Pulmonary Function Test Causes of stroke volume (FVC) reduction 1. Diseases of the thoracic cage such as _________ 1. ____________ injuries 1. Diseases that affect the nerve supply to the respiratory muscles such as __________ 1. Abnormalities of the pleural cavity such _______ 1. Diseases of the lungs such as ________ 1. ____________ lesions 1. Increased pulmonary blood volume such as ___________

1. scoliosis 2. Acute lung 3. muscular dystrophy 4. pneumothorax 5. fibrosis 6. Space occupying 7. left heart failure

Module 9: Anesthetic Management of Patients with Respiratory Disease Flashcards by Luisa Torres

Respiratory diseases

Patients with respiratory diseases are at increased risk of perioperative respiratory complications
Pulmonary complications occurs in up to ________% of patients and leads to increased morbidity and mortality and increased hospital length of stay
Postoperative pulmonary complications are very costly and can average increased healthcare costs of $52,466 per patient

25%

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Risk factors for pulmonary complications

Chronic obstructive pulmonary disease
Asthma
Interstitial lung disease
Pulmonary HTN
Heart failure
Functional status
Hypoalbuminemia
Smoking
Age
OSA
Obesity

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Risk factors for pulmonary complications

The site of surgery is an important risk factor for developing postoperative pulmonary complications

Pulmonary complications increase the closer the incision is to the _________.
Upper abdominal surgery (13-33%) vs. lower abdominal surgery (0-16%)

Surgeries lasting longer than _________ hours are associated with increased risk of pulmonary complications

diaphragm
3

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Risk factors for pulmonary complications

Surgical procedures that may also increase the risk of pulmonary complications

Preoperative Evaluation

Neurosurgery
Head and neck surgery
Trauma surgery
Cardiac surgery with CPB
Esophagectomy
Lung resection

History and Physical
Pulmonary Function Testing
Arterial Blood Gas (ABG) Analysis
Chest X-ray

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Pulmonary Function Tests

_____________:
* It’s the volume of gas exhaled in 1 second by forced expiration from full inspiration

____________.
* It’s the total volume of gas that can be exhaled after a full inspiration

Forced Expiratory Volume (FEV)
Vital Capacity

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Normal

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Obstructive

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Restrictive

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Pulmonary Function Test

The lungs and thorax can be regarded as a simple air pump

The output of the pump depends on the stroke volume, the resistance of the airways, and the force applied to the piston

The ____________is a measure of the stroke volume

forced vital capacity (FVC)

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Pulmonary Function Test

Causes of stroke volume (FVC) reduction

Diseases of the thoracic cage such as _________
____________ injuries
Diseases that affect the nerve supply to the respiratory muscles such as __________
Abnormalities of the pleural cavity such _______
Diseases of the lungs such as ________
____________ lesions
Increased pulmonary blood volume such as ___________

scoliosis
Acute lung
muscular dystrophy
pneumothorax
fibrosis
Space occupying
left heart failure

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Pulmonary Function Test

The forced expiratory volume (FEV) is affected by airway _________ during forced expiration

Any increase in resistance reduces the ventilatory capacity
* Bronchoconstriction such as with ___________
* Structural changes in the airway such as with ______________
* Obstruction of the airways
* Destructive process in the ____________

resistance

asthma
chronic bronchitis
lung parenchyma

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FEV1:

FVC:

Ratio FEV1 to FVC

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Pulmonary Function Test

Expiratory Flow-Volume Curve

Recorded from a __________
It records ________ and _______
It measures _________ and __________

maximal forced expiration
flow rate, volume
inspiration; expiration

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Blood Gases

Arterial PaO2
* Partial pressure of oxygen in arterial blood
* Normal value ____-_____ mmHg

85-100

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Causes of Hypoxemia

Hypoventilation
* The volume of ________ going to the alveoli per unit time is reduced

Two cardinal features of hypoxemia:
* It ALWAYS causes a rise in _________
* It can be abolished by increasing the ______ by delivering oxygen to the patient

fresh gas

PaCO2
PaO2

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Causes of Hypoxemia

Causes of hypoventilation:
* Depression of the ______________
* Diseases of the _______________
* Abnormalities of the ___________
* ______________ disease (_________)

respiratory center (narcotics)
medulla (encephalitis, hemorrhage)
spinal cord (high dissection)
Anterior horn cell (poliomyelitis)

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Causes of Hypoxemia

Causes of hypoventilation
* Diseases of the nerves to the respiratory center ________
* Diseases of the ___________ (myasthenia gravis)
* Diseases of the respiratory muscles ___________
* Thoracic cage abnormalities (crushed chest)
* Upper airway obstruction (_________)

