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Advanced Health Assessment TWU CRNA > Final Exam Information > Flashcards

Final Exam Information Flashcards

1
Q

2 main causes of bronchodilation?

A
  1. Circulating catecholamines such as epinephrine and norepinephrine
  2. Non-parasympathetic nerve releases vasoactive intestinal peptide (VIP) and NO
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2
Q

What type of G-protein binds with Beta 2 receptors after episode and norepinephrine stimulation to cause bronchodilation?

A

Gs protein

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3
Q

7 steps of bronchoconstriction starting with CN X innervation of airway smooth muscle?

A
  1. CNX innervating airway smooth muscle
  2. Cholinergic nerve endings release Act to muscarinic receptor-3
  3. M3 is coupled of Gq protein
  4. Activated Gq protein activates phospholipase C (PLC)
  5. PLC activates inositol triphosphate (IP3) - 2nd messenger
  6. IP3 stimulates calcium release from SR
  7. Increased calcium leads to bronchoconstriction
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4
Q

What type of response does coughing, allergy and infection cause?

A

Inflammatory response mediated by IgE

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5
Q

6 mediators of bronchoconstriciton

A
  1. Cytokines
  2. Complement
  3. Bradykinin
  4. Platelet activtating factors
  5. Histamine
  6. Leukotrienes
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6
Q

What do non-cholinergic C fibers release that cause bronchoconstriction?

A
  1. Substance P
  2. Neurokinin A
  3. Calcitonin gene related peptide
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7
Q

What type of pattern do COPD patients show on PFT?

A

Obstructive pattern

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8
Q

Describe the pathology behind COPD

A

Pathologic deterioration in elasticity or recoil within the lung parenchyma, which normally maintains the airways in an open position

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9
Q

What are the airways of COPD patients predisposed to?

A

Collapse during exhalation

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10
Q

What occurs with the gas velocity in COPD patients?

A

Increase in gas velocity in narrowed bronchiole, which lowers pressure inside the bronchiole and further favors airway collapse

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11
Q

What does bronchospasm and obstruction result from with COPD patients?

A

Increased pulmonary secretions

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12
Q

3 major characteristics of COPD patients?

A
  1. Chronic cough
  2. Progressive exercise limitation
  3. Expiratory airflow obstruction
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13
Q

Patho behind Chronic Bronchitis? (Goblet cells and ciliary 5)

A
  1. Increased mucous production
  2. Loss of mucociliary clearance
  3. Carina = cough
  4. Inflammation causing more irritation
  5. Air trapping
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14
Q

Patho behind Emphysema

A
  1. Damage to collagen and elastin fibers
  2. Airway almost collapse
  3. Lung fibrosis and loss of elastic recoil is landmark sign of emphysema
  4. SOB
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15
Q

Risk factors for COPD (4)

A
  1. Tobacco = primary
  2. Occupational exposure to dust; indoor and outdoor pollution
  3. Respiratory infection
  4. Genetic factors causing reduction in alpha 1 antitrypsin causing the enzyme to be too large
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16
Q

Clinical profile of COPD patients (9)

A
  1. Progressive dyspnea
  2. Chronic cough - mucous secretions
  3. SOB
  4. Expiratory airflow obstruction increases in severity
  5. Decreased breath sounds
  6. Expiratory wheezes
  7. Increased A-P diameter
  8. Hyperinflation in chest x-ray
  9. Use of accessory muscles
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17
Q

PaCO2 characteristics of Emphysema

A

Normal to decreased

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18
Q

PaCO2 characteristics of Chronic Bronchitis

A

Increased

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19
Q

Mechanism of airway obstruction for Chronic Bronchitis

A

Decreased airway lumen due to mucus and inflammation

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20
Q

Mechanism of airway obstruction for Emphysema

A

Loss of elastic recoil

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21
Q

Hematocrit in Chronic Bronchitis patients

A

increased

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22
Q

Hematocrit in Emphysema patients

A

normal

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23
Q

Diffusing capacity in Chronic Bronchitis patients

A

normal

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24
Q

Diffusing capacity in Emphysema patients

A

decreased

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25
Q

Cor pulmonale severity in Chronic Bronchitis

A

Marked

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26
Q

Cor pulmonale severity in Emphysema

A

Mild

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27
Q

Prognosis of Chronic Bronchitis patients

A

Poor

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28
Q

Prognosis of Emphysema patients

A

Good

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29
Q

PaO2 characteristics in Chronic Bronchitis

A

Marked decrease (blue bloater)

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30
Q

PaO2 characteristics in Emphysema

A

Modest decrease (pink puffer)

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31
Q

Dyspnea in Chronic Bronchitis

A

Moderate

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32
Q

Dyspnea in Emphysema

A

Severe

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33
Q

FeV1 of Chronic Bronchitis and Emphysema patients?

A

Decreased

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34
Q

4 characteristics of the PFT of a COPD patient?

