation provides a reliable assessment of V/Q matching and is a useful estimate of the response to therpies
- 2-5%
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4
Q
- degree of right to left shunting
- determination of the shunt
- how do we calculate the shunt?
A
- the degree of R-L pulmonary shunting reflects the passage of pulmonary arterial blood directly to the left side of the circulation through the bronchial and thebesian veins
- Determination of the shunt fraction with pts breathing <100% O2 reflects the V/Q mismatching as well as R-L intrapulmonary shunting
- Calculation from measurements obtained when the pt breathes 100% O2 eliminates the contribution of the V/Q mismatching
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5
Q
Ventilator weaning - essential considerations (not the objective guidelines)
A
- pt is alert
- cooperative
- can tolerate a trial of SV without excessive tachypnea
- no excessive tachycardia
- no respiratory distress
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6
Q
Ventilator Weaning: objective guidelines for discontinuing mechanica ventilation
A
- Vital capacity of >15 mL/kg
- Alveolar-arterial oxygen difference of <350 cmH2O while breathing 100% 02
- Pa02 of >60 mmHg with an Fi02 of <50%
- Negative inspiratory pressure of more than −20 cmH2O
- Normal pHa
- RR <20
- VD:VT of < 0.6
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7
Q
Vent weaning: Breathing at rapid rates with low tidal volumes usually signifies ____
A
- the inability to tolerate extubation
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8
Q
3 options to trial vent withdrawal
A
- 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
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9
Q
Deterioration in oxygenation after vent withdrawal may reflect ____ ____ ____, which can be responsive to ____ or ____ ____ ____ ____ rather than the re-intubating
A
- progressive alveolar collapse
- CPAP
- Non invasive positive pressure ventilation (NIPPV)
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10
Q
Potential things that can interfere with successful extubation
A
- Excessive workload on the respiratory muscles due to hyperinflation
- copious secretions
- bronchospasm
- increased lung water
- increased CO2 production
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11
Q
____ ____ can be considered a bridge.
- this involves ____ ____ with immediate application of a NIV
- this can decrease incidence of ____ ____, shorten ICU stay, and reduce mortaility
- however, NIV may impair ability to ____ ____, and there may be inadequate ____ ____
A
- Noninvasive ventilation (NIV)
- early extubation
- Nosocomial pneumonia
- clear airway secreations; minute ventilation
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12
Q
- Extubation should be considered when pts tolerate ____ min of ____ with CPAP of 5cmH2O without deterioation of ____, ____, or ____ ____
A
Extubation should be considered when pts tolerate 30min of SV with CPAP of 5 cm H2O without deterioration in ABGs, mental status, or cardiac function
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13
Q
PaO2, PaCO2, PEEP, RR, and VC criteria for extubation
A
- PaO2: >60mmHg and a FiO2<50%
- PaCO2: <50mmHg and pHa>7.3
- PEEP: <5cmH2O
- RR: <20
- VC: >15mL/kg
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14
Q
- Pts should be alert, with active____ ____ and the ability to generate an effective cough and clear secretions
- 02 supplementation is often needed after extubation due to ____ ____
- 02 weaning is accomplished by ____ ____ the inspired 02, guided by measurements of Pa02 and/or monitoring of Sp02
A
- laryngeal reflexes
- V/Q mismatching
- gradually decreasing
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15
Q
Acute Respiratory Distress Syndrome: cause, Highest risk of getting it, hallmarks
A
- Caused by inflammatory injury to the lung and manifests as acute hypoxemic respiratory failure
- Sepsis is associated with the highest risk of ARDS
- Hallmarks: Rapid-onset respiratory failure, arterial hypoxemia, and CXR findings similar to cardiogenic pulmonary edema
Proinflammatory cytokines lead to increased alveolar capillary membrane permeability and alveolar edema
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16
Q
- Acute ARDS usually ____ ____, but may progess to ____ ____ with persistent arterial hypoxemia and decreased ____ ____
- Supportive care consists of
A
- resolves completely; fibrosing alveolitis; pulmonary compliance
- ventilation, antibiotics, stress ulcer prophylaxis, DVT prophylaxis, and early enteral feeding
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17
Q
ARDS management
A
- Prone positioning: exploits gravity and repositioning of the heart in the thorax to recruit lung units and inprove V/Q matching
- ECMO: considered in pts with severe hypoxemic and/or hypercapnic respiratory failure as a possible rescue therapy aim of this strategy is to rest the lungs until hypoxemia and respiratory acidosis have resolved
- Optimal fluid mgmt, NMB, inhaled nitric oxide, prostacyclins (PGI2), recruitment maneuvers, surfactant replacement, glucocorticoids, and ketoconazole
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18
Q