(Guillain-Barre syndrome)
myoneural junction
(muscular dystrophy)
tracheal compression by neoplasm)

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Causes of Hypoxemia

__________ Impairment
Equilibration does not occur between the PaO2 in the pulmonary capillary blood and the alveolar gas

In a disease state, if the blood-gas barrier is thickened and diffusion is slowed, the equilibration may be incomplete

Fick’s Law of Diffusion correlates the diffusion capacity
- _________ of the membrane (e.g. fibrosis)
- _________ for diffusion (e.g. emphysema)

Diffusion

Thickness
Surface area

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Causes of Hypoxemia

Diseases that cause diffusion impairment

Sarcoidosis
Asbestosis
Lupus

Rheumatoid lung
Interstitial fibrosis
Scleroderma
Alveolar cell carcinoma

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Causes of Hypoxemia: Shunt

A shunt allows some blood to reach the arterial system without passing through _________ regions of the lung
If a patient with a shunt is given pure oxygen to breath, the arterial PO2 fails to __________ compared to normal patients

ventilated
rise

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Causes of Hypoxemia

Ventilation-Perfusion Inequality

Ventilation and blood flow are mismatched in various regions of the lung, it results in inefficient gas transfer

It occurs in most patients with ________, _________, and vascular disorders such as __________

COPD, interstitial lung disease, PE

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Arterial PaCO2
The normal PaCO2 is __-__ mmHg
Causes of increased arterial PaCO2:

37 - 43

Hypoventilation
Ventilation-perfusion inequality

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Arterial pH

Respiratory acidosis
* Caused by ________ retention
* Depresses pH
* Acute vs chronic respiratory acidosis

Respiratory alkalosis
Seen in ______________.

acute hyperventilation

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Metabolic acidosis
* Caused by a fall in ________
* Acidosis stimulates peripheral chemoreceptors to increase ventilation

Metabolic alkalosis
* Seen in disorders such as ____________
* Usually no ________ compensation

HCO3

severe vomiting
respiratory

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Obstructive Diseases ## Footnote Very common disease in the US, second only to heart disease as a cause of disability benefits from Social Security Administration It’s difficult to distinguish among the various types of obstructive disease One common theme is that they are characterized by _____________.

1. Airway Obstruction 1. Chronic Obstructive Pulmonary Disease * Emphysema * Chronic Bronchitis * COPD, Types A & B 3. Asthma 4. Localized Airway Obstruction * Tracheal obstruction ## Footnote Airway obstruction

# Airway Obstruction Increased airway resistance can be caused by conditions: Inside the _______ In the _______ of the airway In the _______

- lumen - wall - peribronchial region

# Chronic Obstructive Pulmonary Disease (COPD) 1. COPD is a common condition often related to _______ or _________. 1. It’s projected that by 2020, COPD will rank 5th among diseases world wide 1. COPD can lead to increased length of hospital stay and mortality 1. The care of these patients poses a challenge to the anesthesia provider 1. COPD is a term that is applied to patients with either _______, __________, or a combination of both

1. smoking or industrial toxins ## Footnote 5. emphysema, chronic bronchitis

COPD is characterized by the progressive development of airflow limitation that is not fully ___________: 1. Causes loss of _______, which normally maintains the airways open 1. There is decreased ________ of the of the bronchial that leads to collapse during exhalation 3. An increase in the _______ in narrowed bronchioles, lowers the pressure in the bronchiole that leads to airway collapse 4. Active bronchospasm and obstruction results from increased __________ * The patient has a destruction of __________, enlarged __________, and development of __________.

* reversible 1. elastic recoil 2. rigidity 3. air velocity 4. air velocity 5. lung parenchyma, air sacs, emphysema

# COPD Risk Factors

Cigarette smoking Respiratory infection Occupational exposure to dust Genetic factors such alpha1-antitrypsin deficiency

# COPD Signs and Symptoms * Varies with the severity of COPD * As expiratory airway obstruction worsens the patient will have ___________ and have a prolonged ____________ * Breath sounds are decreased with ____________

* tachypnea; expiratory phase * expiratory wheezing

# **Emphysema**: Characterized by enlargement of the air spaces distal to the _____________, with destruction of their walls Types

terminal bronchiole ## Footnote Centriacinar Panacinar

**Chronic Bronchitis** 1. Characterized by excessive ___________ in the bronchial tree, sufficient to cause excessive expectoration of sputum 1. Hallmark is _____________ in the large bronchi and ____________ in the small airways