A
  1. Derease FEV1/FVC ratio
  2. Greater decrease in the forced expiratory flow between 25% and 75% of vital capacity
  3. Increased residual volume
  4. Normal to increased FRC and total lung capacity
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35
Q

Why do we see an increased residual volume with COPD patients?

A

Due to slowing of expiratory airflow and gas trapping being prematurely closed airways

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36
Q

What capacity is either normal or decreased in COPD patients?

A

Vital capacity

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37
Q

Treatment of COPD (5)

A
  1. Smoking cessation (primary)
  2. Oxygen supplementation
  3. Bronchodilators are the mainstay of drug therapy for COPD
  4. Anticholingergic drugs show greater effect than B2 agonists
  5. Inhaled corticosteroids
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38
Q

What is the goal of supplemental oxygen administration for COPD patients?

A

Achieve a PaO2 between 60-80mmHg

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39
Q

3 factors required for home oxygen supplementation for COPD patients

A
  1. PaO2 < 55mmHg
  2. Hct >55%
  3. Evidence of cor pulmonale
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40
Q

Effect of bronchodilators in COPD patients

A

Small increase in FEV1 but may alleviate symptoms by decreasing hyperinflation and dyspnea

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41
Q

What is more effective in asthma treatment, B2 agonists or anticholinergics?

A

B2 agonists

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42
Q

When would broad-spectrum antibiotics be helpful in COPD patients?

A

Acute episode of increased dyspnea associated with excessive or purulent sputum production

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43
Q

When should diuretic therapy be considered for COPD patients?

A

Those with cor pulmonale and right ventricular failure with peripheral edema

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44
Q

What are we looking for preoperatively when getting an ABG on a COPD patient?

A

baseline CO2 and HCO3

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45
Q

3 related risk factors for complications with COPD patients undergoing surgical procedures?

A
  1. Operative site near the diaphragm
  2. > 3 hour surgical time
  3. Muscle relaxants can disrupt normal respiratory muscles
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46
Q

Which drugs do we avoid using with COPD patients undergoing surgical procedures?

A

Those that release histamine

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47
Q

Why do we wait for adequate depth of anesthesia before direct laryngoscopy of COPD patients?

A

They have a hyperactive airway!

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48
Q

5 patient related risk factors of postoperative pulmonary complications

A
  1. Age > 60 years
  2. ASA class 2 and higher
  3. CHF
  4. Preexisting pulmonary disease (COPD)
  5. Smoker
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49
Q

4 procedure related risk factors of postoperative pulmonary complication

A
  1. Emergency surgery
  2. Abdominal or thoracic surgery, head and neck surgery, neurosurgery, vascular/aortic aneurysm surgery
  3. Prolonged duration of anesthesia > 2.5 hours
  4. General anesthesia
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50
Q

Test predictors of postoperative pulmonary complication

A

Albumin level of < 3.5g/dL

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51
Q

4 Postoperative procedures utilized to prevent postoperative pulmonary complications?

A
  1. Deep-breathing exercises
  2. Incentive spirometry
  3. Selective NG tube
  4. Postoperative pain control
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52
Q

What type of anesthesia best reduces the risk of postoperative pulmonary complications?

A

Regional

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53
Q

Which volatile is the best to use with COPD patients?

A

Sevo

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54
Q

Why do we caution using Des in COPD patients?

A

because it is irritable to airway

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55
Q

What do we consider using prior to tracheal manipulation in COPD patients? (4)

A

Inhaled anticholinergics are numero uno, beta-agonists, inhaled or IV steroids, IV lidocaine

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56
Q

6 Ventilator Management considerations for COPD patients

A
  1. Warm and humid fresh gas for long cases
  2. Tidal volume of 6-8 mL/kg
  3. Slow respiratory rates (6-10BPM) provide sufficient time for complete exhalation to occur to minimize air trapping
  4. Avoid hyperventilation
  5. Desflurane causes airway irritation
  6. Ensure complete reversal before extubation
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57
Q

4 considerations for the emergence phase of COPD patients

A
  1. Full reversal of neuromuscular blockers
  2. Rapid shallow breaths of low tidal volume
  3. Awake intubation
  4. Prevent patient from coughing
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58
Q

4 Preoperative risk-reduction strategies to prevent pulmonary complications

A
  1. Smoking cessation for at least 6 weeks
  2. Treat evidence of expiratory airflow obstruction
  3. Treat respiratory infection with antibiotics
  4. Initiate patient education regarding lung volume expansion maneuvers
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59
Q

3 intraoperative risk-reduction strategies to prevent pulmonary complications

A
  1. Use minimally invasive surgery techniques when possible
  2. Consider regional anesthesia
  3. Avoid surgical procedures likely to last longer than 3 hours
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60
Q

2 Postoperative risk-reduction strategies to prevent pulmonary complications

A
  1. Institue lung volume expansion maneuvers such as deep breathing and incentive spirometry or CPAP
  2. Maximize analgesia
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61
Q

What is restrictive lung disease characterized by?