Chronic Intrinsic Restrictive lung disease (Interstitial lung disease): definition and examples
A
- term used for a group of diseases with similar presentation and chest XR findings, leading to restrictive physiology from diffuse parenchymal disease
- Examples: Sarcoidosis
Hypersensitivity Pneumonia
Pulmonary Langerhans Cell Histiocytosis
Pulmonary Alveolar Proteinosis
Lymphangioleiomyomatosis
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19
Q
Interstitial lung disease presentation
A
- usually present with dyspnea & nonproductive cough - this leads to a chronic restrictive lung disease
- pulmonary hypertension and cor pulmonale develop as progressive pulmonary fibrosis causes loss of pulmonary vasculature
- Digit clubbing is common in some ILDs like asbestosis and idiopathic pulmonary fibrosis
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20
Q
Sarcoidosis: definition and pt presentation
A
- Systemic granulomatous disorder that involves many tissues, most commonly in the lungs and intrathoracic lymph nodes
- Pt presentation:
- -often asymptomatic - can be incidentally on CXR
- -crackles are uncommon
- -wheezing may be present if there is bronchiole involvement
- -some pts have dyspnea and cough
- -myocardial sarcoidosis may produce conduction defects and dysthythmias
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21
Q
- In Sarcoidosis, the most common form of neurologic sarcoidosis is ____ ____ ____ ____
- ____ sarcoid is common
- ____ ____ occurs in up to 5% of pts and may interfere with intubation
- ____ ____ may develop
- ____ occurs in <10% of pts but this is a classic manifestation of sarcoidosis
A
- Unilateral facial nerve palsy
- endobronchial
- Laryngeal sarcoidosis
- cor pulmonale
- hypercalcemia
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22
Q
- ____ activity is increased with sarcoidosis, likely because of its production by granuloma cells
- Other markers that have been studied include ____, serum and bronchoalveolar lavage levels of ____, and serum soluble ____ receptors
- ____ test is used to detect sarcoidosis and is similar to a tuberculin test
- Advanced pulmonary fibrosis may lead to ___ ____
A
- Angiotensin-converting enzyme activity
- Serum Amyloid A,
- adenosine deaminase
- IL2
- Kveim
- pulmonary hypertension
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23
Q
Sarcoidosis Procedures
A
Procedures such as mediastinoscopy, endobronchial/transbronchial ultrasound, and bronchoscopy may be necessary to provide tissue or bronchoalveolar lavage for diagnosis
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24
Q
What are corticosteroids used for with sarcoidosis?
A
Corticosteroids are used to suppress symptomes of sarcoidosis and treat hypercalcemia
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25
Hypersensitivity Pneumonitis: characterized by, and S/S
* Characterized by: diffuse intersitial granulomatous after inhalation of fungi, spores, animal or plants in dust (may be acute, subacute, or chronic)
* S/S: dyspnea, cough 4-6 hours after inhailing antigen, leukocytosis, eosinophilia and often arterial hypoxemia
* repeat episodes may lead to pulmonary fibrosis
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26
Hypersensitivity Pneumonitis: CT shows, what procedures should pts get? treatment
* CT shows ground-glass opacities in the mid to upper lung zones
* Pts may present for procedures such as bronchoscopy, transtracheal or transbronchial biopsy, and cryobiopsy
* treatment consists of antigen avoidance, glucocorticoids, and lung transpant
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27
Pulmonary Langerhans Cell Histiocytosis: definition
* Pulmonary fibrosis accompanies the disease process previously known as eosinophilic granuloma (histiocytosis X)
* In this disease the inflammation is usually around smaller bronchioles, causing destruction of the bronchiolar wall and surrounding lung parenchyma
* The disease usually affects the upper and middle zones of the lung
* Has strong association with smoking tobacco
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28
Pulmonary Langerhans Cell Hystiocytosis: diagnosis and treatment
* 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
* Treatment consists of smoking cessation, systemic glucocorticoids, and symptomatic support
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29
Pulmonary Alveolar Proteinosis (PAP): Characterized by
* 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
* could occur independantly ro associated with chemotherapy, AIDS or inhalation of mineral dust
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30
Pulmonary Alveolar Proteinosis (PAP): Diagnosis and treatment
* CXR: batwing distribution of alveolar opacities in middle and lower lung
* Treatment of severe cases requires **whole-lung lavage under GA** to remove the alveolar material and improve macrophage function
* Lung lavage in pts with hypoxemia may temporarily decrease oxygenation further
* Airway management during anesthesia for lung lavage includes Double lument ETT to lavage of each lung separately and optimize oxygenation during the procedure
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31
Lymphangioleiomyomatosis: definition
