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Respiratory_class 1 > final review > Flashcards

final review Flashcards

1
Q

Where is the larynx located at birth? Adult?

A

Birth - C3-C4
Adult - Anterior C3-C6
(between pharynx and trachea)

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2
Q

What is normal A-O extension?

A

35 degrees

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3
Q

Name the Mallampati classes

A

Class. 1: full view of uvula and tonsillar pillars, soft palate

Class. 2: partial view of uvula or uvular base, partial view of tonsils, soft palate

Class. 3: soft palate only

Class. 4: hard palate only

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4
Q

Airway Innervation

Sphenopalatine ganglion

A

Middle division CN 5

nasal mucosa, superior pharnx, uvula, tonsils

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5
Q

Airway Innervation

Glossopharyngeal nerve

A

CN 9
(lingual back 1/3, pharyngeal, tonsillar nerves)
oral pharynx, supraglottic region

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6
Q

Airway Innervation

Internal branch Superior Laryngeal nerve

A

CN 10

mucus membrane above the VC’s, glottis

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7
Q

Airway Innervation

Recurrent Laryngeal nerve

A

CN 10

Trachea below vocal cords

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8
Q

The SLN splits into what two nerves?

A

Internal SLN

External SLN

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9
Q

Internal SLN provides ______ to supraglottic & ventricle compartment,

A

Sensation

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10
Q

What does stimulation of the internal SLN cause?

A

Laryngospasms

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11
Q

External SLN provides _____ innervation of cricothyroid muscle

A

Motor

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12
Q

Vagus Nerve is CN ___, the LEFT RLN passes at the ________, provides _______ information to the infraglottis, and provides _____ innervation to all larynx muscles except _______

A 
10
aortic arch
sensory
motor
cricothyroid muscle
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13
Q

Stimulation of the RLN causes

A

abduction of the VC

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14
Q

Damage to the RLN causes

A

VC adduction

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15
Q

How is a Childs larynx different than an adults?

A

A Childs larynx is cone shapes narrowing inferiorly

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16
Q

The trachea is a flexible cylindrical tube supported by 20-25 ______ cartilages

A

C-shaped

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17
Q

The carina (level T5-7) divides into 2 bronchi @ _____ from teeth

A

25cm

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18
Q

Bronchials have ____ smooth muscle

A

thick O

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19
Q

__________ transmits motor stimulation to diaphragm

A

Phrenic nerve (C 3,4,5)

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20
Q

Intercostal nerves (T 1-11) send signals to the ____________

A

external intercostal muscles

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21
Q

The act of inhaling is what type of ventilation?

A

negative pressure ventilation

lungs expand passively as pleural pressure falls

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22
Q

How does the diaphragm move with inspiration and expiration?

A

inspiration - diaphragm moves down

Expiration - diaphragm moves up

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23
Q

Explain Tidal Volume

A

volume of air inspired/expired during normal breathing (~500ml)

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24
Q

Explain Inspiratory Reserve Volume

A

Maximum volume of air inspired from resting end-inspiratory level

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25
Q

Explain Expiratory Reserve Volume

A

maximum air expired from resting end-expiratory

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26
Q

Explain Residual Volume

A

Volume of air remaining in the lungs after maximum expiration (~1200)

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27
Q

Explain Inspiratory Capacity

A

maximum volume of air inspired from end-expiratory

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28
Q

Explain Vital Capacity

A

Maximum volume of air expired from maximum inspiratory level

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29
Q

Explain Functional Residual Capacity

A

volume of air remaining in lungs at end-expiratory

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30
Q

Explain Total Lung Capacity

A

volume of air in lungs after maximal inspiration

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31
Q

Remember: A capacity is always a sum of certain lung volumes.
What is FRC?

A

FRC = ERV + RV

2.5L

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32
Q

REMEMBER: Spirometry cannot measure ___________ thus ____________ and ____________ cannot be determined using spirometry alone.

A

Residual Volume (RV)

Functional Residual Capacity (FRC) and Total Lung Capacity (TLC)

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33
Q

How can FRC and TLC be measured? (3)

A

1) Helium dilution
2) Nitrogen washout
3) body plethysmography

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34
Q

In flow volume loops, where is the inspiration and expiration?

A

inspiration bottom half

expiration top half

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35
Q

What are some functions are surfactant?

A

Lowers surface tension of alveoli & lung

Promotes stability of alveoli

Prevents transudation of fluid into alveoli

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36
Q

Pousilles law, Radius is to the 4th power.