A

reduced lung compliance and lung volumes

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62
Q

Intrinsic causes of restrictive lung disease?

A

inflammation or scarring of the lung parenchyma

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63
Q

Examples of pathology that leads to intrinsic causes of restrictive lung disease?

A

pulmonary fibrosis, aspiration pneumonia, pulmonary edema

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64
Q

Extrinsic causes of restrictive lung disease?

A

disorders of the pleura, diaphragm, or chest wall that limit lung expansion

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65
Q

Examples of pathology that leads to extrinsic causes of restrictive lung disease?

A

COPD

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66
Q

Pathophysiology of restrictive lung disease?

A

reduces compliance of the lung, pleura, diaphragm or chest wall

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67
Q

How does the pathophysiology behind restrictive lung disease effect the work of breathing?

A

Increases work of breathing, causing rapid but shallow breathing

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68
Q

What is the effect of hyperventilation in patients with restrictive lung disease?

A

Keeps the PaCO2 at normal levels until the restrictive disorder is very severe

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69
Q

When is gas exchange effected in restrictive lung disease?

A

When the disease is advanced

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70
Q

Describe scoliosis

A

Lateral curvature with rotation of the vertebral column

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71
Q

Describe kyphosis

A

anterior flexion of the vertebral column

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72
Q

What would severe deformities in kyphoscoliosis lead to?

A

Chronic alveolar hypoventilation, hypoxemia, pulmonary hypertension, and cor pulmonale

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73
Q

What would be considered severe deformity in kyphoscoliosis?

A

scoliotic angle > 100 degrees

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74
Q

When is respiratory failure most likely to occur in patients with kyphoscoliosis?

A

Those with a vital capacity of less than 45% of the predicted value and a scoliotic angle of more than 110 degrees

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75
Q

What are patients with severe kyphoscoliois at increased risk of developing?

A

Pneumonia and hypoventilation when exposed to central nervous system depressant drugs

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76
Q

What type of approach do we use when administering regional blocks in the kyphoscoliotic patients?

A

paramedian approach

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77
Q

What do we know about patients who have supplemental oxygen before they get to the OR?

A

They will de-sat quickly and require minimal preoperative sedation

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78
Q

By how much should you increase your FiO2 for every L oxygen from NC a patient is on?

A

3-4% increase in FiO2

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79
Q

Universal color of oxygen tank

A

green

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80
Q

Universal color of nitrous oxide tank?

A

blue

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81
Q

Universal color of air tank?

A

yellow

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82
Q

Service pressure psi of oxygen tank?

A

1,900 psi

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83
Q

Service pressure psi of nitrous oxide tank?

A

745 psi

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84
Q

Service pressure psi of air tank?

A

1,900 psi

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85
Q

What is the pressure in an oxygen cylinder directly proportional to?

A

the volume of oxygen in the cylinder

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86
Q

When do nitrous oxide tanks start to lose psi?

A

Nitrous oxide tanks will not lose psi until the tank is 75% consumed

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87
Q

What label do we read to figure out the pressure in a tank of gas?

A

the E cylinder, not the wall outlet

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88
Q

Describe Biot’s respiration, i.e. ataxic respirator (4)

A
  1. Periodic breathing because the presence of apnea
  2. Poor prognosis
  3. Neuron damage
  4. 2-4 equal breaths, apnea, 2-4 equal breaths
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89
Q

Describe cheyne-stokes respirator (4)

A
  1. Periodic breathing with gradual hyperpnea/hypopnea and apnea
  2. sleep/hypoxemia/drugs
  3. Hypoperfusion of the respiratory centers in the brain
  4. Gradual increase in tidal volume and the apnea
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90
Q

Describe kussmauls breathing (3)

A
  1. Metabolic acidosis
  2. Hyperpnea
  3. rapid, deep, labored breathing
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91
Q

Causes of kussmauls breathings?

A 
K = Ketones (DKA)
U = uremia
S = sepsis
S = salicylates
M = Methanol
A = Aldehydes
(U)
L = Lactic acid
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92
Q

4 things we would seen on inspection of patients with pulmonary issues?

A
  1. Hyperpnea: Increased rate and tidal volume
  2. Hyperventilation
  3. Cyanosis: deoxyhgb is 5gm/dL
  4. Clubbing of the fingers, especially in those with cardiovascular disease
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93
Q

Characteristic chest-xray of emphysema would show?

A

hyperinflation of the chest and increased anterior/posterior diameter

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94
Q

What does a normal lung transmit upon palpation?

A

Palpable vibratory sensation (fremitus) to the chest wall

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95
Q

Describe palpation of the lungs

A

Place the ulnar aspects of both hands firmly against either side of the chest while the patients says the words “Ninety-nine”

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96
Q

Describe fremitus when consolidation such as pneumonia is present?