1. mucus production 2. enlarged mucous glands; chronic inflammation

# COPD 1. A chronic productive cough, progressive exercise limitation, and ___________ airflow obstruction 1. Symptoms may be non-specific but a diagnoses is likely in a _________ Emphysema vs bronchitis ## Footnote 1. Pulmonary function test Decrease in ___________ Lung volumes are _________ 1. Chest X-ray Abnormalities may be minimal ____________ ________ may be present

1. Expiratory 2. Smoker ## Footnote 1. - FEV1/FVC ratio 2. - Increased (RV, FRC, and TLC) CXR: Hyperlucency Bullae

# Chronic Bronchitis/Emphysema

# COPD The treatment of COPD is aimed at relieving the symptoms and halting the progression of the disease * Smoking cessation * Oxygen supplementation is recommended if the PaO2 is less than _________ mmHg, the hematocrit is greater than ________%, or there is evidence of cor pulmonale with the goal to maintain the PaO2 between ____-____ mmHg ## Footnote Drug therapy * ___________ are the mainstay * Anticholinergic drugs * Inhaled corticosteroids * Broad-spectrum antibiotics * Annual flu and pneumococcal vaccination * Diuretic therapy _____________ reduction therapy

* 55, 55, 60-80 ## Footnote - Bronchodilators - Lung volume

# COPD Management of Anesthesia – Preoperative * Pulmonary Function Test * Clinical findings are more predictive of pulmonary complications than _______ results * Smoking history * Nutritional status Poor nutritional status with serum ________ <________mg/dL is powerful predictor of postoperative pulmonary complications

* spirometric * albumin, 3.5

# COPD Management of Anesthesia – Intraoperative ________ is suitable for surgeries that do not involve the peritoneum * Great choice if large amounts of sedatives and anxiolytics are not needed * Regional anesthesia that produces sensory anesthesia above _______ is not recommended ## Footnote General anesthesia * Inhaled agents are a good choice as they are eliminated rapidly and minimize residual ventilator depression post-op * Volatile agents cause ____________ (Sevoflurane) * Avoid _________ as it causes airway irritation and increased airway resistance * Emergence may be prolonged with inhaled agents due to ___________ of the inhaled agents * Limit the use of ______________ * Be careful with opioids as they can lead to prolonged ventilator depression * Make sure you humidify the inspired gases

Regional, T6 ## Footnote - bronchodilation - Desflurane - air trapping - nitrous oxide

# COPD Mechanical ventilation * ________ tidal volumes and ________ rates * Tidal volumes of __-___ mL/kg * Respiratory rates of : Ventilator settings should allow sufficient _______ time to avoid air trapping ## Footnote Air trapping can be detected by the following methods * The ETCO2 waveform does not ________ and its still upsloping at the time of the next breath * When the _________ on the ventilator does not reach baseline or zero * Direct measure of _________ (done by advanced ventilators) * When you disconnect the ventilator and notice that the ________ increases from the release of PEEP Avoid barotrauma by preventing high positive airway pressures

* larger, smaller * 6 - 8 * 6 - 8 Expiratory ## Footnote - plateau - expiratory flow - PEEP - BP

# COPD Management of Anesthesia – Postoperative Prophylaxis against postop pulmonary complications is important especially maintaining the ________ * Lung expansion maneuvers * Incentive spirometry * Deep breathing exercises * Chest physiotherapy * Positive pressure breathing techniques * Early ambulation

FRC

In patients with severe COPD, postop mechanical ventilation may be necessary: * Patients with a FEV1/FVC ratio of less than _______with a preoperative PaCO2 greater than ______ mmHg may need postoperative mechanical ventilation * Remember if the patients “lives” with a high PaCO2, do not try to correct it back to normal

- 0.5, 50

# Asthma Disease characterized by increased _________ of the airways to various stimuli and manifested by inflammation and widespread narrowing of the airways that changes in severity, either spontaneously or as a result of treatment ## Footnote Signs and Symptoms * It’s an ________ disease * Most attacks are short lived * It can be life-threatening if not treated * Clinical manifestations include ______, productive or nonproductive cough, dyspnea, chest discomfort or tightness that leads to _________.

responsiveness ## Footnote - episodic - wheezing - air hunger

# Asthma Pathology * The smooth muscle of the airways contract during an attack, causing __________ * There is also hypertrophy of ___________, edema of the _________, and extensive infiltration by ________ and ________. * The __________ is increased in the airways and slow moving

* bronchoconstriction * mucous glands * bronchial wall * eosinophils and lymphocytes * mucous