  • **reducing r by 16% will _________
  • **reducing r by 50% will _________
A

double the R
increase R 16-fold

(major site of resistance is medium sized bronchi - 7th division)

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37
Q 
Pressures
RA
RV
PA
Pulm Capillaries
LA
LV
Aorta
A 
RA 3-5
RV 25/0
PA 25/8 (mean 14)
Pulm Capillaries 10.4
LA 8
LV 120
Aorta 120/80 (mean 90)
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38
Q

What are 2 mechanisms that decrease PVR?

A

recruitment - opening of previously closed vessels

Distention - increase caliber of vessels

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39
Q

What is capillary volume at rest? maximal volume?

A

rest - 70 ml (1 ml/kg body weight) normal volume at rest

maximal - 200 ml

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40
Q

normal alveolar PO2

normal alveolar PCO2

A

100

40

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41
Q

Inspired air PO2/PCO2

A

PO2 150/PCO2 0

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42
Q

Venous blood PO2/PCO2

A

PO2 40/PCO2 45

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43
Q

Pulmonary blood flow:

Explain zone 1

A

@ Apex

PA>Pa>PV (Alveolar pressure collapses both artery & vein)

ventilated but not blood flow = no gas exchange

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44
Q

Pulmonary blood flow:

Explain zone 2

A

Middle

Pa>PA>PV (intermittent opens with systole, closes with diastole)

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45
Q

Pulmonary blood flow:

Explain zone 3

A

Base

Pa>PV>PA

Most ideal (optimum gas exchange and blood flow)

You can convert entire lung to zone 3 with exercise

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46
Q

Using positive pressure ventilation increases zone

A

2

47
Q

V/Q mismatch improves as you move

A

down the lung

48
Q

PVR: vasoconstrictors

A

reduced PAO2
Increased PCO2
Histamine
Thromboxane A2

49
Q

PVR: vasodilation

A

Increased PAO2
Nitric Oxide
Prostacycline

50
Q

Explain hypoxic pulmonary ventilation

A

HPV is produced by alveolar hypoxia

Localized response of the pulmonary arterioles

Shift of flow to better ventilated pulmonary regions - balances V/Q ratio

opposite reaction than systemic circulation to hypoxia

51
Q

normal CO2 production at rest

A

200ml/min.

52
Q

Normal PO2 at rest

A

250 ml/min

53
Q

When is alveolar air expired?

A

at the end of exhalation

1st - dead space
2nd - mixed dead space and alveolar air
3rd - alveolar air

54
Q

What is Ficks Law?

What is normal Oxygen consumption

A

method of determining CO, blood flow throw lungs/min

VO2 @ rest = 300ml/min

55
Q

normal V/Q ratio

A

Ventilation 4L/min / Perfusion 5L/min

or 0.8

56
Q

What is a shunt

A

perfused but not ventilated

Blood is being shunted from pulmonary artery to pulmonary vein without participating in gas exchange in lungs

57
Q

In a physiologic shunt, V/Q is ____ normal

A

below

58
Q

In dead space, VQ is ______ than normal

A

greater

59
Q

Dead space =

A

ventilated but not perfused

When physiologic dead space is great much of work of breathing is wasted effort because ventilated air does not reach blood

60
Q

What is rough rule sats and PAO2

A

PaO2: 40,50,60 for Sat.: 70,80,90

61
Q

What is mixed venous blood in PA?

What is the HB P50 point

A

40

27

62
Q

explain HBG-O2 affinity when shifted to left and right

A

left - Hb has higher affinity for O2

Right shift - Hb has less affinity for O2

63
Q

Causes of a right shift

A 
Acidosis (High H) (Bohr effect)
High PaCO2
Fever (High temp)
High 2,3 DPG
High metabolism
Exercise

(H’s!!!)

64
Q

Causes of a left shift

A 
ALkolosis (low H)
Low PaCo2
Hypothermia (coLd)
Low 2,3 DPG
methnomoglobin

(L’s)

65
Q

O2 content in the blood is the sum of O2 carried on ____ and dissolved in _____

A

HGB

plasma

66
Q

What is the equation for O2 content?