A

Will be pronounced over the lung with pneumonia

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97
Q

Describe fremitus when a patient has a pleural effusion

A

fremitus over an effusion will be decreased

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98
Q

3 descriptors of the percussion procedure for the lungs

A
  1. Generates audible sounds and vibrations
  2. Determines whether underlying tissue is filled with air or fluid
  3. Starts at apex, progressively from top to bottom
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99
Q

What tone does normal percussion give?

A

resonance

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100
Q

What tone does a pneumothorax give when percussing the lungs?

A

hyper resonance

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101
Q

4 common errors auscultating the lungs

A
  1. listening through patients gown
  2. attempting to auscultate in a noisy room
  3. interpreting chest hair sounds as adventitious lung sounds
  4. auscultating only convenient areas
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102
Q

Location of vesicular breath sounds?

A

majority of lungs

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103
Q

location of broncho-vesicular breath sounds?

A

near the main stem bronchi

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104
Q

Location of bronchial breath sounds?

A

over the trachea

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105
Q

Expiratory pitch and intensity of vesicular breath sounds

A

Pitch: low
Intensity: soft

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106
Q

Expiratory pitch and intensity of broncho-vesicular breath sounds

A

Pitch: medium
Intensity: medium

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107
Q

Expiratory pitch and intensity of bronchial breath sounds

A

Pitch: high
Intensity: usually loud

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Perfectly
108
Q

Inspir:Exp duration of vesicular breath sounds

A

inspir. > expir.

109
Q

Inspir:Exp duration of broncho-vesicular breath sounds

A

inspir. = expir.

110
Q

Inspir:Exp duration of bronchial breath sounds

A

expir. > inspir.

111
Q

4 abnormal breath sounds

A
  1. rales (crackles)
  2. rhonchi
  3. wheezing
  4. Stridor - emergency with partial obstruction of airway
112
Q

Electrolyte abnormality seen with removal of parathyroid gland?

A

hypocalcemia

113
Q

Purpose of PFT?

A

determine and categorize the nature and severity of obstruction/restriction

114
Q

What is a major pitfall of PFTs?

A

testing is effort-dependent

115
Q

What are the predicted values of PFT based on?

A

age, gender, height, race

116
Q

How does height influence PFTs?

A

Tall person has larger lung volumes

117
Q

How does age influence PFTs?

A

Volumes decrease with age

118
Q

How does sex influence PFTs?

A

lung volumes smaller in females

119
Q

How does race influence PFTs?

A

Smaller volumes in asian, hispanics, and blacks by 12-15%

120
Q

What would be considered an abnormal PFT?

A

less than 80% of predicted values

121
Q

Describe fixed airway obstructions effect on PFTs

A

Large goiter causes obstruction in the upper airway leading to plateaus in both inspiratory and expiratory sections on the PFT

122
Q

Describe variable extrathoracic obstructions effect on PFTs

A

Only the inspiratory limb of the volume-flow loop plateaus

123
Q

What causes closure of the extrathoracic airway in inspiration?

A

generation of negative intrathoracic pressure

124
Q

3 common causes of variable extra thoracic obstructions?

A

vocal cord paralysis, vocal cord neoplasms, neoplasm in the neck

125
Q

Describe variable intrathoracic obstruction effect on PFTs

A

During exhalation, positive intrathoracic pressure narrows the airway and results in plateau of the expiratory limb of the flow-volume loop

126
Q

What will be preserved in patients with variable intrathoracic obstructions?

A

Forced vital capacity will be preserved, but marked reductions of FEV1

127
Q

2 common causes of variable intrathoracic obstructions

A

endobronchial tumors, tracheomalacia

128
Q

What is closing volume?

A

the volume remaining above RV where expiration below FRC closes some airways

129
Q

Describe FRC and closing capacity in relation to age

A

With age, both are increased but CC is more steeply increased

130
Q

What does normal airway closure depend on?

A

Age, younger patients do not close until lung volumes are near or at RV

131
Q

Preoperative evaluation of patients undergoing cardiothoracic surgery in focuses on what?

A

Focus on the extension and severity of disease

132
Q

Thoracic surgery is considered high risk as it is, but which patients are at an even higher risk of complications than normal? (4)

A
  1. advanced age
  2. poor general health status
  3. COPD
  4. One working lung
133
Q

What surgical procedure reduces the incidence of postoperative complications of thoracic surgery patients?

A

video assisted thoracotomy (VAT)

134
Q

What do we try to optimize the PFT to before thoracic surgery?

A

as close to 80% of predictive value as possible

135
Q

3 things to consider in a patient who is undergoing thoracic surgery and experiences dyspnea?