* Rare multisystem disease that results in proliferation of smooth muscle in airways, lymphatics, and blood vessels mostly in women of reproductive age
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32
Lymphangioleiomyomatosis: diagnosis, s/s, treatment
* PFTs show restrictive and obstructive disease with a decrease in diffusing capacity
* Sx: progressive dyspnea, hemoptysis, recurrent pneumothorax, & pleural effusions
* Treatment with Sirolimus (immunosuppressive) is indicated in symptomatic pts w/progressive disease
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33
* Aging is associated with physiologic lung changes including: (2)
* this leads to increased ____ ____ and decrased ____ ____
* geriatric pts breathe at a higher ____ ____ with an increased ____
* decreased chest wall compliance and decrased elastic recoil
* increased residual volume and decreased vital capacity
* higher lung volume with increased FRC
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34
* ____ and the anteroposterior diameter of the chest increase with aging, this decrases the efficiency of the ____
* there is a rapid decline of ____ and ____ with age, even more rapid decline in pts with reactive airways
* Kyphosis; diaphragm
* FEV1 and FVC
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35
Chronic Extrinsic Restrictive lung disease: thoracic extrapulmonary causes
* often due to disorders of the thoracic cage that interfere with lung expansion
* deformities of the sternum, ribs, vertebrae and costovertebral structures include: ankylosing spondylitis, flail chest, scoliosis, and kyphosis
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36
Chronic Extrinsic restrictive lung disease: thoracic extrapulmonary - work of breathing, lung expansion, coughing
* increased WOB because of abnormal mechanics, increased airway resistance and decreased lung volumes
* thoracic deformity can compress pulmonary vasculatrue and cause RV dysfunction
* poor ability to cough leads to recurrent pulmonary infections
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37
costovertebral skeletal deformities: 2 types, presentation, and causes
* Scoliosis and kyphosis
* They may present in combination as kyphoscoliosis, which leads to severe restrictive impaired lung function
* Kyphoscoliosis may be idiopathic (80% cases), from a neuromuscular disorder, or from congenital vertebral malformations
* Commonly begins in late childhood/early adolescence and may progress during periods of rapid skeletal growth
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38
* pts with Kyphoscoliosis related to a neuromuscular disorder have more ____ ____ than idiopathic kyphoscoliosis
* this results in decreased ____ ____ and increased WOB
* the severity of respiratory compromise correlates with the degree of spinal ____
* respiratory compromise
* ventilatory capacity
* curvature
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39
Chronic Extrinsic Restrictive lung disease: pectus carinatum (AKA pigeon chest)
* deformity of sternum characterized by the outward projection of the sternum & ribs
* cause unknown, does run in families
usually more of a cosmetic concern, but may cause respiratory symptoms or asthma
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40
Chronic Extrinsic Restrictive Lung Disease: multiple rib fractures, can produce flail chest when?, S/S, treatment
* Flail chest with parallel vertical orientation of fractures - flail chest is paradoxical inward movement of teh unstable portion of the thoracic rib cage
* S/S: pain, increase WOB, inability to cough, atelectasis, lung contusion results in low compliance and low FRC
* Treatment: PPV until stabilization
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41
Pulmonary disorders: definition for:
- pleural effusion
- pneumothorax
- idiopathic spontaneous pneumothorax
- secondary pneumothorax
* Pleural effusion: fluid (blood, serous fluid, pus, lipids) in pleural space
Diagnosis made with CXR, CT, or bedside US (preferred)
* Pneumothorax: gas in the pleural space caused by disruption the parietal pleura or visceral pleura. May be spontaneous or secondary to pathology
* Idiopathic spontaneous PTX occurs most often in tall, thin men age 20-40 and is caused by rupture of apical subpleural blebs
* Secondary PTX: may occur as a complication of COPD, pulmonary malignancies, cystic fibrosis, or lung abscesses
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42
Tension pneumothorax: definition, S/S, treatment
* medical emergency and develops when gas enters the pleural space during inspiration and can't escaping during exhalation
* respiratory distress, tachypnea, SOB, hypoxia, pleuritic chest pain, tachycardia, HoTN, **trachea may be deviated away from PTX**, breath sounds are decreased/absent on the side of PTX
* if the pt is on vent, increased airway pressures and decreased TV can be observed
* Treatment: **Immediate evacuation through a needle or small-bore catheter placed into the second anterior intercostal space can be lifesaving**
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43
Pulmonary disorders: Definition for
- Pleural fibrosis
* 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.