A

CaO2 = (SO2 * [Hb] * 1.31) + (PO2 * 0.003)

67
Q

Most CO2 is transported as

A

bicarb (70%)

68
Q

The dorsal respiratory group (DRG) controls _____ & ______. The _____ & _____ deliver sensory information to the DRG. The DRG receives signals from 3 sources:

A

inspiratory and expiratory
Vagal (X) & Glossopharyngeal (IX)

Peripheral chemoreceptors
Baroreceptors
Lung receptors

69
Q

The Chemo-sensitive area of the brainstem located on the ________. It responds to changes in

A

ventral medulla surface

PCO2 or H ion concentration

70
Q

CO2 is highly permeable to the BBB so blood and brain concentrations are

A

equal

71
Q

Release of H ions in the brain stimulates

A

respiratory center activity

72
Q

Pco2 changes rapidly cause change in rate of pulmonary ventilation. Drastic increase in _____ caused by increase in Pco2

A

ventilation

73
Q

Peripheral chemoreceptors are located in _____ & _____

A

carotid and aortic bodies

74
Q

In peripheral chemoreceptors, ______ nerve fibers pass via _____ to act on DRG

A

afferent

CN IX

75
Q

In peripheral chemoreceptors, aortic bodies from _____ to DRG

A

CN X

76
Q

Peripheral chemoreceptors are stimulated by ______. Impulse rate is sensitive to drops in PaO2 from a range of ___ mmHg to ___ mmHg (hypoxia)

A

hypoxemia

60 to 30

77
Q

High Risk PFT results (4)

A

FEV1 < 2L
FEV1/FVC < 0.5
VC < 15cc/Kg in adult & < 10cc/Kg in child
VC < 40 to 50% than predicted

78
Q 
Intubation Criteria:
Mechanics - 3
Oxygenation - 2
Ventilation - 2
Clinical - 6
A

Mechanics: RR>35, VC <15cc/Kg in adult or <10cc/Kg in child, MIF more neg. than -20cmH2O

Oxygenation: PaO2 < 70mmHg on FiO2 of 40%, A-a gradient > 350mmHg on 100% O2

Ventilation: PaCO2 > 55 (except in chronic hypercarbia), Vd/Vt > 0.6 (remember normal dead space is 30%)

Clinical: airway burn, chemical burn, epiglottitis, mental status change, rapidly deteriorating pulmonary status, fatigue

79
Q

Extubation criteria

A

VSS, awake & alert, resp. rate < 30
ABG on FiO2 of 40%  PaO2 >70 and PaCO2 <55
MIF is more negative than -20cm H2O
Vital capacity (VC) > 15cc/Kg

80
Q

Normal ABG values

A 
pH:  7.35 – 7.45
PCO2:  35 – 45 mmHg
PO2:  75 – 105 mmHg
Bicarbonate:  20 – 26 mmoles/L
Base excess:  -3 to +3 mmoles/L
81
Q

*Rule: an increase of PCO2 by 10 mmHg causes a _____ in pH by ___, likewise, a decrease of PCO2 by 10 mmHg will _____ pH by ______

A

decrease 0.08

increase 0.08

(opposites)

82
Q

What is an A-a gradient, what is a rough rule for measurement

A

a measure of efficiency of lung

age/3

83
Q

What is the treatment for an large A-a gradient

A

Tx is supplemental O2, adjust ventilation, tx atelectasis, add PEEP, TREAT UNDERLYING CAUSE

84
Q

Rule: a decrease in bicarb by 10 mmoles _______ the pH by 0.15, likewise, an increase in bicarb. By 10 mmoles ______ pH by 0.15

A

decrease 0.15
increase 0.15

(same)

85
Q

What is Total body bicarb. deficit =

What do you replace?

A

(base deficit * wt in Kg * 0.4), in mEq/L, usually replace ½ of deficit

86
Q

T/F: Pulse Ox is mandatory intraoperative monitor

A

true

87
Q

What is infrared and red light in pulse ox

A

infrared - 940nm, oxyhemoglobin absorbs more of this light, corresponds to 100% sat

red - 660nm, deoxyhemoglobin absorbs more of this light, corresponds to 50% sats

88
Q

Carboxyhemoglobin (COHb) – from CO poisoning is viewed as oxyhemoglobin by pulse ox. and shows a SpO2 of ____, this is an overestimation of the true oxygenation, co-oximeter used to distinguish between the two

A

100%

89
Q

Causes of methemoglobin

A

nitrates, nitrites, sulfonamides, benzocaine (hurricane spray), nitroglycerine (NTG), nitroprusside (SNP)

90
Q

methemoglobin absorbs equally at both wavelengths, 1:1, shows a SpO2 of

A

85%

91
Q

How os methemoglobin treated

A

low dose methylene blue or ascorbic acid

92
Q

Does fetal HGB and bilirubin affect pulse ox?

A

no

93
Q 
Capnography:
AB
BC
CD
DE
What is D?
A 
AB - begin. exhalation (dead space gas)
BC - exhale dead space and alveolar gas
CD - alveolar plateau 
DE - inspiration
What is D? - highest CO2
94
Q

In the awake and lateral position, the dependent lung is

A

better perfused and ventilated

95
Q

What are some things that favors the upper lung?