A
  1. how bad is it
  2. do they have severe exertional dyspnea?
  3. Consider post-op vent support
136
Q

4 things to consider in patients who have a cough before thoracic surgery

A
  1. Is is a recurrent, productive cough?
  2. Hemoptysis may indicate tumor in the main stem bronchus
  3. Get a sputum culture to determine need for ABX
  4. coughing increases airway irritability, need to blunt reflexes before intubation
137
Q

Cigarette smoking and the airway (4)

A
  1. Makes airway irritable
  2. Causes cough, mucous hyper secretion and airflow obstruction
  3. Passive and active smokers are affected
  4. Respiratory events such as re-intubation, laryngospasm, bronchospasm, aspiration, hypoventilation and hypoxemia can occur
138
Q

3 CV effects of nicotine?

A
  1. Stimulates the adrenal medulla to secrete adrenaline
  2. SNS stimulation causes increases in HR, BP and peripheral vascular resistance
  3. Myocardial contractility is increased, leading to an increase in oxygen demand and consumption
139
Q

2 pulmonary effets of nicotine?

A
  1. narrowing of small airways, causing an increase in coming volume
  2. hyper-irritable airways
140
Q

4 effects of GA on smokers?

A
  1. atelectasis
  2. reduces compliance
  3. decreased FRC
  4. impaired oxygen exchange
141
Q

Benefits of smoking cessation for 12-24 hours (4)

A
  1. Decreased carboxyhgb (normal < 1.5%, smokers 5-15%)
  2. Increased tissue oxygenation
  3. Decreased CV nicotine effects
  4. Increased secretions and more reactive airways
142
Q

Benefits of smoking cessation for 2 to 4 weeks?

A

decreased secretions and decreased airway reactivity

143
Q

Benefits of smoking cessation for 5 to 8 weeks?

A

decreased incidence of post-op complications; improves mucociliary clearance, airway irritability, closing volume

144
Q

What volatile anesthetic do we avoid in smokers?

A

Desflurane

145
Q

Relate smokers and requirement of analgesic agents

A

smokers require higher doses of analgesics

146
Q

What receptors effect the emetogenic effects in smokers

A

alpha 4, beta 2 and alpha 7 acetylcholine receptors

147
Q

Patients at higher risk of respiratory compromise can’t do what in an exercise tolerance test?

A

cannot walk or climb 3 flights of stairs

148
Q

Factors for acute lung injury?

A

alcohol abuse and pneumonectomy

149
Q

Intraop factors for ALI?

A

high ventilatory pressures and cautious fluid administration

150
Q

What pathology would you suspect if a chest x-ray showed hyperinflation and increased vascular markings?

A

emphysema

151
Q

What are good predictors of cardiac complications during surgery?

A

unstable angina, MI within 6 weeks, arrhythmias

152
Q

What CV pathology warrants postponement of surgery?

A

Acute MI within 7 days

153
Q

2 main things to look at on a proeoperative ABG?

A
  1. PO2

2. O2 saturation

154
Q

What is the significance of hypercapnia on preoperative ABG?

A

not indicative of postoperative complications

155
Q

What finding on an ABG is indicative of poor surgical outcomes?

A

O2 sat < 90% (hypoxemia)

156
Q

What is the most common double lumen ETT?

A

left double lumen

157
Q

Where do we place patient padding for intrathoracic surgeries?

A

below the head of the neck, shoulders, arms, legs and scrotum in males

158
Q

what patient position is used for thoracic surgery?

A

lateral decubitus position with the operative or nondependent side up

159
Q

General descriptor of asthma?

A

Chronic inflammatory disease (hyper-irritability) of the airways that is reversible

160
Q

Describe extrinsic asthma

A

Also termed allergic asthma, familial, increased levels of IgE in serum

161
Q

Describe intrinsic asthma

A

Also termed idiosyncratic asthma, which is related to PSNS abnormality

162
Q

Pathogenesis of asthma

A

Hyper-irritability of the tracheobronchial tree causing local inflammation

163
Q

What is asthma provoked by?

A

Exposure to irritating stimulus

164
Q

What mediators are released that cause the physiologic changes seen in asthma patients?

A

mast cells, eosinophils, macrophages, and other mediators

165
Q

What signs do we see with exacerbation of asthma? (4)

A
  1. Contraction of the smooth muscle
  2. Airway edema
  3. Increased capillary permeability
  4. Mucous secretions
166
Q

What is chromalyn sodium?

A

A mast cell stabilizer

167
Q

Inflammation of what type of muscle is seen in Asthma

A

inflammation of smooth muscle

168
Q

What receptors innervate the smooth muscle of the lungs?

A

Beta (bronchodilation) and muscarinic innervation (bronchoconstriction)

169
Q

What Immunoglobulin complex causes the inflammatory response in asthma patients?

A

IgE

170
Q

What beta agonist would we use in asthma patients?

A

Albuterol

171
Q

What anticholinergic would we use in asthma patients?

A

Ipatropium Bromide

172
Q

Risk factors associated with asthma? (7)

A
  1. Lower respiratory viral infections
  2. GERD
  3. Inhaled irritants
  4. Post nasal drip
  5. Secondhand smoke
  6. Environmental
  7. Samter’s Triad
173
Q

Lower respiratory viral infection associated as a risk factor for asthma?