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44
Pulmonary disorders: definition for
- acute mediastinitis
* caused by bacterial contamination after esophageal perforation
* Symptoms include chest pain & fever. It is treated with broad-spectrum abx & surgical drainage
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45
Plumonary disorders definition for
- mediastinal masses (anterior, middle, posterior)
* Anterior mediastinal masses: thymomas (20%, most common), germ cell tumors, lymphomas, intrathoracic thyroid tissue, & parathyroid lesions
* Middle mediastinal masses: tracheal masses, bronchogenic and pericardial cysts, enlarged lymph nodes, and proximal aortic disease (i.e., aneurysm or dissection)
* Posterior mediastinal masses: neurogenic tumors and cysts, meningoceles, lymphomas, descending aortic aneurysms, and esophageal disorders such as diverticula and neoplasms
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46
Treatment and preop conciderations of mediastinal mass
* many requre surgery, radiation, chemo (some just need careful surveillance)
* Preop: measure flow-volume loop, chest imaging, and eval for airway compression evidence
* the side of the mass and degree of tracheal compression can be evaluated by a CT
* degree of airway obstruction = fiberoptic bronchoscopy with topical anesthesia
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* mediastinal masses - you can do all the evaluating you want, but...
* **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
* Preop radiation of a malignant mass to decrease its size should be considered whenever possible
* LA technique is best for symptomatic pts requiring a diagnostic tissue biopsy
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NonPulmonary restrictive physiology: definition:
- Asphyxiating thoracic dystrophy
* AKA: “Jeune syndrome:” autosomal recessive disorder with skeletal dysplasia and multiorgan dysfunction
* associated with cysts in kidney, pancreas, and liver
* retinal abnormality with short ribs, narrow thorax, short limbs, and polydactyly
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49
NonPulmonary restrictive physiology Definition:
- Fibrodysplasia ossificans
* hereditary disorder caused by a genetic variation in bone morphogenetic protein (BMP) type 1
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50
NonPulmonary restrictive physiology Definition:
- Poland Syndrome
* partial or complete absence of pectoral muscles, commonly affecting one side. Pts may also have paradoxic respiratory motion due to the absence of multiple ribs
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Extrathoracic causes of restrictive lung disease: neuromuscular and are characterized by
* Neuromuscular disorders that interfere with CNS input to the skeletal respiratory muscles can result in restrictive lung disease
* abnormalities of the spinal cord, peripheral nerves, NMJ, or skeletal muscles may result in restrictive pulmonary defects **characterized by an inability to generate normal respiratory pressures**
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* Mechanical disorders usually preserve an effective ____, the expiratory muscles are weak in NM disorders which prevents an ____ ____
* severe NM disorders are dependent on their state of ____ to maintain adequate ventilation
* during sleep, ____ and ____ may develop and contribute to cor pulmonale
* cough; adequate/forceful cough
* wakefulness
* hypoxemia and hypercapnia
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RLD - NM disorders:
- Gullian-Barre syndrome
- Myasthenia gravis
* Guillain-Barré syndrome: 20-25% pts require mechanical ventilation
Ventilatory support is needed on average for 2 months
* Myasthenia gravis: most common disease affecting neuromuscular transmission that may result in respiratory failure
-Pts are resistant to succinylcholine and sensitive to ND-NMBs
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RLD - NM disorders: Muscular dystrophy
* **are predisposed to pulmonary complications**
* chronic alveolar hypoventilation occurs due to inspiratory muscle weakness
expiratory muscle weakness impairs cough
* weakness of swallowing muscles may lead to pulmonary aspiration
* **As with all neuromuscular syndromes, CNS depressant drugs should be avoided or administered in minimal doses**
* Nocturnal ventilation with noninvasive techniques such as nasal intermittent positive pressure or external negative pressure ventilation may be useful
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Spinal Cord Injuries
* In quadriplegic pts w/ injury below T4, breathing is maintained solely or predominantly by the diaphragm
* Higher levels of injury result in diaphragmatic paralysis
* Because the diaphragm is active only during inspiration, coughing is almost totally absent
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* With spinal cord injuries - diaphragmatic breathing has a paradoxis ____ motion of the upper thorax during inspiration, resulting in a diminished Vt
* Quadriplegic pts have mild degrees of ____ ____ caused by the parasympathetic tone that is unopposed by sympathetic activity from the spinal cord
* the used of ____ ____ drugs can reverse
* inward
* bronchial constriction
* anticholinergic bronchodialating drugs
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57
RLD - Obesity
- decreases in what?