A

Positive pressure ventilation
Muscle paralysis
Rigid bean bag
open PTX of upper lung

96
Q

Factors that inhibit HPV

A

hypocapnea,

Vasodilators: nitroglycerin (NTG), nitroprusside (SNP), b-adrenegic agonists (dobutamine), calcium channel blockers

inhalation agents

97
Q

Hypoxia during one lung ventilation

A
  • FIO2 of 0.8 to 1.0
  • Check tidal volumes – want 10cc/Kg, suction ETT
  • Fiberoptic scope to ensure proper ETT placement
  • Adjust RR to keep PaCO2 at 40mmHg
  • Add 5cm H2O CPAP to nondependent lung – warn surgeon
  • Add 5cm H2O PEEP to dependent lung – tx’s atelectasis but may increase vascular resistance
    Increase both CPAP and PEEP slowly
  • Ask surgeon to clamp or ligate nondependent PA
  • Return to two lung ventilation always an option
98
Q

What triggers MH?

A 
Inhalation agents (not N2O)
succs
99
Q

The ________ receptor (Ca release channel) fails in the sarcoplasmic reticulum leading to decreased ___ reuptake from within the cell (myocyte) causing a 500-fold increase in intracellular Ca, leading to sustained muscle contraction, glycolysis, and heat production.

A

ryanodyne

Ca

100
Q

Abnormal _________ coupling results in prolonged and irreversible muscle contracture.

A

excitation-contraction

101
Q

Most sensitive sign of MH

Most specific sign of MH

A 
Unexplained Tachycardia
Increasing EtCO2 (2-3X)
102
Q

Other intra-op signs of MH

A

decrease in SaO2 & SpO2,
rigidity despite muscle relaxant onboard, dysrhythmias,
tachypnea,
cyanosis,
sweating,
unstable BP,
mottling of skin,
trismus (masseter spasm) after succinylcholine,
darkening of blood in surgical field, decreased mixed venous saturation,
cola-colored urine,
heating and exhaustion of CO2 absorber, hyperthermia

103
Q

Labs for MH

A

initial metabolic acidosis then a combined metabolic & respiratory acidosis, hyperkalemia,
hypercalcemia,
hyperphosphatemia,
creatinine kinase (CK) > 1000 IU, myoglobinuria,
hypoxemia

104
Q

Factors that increase MAC

A 
Age:  term infant to 6 months of age has the highest MAC requirement****
Hyperthermia
Chronic EtOH abuse***
Hypernatremia
Drugs that increase CNS catecholamines
105
Q

Factors that decrease MAC

A 
Hypothermia: for every 1 deg. C drop in body temp – MAC decreases 2 to 5%
Preop medications
IV anesthetics, opioids
Neonate/Premature infants
Elderly
Pregnancy***
Acute EtOH ingestion
Lithium
Cardiopulmonary bypass (CPB)
Hyponatremia
Alpha 2 agonists
Calcium channel blockers
Severe hypoxemia – PaO2 < 38 mmHg
106
Q

Factors that have no effect on MAC

A 
Thyroid gland dysfunction
Duration of anesthesia
Gender
Hyper/hypokalemia
Hyper/hypocarbia
107
Q

What is the second gas effect

A

The ability of a large volume uptake of a first gas (N2O) to accelerate the rate of rise of the alveolar partial pressure of a concurrently administered companion gas (agent) thus speeding induction

108
Q

What is diffusion hypoxia

A

This results from the dilution of alveolar O2 concentration by a large amount of N2O “outgasing” or leaving the pulmonary capillary blood at the conclusion of N2O administration

Rapid desaturation can be seen, especially with a concurrently decreased FRC: pregnancy, obesity, children

109
Q

How do you avoid diffusion hypoxia?

A

Don’t extubate while on 70% N2O

Avoided by administering 100% O2 following N2O use

110
Q

Nicotine stimulates _____ ______ – catecholamines released from adrenal medulla – increasing HR, BP, and SVR – persists ___ minutes after last cigarette

A

sympathetic ganglia

30

111
Q

If pt is a smoker, Pre-O2 well and avoid instrumentation of airway until

A

deep level of anesthesia

112
Q

Advise stopping at least ___ hours prior to surgery

A

12

113
Q

Cessation of > __ weeks will reduce post-op pulmonary complications

A

8

114
Q

In COPD patients to avoid bronchospasm, what should you do?

A

avoid *histamine releasing drugs

Pentothal (STP), Morphine (MSO4), Atracurium, Mivacurium, Neostigmine

Tx with nebulized albuterol especially before extubation

Respiratory_class 1 (2 decks)

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