A

Respiratory Syncytial Virus (RSV) infection provokes hyperactivity for up to 6 weeks or longer

174
Q

How do we lower the need for asthma medications in GERD patients?

A

Treatment of GERD with H2 receptor antagonists

175
Q

Inhaled irritants associated with risk factors for asthma? (4)

A
  1. Dust mites
  2. Animal dander
  3. Mold
  4. Dust
176
Q

What can the effect of inhaled irritant be primarily ablated to?

A

B2 adrenergic agonists immediately preoperatively

177
Q

Post-nasal drip is the reason for what what in asthmatic patients?

A

It is the reason why wheezing is worse in the morning

178
Q

What is Samter’s Triad?

A
  1. Sensitive to NSAIDS (ASA)
  2. Hx of nasal polyps
  3. Hx asthma
179
Q

What is the general thought about intubation and reactive airways?

A

If possible intubation should be avoided in patients with reactive airways as it is associated with an increase in pulmonary complications (utilize regional anesthesia as much as possible)

180
Q

Clinical features associated with asthma?

A
  1. Dyspnea and tachypnea may lead to difficulty speaking
  2. Chest tightness and tachycardia
  3. Wheezing
  4. Dyspnea
  5. Coughing
  6. Pulsus paradoxus
  7. Visible use of accessory muscles
181
Q

Describe pulsus paradoxus

A

A fall in SBP > 10mmHg during spontaneous inspiration when BP should stay the same or slightly increase

182
Q

What is pulsus paradoxus related to?

A

Hyperinflation of lungs causes decreased after load to Right and Left Ventricle, as well as, decreased preload to Left Ventricle

183
Q

What is hypoxia?

A

Decreased tissue supply of oxygen

184
Q

What is the universal finding during asthma attacks?

A

hypoxemia (PaO2 < 80 mmHg)

185
Q

What is normal PaO2?

A

80-100 mmHg

186
Q

What is a very common ABG finding after asthma attacks?

A

Hypocarbia and respiratory alkalosis

187
Q

What is a late sign during asthma attacks?

A

CO2 retention; Elevated PaCO2 suggests air trapping, respiratory fatigue and impending respiratory failure

188
Q

What is FEV1?

A

The volume of air that can forcefully exhaled in 1 second

189
Q

FEV1, FEV1/FVC ratio and FEF in asthma patients?

A

the 25-75% is reduced

190
Q

What is FVC?

A

The volume of air that can be exhaled with maximum effort after a deep inhalation

191
Q

Describe FVC in asthma?

A

It is normal but decreased during a severe attack

192
Q

RV in asthma?

A

markedly increased

193
Q

FRC in asthma?

A

increased as a result of air trapping

194
Q

Describe EKG and PVR in acute right heart failure

A

EKG: right ventricle strain with right axis deviation during severe attacks with some PVC
PVR: Increased due to workload of the right heart

195
Q

What occurs with the ventricle during asthmatic attacks?

A

Ventricular irritability

196
Q

Chest x-ray characteristic of asthma patients?

A

Hyperinflation

197
Q

What is the mainstay of asthma treatment?

A

Beta 2 agonist

198
Q

What is the mechanism of action of beta 2 agonists?

A

They cause an increase in cAMP resulting in smooth muscle relaxation and bronchiole dilation

199
Q

Where do beta 2 agonists have the greatest effect?

A

Greatest effect on medium and small airways

200
Q

Examples of SABAs?

A

albuterol (proventil, ventolin)

201
Q

Examples of LABAs?

A

salmeterol (serevent)

202
Q

Describe anticholinergics and asthma

A

Slower onset but longer duration of action that Beta 2 Adrenergic Agonists, they are slightly more effective on larger conducting airways

203
Q

Give an example of anticholinergics used in asthma

A

ipratropium bromide (atrovent) given by nebulizer or metered-dose inhaler

204
Q

Describe leukotrienes

A

Leukotrienes are 1,000 times more potent bronchial constrictors than histamine so for moderate to severe asthma, leukotriene antagonists have become a mainstay of treatment

205
Q

Example of a leukotriene antagonist

A

Montelukast (singulair)

206
Q

What is the drug of choice for Samter’s Triad

A

Montelukast

207
Q

What is the effect of inhaled corticosteroids in asthma?

A

Limit negative systemic effects while still providing potent anti-inflammatory effects on the airways

208
Q

What is the effect of routine use of inhaled corticosteroids in asthma?

A

Routine use reduces airway reactivity and inflammation which results in improved symptom control and lung function

209
Q

What are oral or parenteral steroids reserved for with asthma patients?

A

Acute exacerbations of asthma unresponsive to maximal bronchodilator therapy

210
Q

Examples of corticosteroids used for asthma?

A

Prednisone (prelone) and beclomethasone (vanceril)

211
Q

When is cromolyn sodium used?

A

prophylactically, it is not useful in acute periods

212
Q

What is the action of cromolyn sodium?