- BMI>40 leads to decrease in?
- with extreme obesity, FRC may exceed what?
- what has a good correlation with impaired lung function?
* decreases in FEV1, FVC, FRC and ERV
* BMI>40: decreased RV and TLC
* extreme obesity, FRC may exceed closing volume and approach RV (FEV1/FVC ratio is usually preserved)
* increased wiast-to-hip ratio and/or abdominal girth has a good coorelation with impaired lung function
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* buildup of ____ in the anterior abd wall and viscera hinders ____ ____, diminishing basal lung expansion, and causes closure of ____ ____ units
* this leads to ____ / ____ abnormalities and arterial hypoxemia = respiratory compromise especially during ____ and in the perioperative period
* adipose tissues; diaphragmatic movement; peripheral lung units
* ventilation/perfusion; sleep
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* adipose cells release ____ that play a part in systemic inflammation triggered by obesity-related ____ and obesity-related ____ disorders such as OSA, obesity ____ syndrome and COPD
* adipocytokines
* hypoxemia
* respiratory disorders
* hypoventilation
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RLD - preggers
- how can it lead to RLD?
* subcostal angle of the rub cage widens
* the circumference of the lower chest wall increase (anteroposterior diameter and transverse diameter of the chest wall increases)
* the diaphragm moves cephalad
* increased levels of relaxin
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RLD - preggers
- changes peak at?
- chest wall normalizes when?
- the enlarging uterus pushed the diaphragm up by ____cm
* Changes peak at 37th week
* Chest wall configuration normalized about 6 months postpartum, except for subcostal angle - which remains wider by 20%
* 4cm
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RLD - anesthetic management
- what to avoid?
- monitor for? (2 things)
- is mechanical ventilation good?
- how should we change it?
- what about a vent after the surgery?
* avoid drugs with prolonged respiratory depressant effects
* maintain viligance for pneumothorax and the need/avoidance of N2O
* intraop mechanical ventilation facilitates optimal oxygenation
* since lungs have poor compliance, may need increased inspiratory pressures
* postop mechanical ventilation is ofte needed for pts with impaired pulm function
* **restrictive lung disease also contributes to the risk of perioperative pulmonary complications**
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RLD - diagnostic procedures
This one has generally replaced rigid bronchoscopy for visualizing the airways and obtaining samples for culture, cytologic examination, and biopsy, what is it?
Fiberoptic bronchoscopy
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RLD diagnostic procedures: This one makes a pneumothorax occur in 5-10% of pts after it, and in 10-20% of pts after it for lung lesions, what is it?
lung biopsy
- Pneumothorax occurs in 5-10% of pts after transbronchial lung biopsy and in 10-20% after percutaneous needle biopsy of peripheral lung lesions
The major contraindication to pleural biopsy is a coagulopathy
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RLD diagnostic procedures: this one is performed with GA through a small transverse incision just above the suprasternal notch
mediastinoscopy
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What is the procedure for a mediastinoscopy? what are the risks?
* blunt dissection along the pretracheal fascia - this permits biopsy of paratracheal nodes down to the carina
* risks include: pneumothorax, mediastinal hemmorrhage, venous air embolism and RLN injury
* the mediastinoscope can also exert pressure on the right innominate artery, causing loss of pulses in the right arm and compromise of right carotid artery blood flow
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