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Mar: Sem 2 - Health Assessment > Exam 4 Restrictive Lung diseases Part II (Mar) > Flashcards

Exam 4 Restrictive Lung diseases Part II (Mar) 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
  1. SIMV: which allows progressively fewer mandatory breaths until pt breathing on their own
  2. Intermittent trials of total removal of mechanical support and breathing through a T-piece
  3. 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
Q

Hypersensitivity Pneumonitis: characterized by, and S/S

A
  • 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
Q

Hypersensitivity Pneumonitis: CT shows, what procedures should pts get? treatment

A
  • 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
Q

Pulmonary Langerhans Cell Histiocytosis: definition

A
  • 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
Q

Pulmonary Langerhans Cell Hystiocytosis: diagnosis and treatment

A
  • 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
Q

Pulmonary Alveolar Proteinosis (PAP): Characterized by

A
  • 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
Q

Pulmonary Alveolar Proteinosis (PAP): Diagnosis and treatment

A
  • 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
Q

Lymphangioleiomyomatosis: definition

A
  • 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
Q

Lymphangioleiomyomatosis: diagnosis, s/s, treatment

A
  • 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
Q
  • Aging is associated with physiologic lung changes including: (2)
  • this leads to increased ____ ____ and decrased ____ ____
  • geriatric pts breathe at a higher ____ ____ with an increased ____
A
  • 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
Q
  • ____ 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
A
  • Kyphosis; diaphragm
  • FEV1 and FVC

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35
Q

Chronic Extrinsic Restrictive lung disease: thoracic extrapulmonary causes

A
  • 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
Q

Chronic Extrinsic restrictive lung disease: thoracic extrapulmonary - work of breathing, lung expansion, coughing

A
  • 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
Q

costovertebral skeletal deformities: 2 types, presentation, and causes

A
  • 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
Q
  • 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 ____
A
  • respiratory compromise
  • ventilatory capacity
  • curvature

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39
Q

Chronic Extrinsic Restrictive lung disease: pectus carinatum (AKA pigeon chest)

A
  • 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
Q

Chronic Extrinsic Restrictive Lung Disease: multiple rib fractures, can produce flail chest when?, S/S, treatment

A
  • 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
Q

Pulmonary disorders: definition for:
- pleural effusion
- pneumothorax
- idiopathic spontaneous pneumothorax
- secondary pneumothorax

A
  • 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 ofCOPD, pulmonary malignancies, cystic fibrosis, or lung abscesses

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42
Q

Tension pneumothorax: definition, S/S, treatment

A
  • medical emergency and develops when gas enters the pleural spaceduring inspiration andcan’tescaping during exhalation
  • respiratory distress, tachypnea, SOB, hypoxia, pleuritic chest pain, tachycardia,HoTN, tracheamay be deviated away from PTX, breathsounds are decreased/absent on the side of PTX
  • ifthe pt is on vent, increased airway pressures and decreased TV can be observed
  • Treatment: Immediateevacuation through a needle or small-bore catheter placed into the secondanterior intercostal space can be lifesaving

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43
Q

Pulmonary disorders: Definition for
- Pleural fibrosis

A
  • 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
Q

Pulmonary disorders: definition for
- acute mediastinitis

A
  • 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
Q

Plumonary disorders definition for
- mediastinal masses (anterior, middle, posterior)

A
  • 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
Q

Treatment and preop conciderations of mediastinal mass

A
  • 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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47
Q
  • mediastinal masses - you can do all the evaluating you want, but…
A
  • 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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48
Q

NonPulmonary restrictive physiology: definition:
- Asphyxiating thoracic dystrophy

A
  • 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
Q

NonPulmonary restrictive physiology Definition:
- Fibrodysplasia ossificans

A
  • hereditary disorder caused by a genetic variation in bone morphogenetic protein (BMP) type 1

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50
Q

NonPulmonary restrictive physiology Definition:
- Poland Syndrome

A
  • 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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51
Q

Extrathoracic causes of restrictive lung disease: neuromuscular and are characterized by

A
  • 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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52
Q
  • 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
A
  • cough; adequate/forceful cough
  • wakefulness
  • hypoxemia and hypercapnia

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53
Q

RLD - NM disorders:
- Gullian-Barre syndrome
- Myasthenia gravis

A
  • 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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54
Q

RLD - NM disorders: Muscular dystrophy

A
  • 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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55
Q

Spinal Cord Injuries

A
  • 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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56
Q
  • 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
A
  • inward
  • bronchial constriction
  • anticholinergic bronchodialating drugs

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57
Q

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?

A
  • 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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58
Q
  • 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
A
  • adipose tissues; diaphragmatic movement; peripheral lung units
  • ventilation/perfusion; sleep

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59
Q
  • 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
A
  • adipocytokines
  • hypoxemia
  • respiratory disorders
  • hypoventilation

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60
Q

RLD - preggers
- how can it lead to RLD?

A
  • 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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61
Q

RLD - preggers
- changes peak at?
- chest wall normalizes when?
- the enlarging uterus pushed the diaphragm up by ____cm

A
  • 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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62
Q

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?

A
  • 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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63
Q

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?

A

Fiberoptic bronchoscopy

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64
Q

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?

A

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

sldie 59

65
Q

RLD diagnostic procedures: this one is performed with GA through a small transverse incision just above the suprasternal notch

A

mediastinoscopy

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66
Q

What is the procedure for a mediastinoscopy? what are the risks?

A
  • 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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Mar: Sem 2 - Health Assessment (32 decks)

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