A

Stabilizes mast cells to reduce IgE mediated release of histamine and leukotrienes

213
Q

Describe immunomodulators

A

Namely omalizumab, are anti-IgE antibodies reserved for severely allergic asthmatics with elevated IgE levels

214
Q

What is the issue with immunomodulators even though they may decrease steroid requirements in asthma patients?

A

They have been associated with anaphylaxis

215
Q

How often are immunomodulators given?

A

Administered SQ every 2 to 4 weeks

216
Q

6 steps in the drug treatment of asthma attacks

A
  1. SABA (causes tachycardia)
  2. 1 + ICS (low dose)
  3. 2+ LABA
  4. 3+ leukotriene inhibitors
  5. 4+ immunomodulator (IgE)
  6. 5+ oral corticosteroids
217
Q

What is the issue with low dose ICS?

A

they can cause osteoporosis, PNE, fungal infection of mouth

218
Q

Which patients do we not use immunomodulators in?

A

Cancer or lymphoma

219
Q

When do we perform PFTs preoperatively?

A

Only in high risk patients, want to look at the results before and after bronchodilator administration

220
Q

Preoperative considerations for asthma patients? (6)

A
  1. Presence of upper respiratory infection
  2. Infection increases airway responsiveness for 2 weeks or more
  3. Respiratory complications increased 11-fold for a child with URI and GETA
  4. High risk for laryngospasm and bronchospasm
  5. Stress dose steroids
  6. Prophylactic inhaler
221
Q

What do you do if your patient experiences a severe asthma attack before an elective surgery?

A

Delay until beta agonist and pulmonologist consult if they don’t work

222
Q

How do you induce patients who are experiencing severe asthma attacks before surgery?

A
  1. Block airway reflexes before DL and intubation
  2. Relax smooth muscle
  3. Prevent release of mediators
  4. LTA 4%/4mL of lidocaine
223
Q

What other two meds can be used to induce asthma patients?

A

Propofol and ketamine are bronchodilators

224
Q

What is the goal of RSI with asthma patients?

A

Prevent aspiration and asthmatic attack

225
Q

What are the symptoms of severe bronchospasm intraoperatively? (3)

A
  1. Increased airway pressure, peak pressures will increase
  2. Upsloping CO2 curves
  3. Desaturation
226
Q

What do the signs and symptoms of intra-op bronchospasm mimic?

A

Light anesthesia

227
Q

What is the dose of lidocaine prior to extubation to suppress airway reflexes?

A

1-1.5 mg/kg prior to extubation

228
Q

What can apnea or hypoventilation be attributed to after surgery in asthma patients?

A
  1. Respiratory depression caused by opioids and gases

2. Residual MR blockade

229
Q

What does ketorolac cause, making it less than ideal for asthma patients?

A

Increases airway resistance hence avoided in aspirin intolerant asthma

230
Q

4 categories of respiratory function

A
  1. Anesthetic depth and respiratory pattern
  2. Mechanism of hypoxemia
  3. Atelectasis
  4. Pneumoperitoneum
231
Q

Anesthetic depth and respiratory pattern: what does inadequate anesthesia (<1MAC) cause? (3)

A
  1. Hyperventilation
  2. Vocalization
  3. Breath-holding
232
Q

At 1MAC what happens to the respiratory rate?

A

RR is slower

233
Q

What happens to FRC when body position changes from upright to supine? When anesthesia has been induced? Muscle paralysis?

A

Supine: FRC is reduced by 0.5 to 1.0 L
Anesthesia: FRC decreases by 0.4 to 0.5 L
Muscle paralysis: further decrease in FRC

234
Q

What happens to end-expiratory lung volume?

A

reduced (close to or equal to RV)

235
Q

The average reduction corresponds to around ___% of awake FRC and may contribute to what two things?

A

20%

  1. Altered distribution of ventilation
  2. Impaired oxygenation of blood
236
Q

What are the 3 common mechanisms of hypoxemia?

A
  1. Equipment malfunction
  2. Hypoventilation
  3. Decrased FRC
237
Q

What two things are associated with equipment malfunction?

A

mechanical failure of anesthesia apparatus to deliver O2 to the patient and improper ETT position

238
Q

What 3 things could occurr regarding mechanical failure of anesthesia apparatus to deliver O2 to the patient?

A
  1. Disconnection from the O2 supply system (usually at the junction of the ETT and the elbow connector)
  2. An empty/depleted O2 cylinder
  3. Substitution of a nonoxygen cylinder at the O2 yoke because of absence/failure of the pin index
239
Q

What does PISS stand for?

A

Pin Index Safety System

240
Q

What is the purpose of the PISS system?

Pin placement for oxygen?

A

PISS prevents misconnections!

Each cylinder valve has a unique arrangement of pins that corresponds to its intended contents. Pin arrangement matches holes in the yoke which is where the cylinders attach to the gas machine

Pin placement for O2 is 2 and 5!

241
Q

What does DISS stand for?

A

Diameter Index Safety System

242
Q

What is the purpose of DISS?

A

Attaches anesthesia machine to wall outlet, prevents placing wrong gas from wall to machine

243
Q

What type of intubation results in almost no ventilation?

A

Esophageal intubation

244
Q

What position of the head causes the ETT to migrate deeper into the trachea? Cephalad migration of the ETT?

A

Caudad (deeper): flexion

Cephalad (outward): extension

245
Q

Is the right or left stem straighter, making it more likely to intubate?

A

RIGHT!

246
Q

What happens to Vt, airway resistance, lung compliance, and drive to breathe spontaneously with hypoventilation?

A
  • Reduced Vt
  • Airway resistance increased d/t reduced FRC, ET intubation, presence of external breathing apparatus and circuitry
  • Lung compliance is reduced as a result of FRC
  • Pts may have a decreased drive to breathe spontaneously during general anesthesia
247
Q

The effect of decreased FRC on hypoxemia is very significant clinically. What kind of patient is the reduction in FRC more pronounced in?

A

Obese patients

The reduction in FRC continues into the postop period

248
Q

What are 4 common causes of decreased FRC?

A
  1. Supine
  2. Induction of anesthesia
  3. Paralysis
  4. Surgical position
249
Q

From upright to the supine position, FRC decreases by how much? This is due to ___ (cm) cephalad displacement of the diaphragm by the abdominal viscera.

A
  • FRC decreases by 0.5 to 1.0 L

- 4 cm cephalad displacement of the diaphragm

250
Q

What occurs after induction of general anesthesia?

A

There is a loss of inspiratory tone

251
Q

The magnitude of these changes in FRC related to paralysis depend on what?

A

Body habitus - the pressure on the diaphragm caused by the weight of the abdominal contents during paralysis is high

252
Q

How does surgical position affect FRC? Trendelenburg position?

A

Supine position: the abdominal contents force the diaphragm cephalad and reduce FRC

T-burg: abdominal contents push the diaphragm further cephalad (diaphragm must not only ventilate the lungs but also lift the abdominal contents out of the thorax)

253
Q

Surgical position predisposes us to what two things?

A

decreased FRC & atelectasis

254
Q

The decrease in FRC related to Trendelenburg position is exacerbated in what patients?

A

Obese

255
Q

What are two additional factors that may decrease pulmonary compliance and FRC?

A

Increased pulmonary blood volume and the gravitational force on the mediastinal structures

256
Q

What body position will the dependent lung experience a moderate decrease in FRC and is predisposed to atelectasis whereas the independent lung may have increased FRC?

A

lateral decubitus position

257
Q

Atelectasis appears in approximately what % of all patients who are anesthetized?

A

90%!

It is seen during spontaneous breathing and after muscle paralysis and whether intravenous or inhaled anesthetics are used

258
Q

How do we prevent atelectasis during anesthesia?

A

5-10 cmH2O PEEP, indiscriminate use of PEEP in routine anesthesia

259
Q

What does increased intrathoracic pressure from PEEP cause? (2)

A

it impedes venous return and decreases cardiac output

260
Q

What happens after discontinuation of PEEP?

A

The lung recollapses rapidly (when you start waking the patient up, turn off PEEP to make sure pt can maintain oxygenation without the PEEP)

261
Q

What drug does not impair muscle tone and does not cause atelectasis? What happens if muscle relaxation is required?

A

Ketamine

If muscle relaxation is required, atelectasis will appear as with other anesthetics

262
Q

What are the two recruitment maneuvers?

A

Sigh maneuver and VC maneuver

263
Q

What is the sigh maneuver and why do we use it?

A

double Vt

advocated to reopen any collapsed lung tissue; airway pressure of 20 cmH2O

264
Q

What is the VC maneuver and why do we use it?

A

For complete reopening of all collapsed lung tissue

inflation pressure of 40 cmH2O is required for 7-8 seconds (then release bag and put pt back on vent)

265
Q

Why is ventilation of the lungs with pure oxygen not good? Ventilation during anesthesia should be done with what fraction of inspired oxygen?

A

Pure O2 resulted in rapid reappearance of atelectasis

FiO2 of 0.3 to 0.4 (should be increased only if arterial oxygenation is compromised)

266
Q

If 100% FiO2 causes atelectasis, then why do we preoxygenate/denitrogenate prior to induction?

A

we want to increase O2 reserve in FRC when pt is still awake so when they go to sleep and become apneic, we have some time before sat goes down - want to buy time! This is especially important in obese pts

267
Q

Pneumoperitoneum: what do we want IAP to be to be at?

A

<15 mmHg or else bad things will happen…

268
Q

Pneumoperitoneum causes what respiratory changes when IAP > 15 mmHg? (4)

A
  1. Low FRC and VC
  2. Formation of atelectasis
  3. Reduced respiratory compliance
  4. Increased peak airway pressure

Advanced Health Assessment TWU CRNA (4 decks)

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