# Asthma Pathogenesis * It’s a _____________, and genetic and environmental factors such as viruses, occupational exposure, and allergens contribute to its initiation and continuance * Epidemiologic studies indicate that asthma begins in ________ in a majority of cases * ________ factors has led to an increase in asthma over the last 20 years

* heterogeneous disease * childhood * Environmental

# Asthma Hypothesis * Children not exposed to typical childhood infectious agents have a greater incidence of developing an ________ or _________ * Obesity, poor physical fitness, and exposure to pollutants can predispose you to asthma The trigger to asthma _______ always be identified

- allergic diathesis or asthma - allergic diathesis or asthma

# Asthma Diagnosis utilizing spirometry * The typical asthmatic patient has an FEV1 that is less than __________% * Flow-volume loops show characteristic __________ scooping of the expiratory limb of the loop * Flow-volume loops in which the inhaled or exhaled portion of the loop is ____________ helps distinguish wheezing caused by airway obstruction from asthma or another cause

- 35 - downward - flat

# Asthma Diagnosis ABG * Mild asthma is accompanied by a normal ____ and ______ * _________ and ________ during an asthma attack usually results in in hypocarbia and respiratory alkalosis * __________ can occur with muscle fatigue Chest X-ray * __________ of the lungs

* PaO2 and PaCO2 * Tachypnea and hyperventilation * Hypercarbia ## Footnote Hyperinflation

# Asthma Treatment 1. Emphasis of treatment is preventing and controlling _______________ 1. Asthma treatment has 2 components * Controller treatments modify the airway so that acute airway narrowing occurs less frequently Inhaled and systemic ______, ________, and _____________. * Reliever or rescue treatments treat acute bronchospasm B-adrenergic agonists and anticholinergic drugs _________ is the B2-agonist most commonly used

1. bronchial inflammation 2. - - corticosteroids, theophylline, and antileukotrienes - Albuterol

# Asthma Bronchoactive drugs B-adrenergic agonist B1- receptors in the heart (increase HR and force of contraction) B2 – receptors relax smooth muscle in the bronchi, blood vessels, and uterus _____________ are used to treat asthma 1. _____,______,____ and _________ (intermediate duration) 1. _______ and _________(long-acting agents used in combination with a corticosteroid) Drugs are delivered by aerosol ## Footnote Inhaled corticosteroid * They inhibit the inflammatory/immune response, and they enhance ___________ expression or function * Patients who use __________ more than twice a week are placed on corticosteroids

- B2 selective adrenergic agonist 1. Metaproteranol, albuterol, terbulatine, and pirbuterol 2. Formoterol and salmeterol ## Footnote - B receptor - B2 agonist

# Asthma Bronchoactive drugs Other treatments __________________ * Theophylline and aminophylline * Mechanism of action is unknown but they have modest anti-inflammatory properties __________________ * Useful in reversible bronchoconstriction in patients with COPD __________ and ____________ Mast cell stabilizers Block airway inflammation

* Methyxanthines * Anticholinergics * Cromolym and Nedocromil

# Asthma Status asthmaticus _____________ that does not resolve despite treatment It is life-threatening Emergency treatment * ___________ by inhalation * ___________

Bronchospasm * B2 - agonist * Corticosteroids

# Asthma Management of Anesthesia – Preoperative Assess disease severity, the effectiveness of the current treatment, and the potential need for additional treatment before surgery Goal is to come with an anesthetic plan that prevents or blunts ____________ ## Footnote Pre-op evaluation Ask the patient about the severity and characteristics of the asthma Age of onset Triggering events Hospitalizations for asthma Allergies Cough Sputum characteristics Current medications Anesthetic history

expiratory airflow obstruction

# Asthma Management of Anesthesia – Preoperative * Listen to the patients breath sounds * Assess labs, blood ____________ often parallels the degree of airway inflammation and airway hyperactivity * PFT before and after bronchodilator treatment: A reduction of FEV1 or FVC of less than __________% as well as FEV1/FVC less than ________% of predictive values, is considered a risk factor for preoperative complications Assess if the patients needs any treatments prior to anesthesia Antibiotics Bronchodilator therapy Supplementation with stress-dose corticosteroids, if the patient is on chronic steroids **The patients should be free from prior to surgery**

* eosinophils count * 70; 65 * wheezing

# Asthma Management of Anesthesia – Intraoperative * During induction and maintenance, airway reflexes must be suppressed to avoid bronchoconstriction * Regional anesthesia should be considered in ______________ * General anesthesia should be accomplished with an intravenous induction * Propofol’s bronchodilating effects is unknown * Ketamine has bronchodilating effects but increases ____________ * Lidocaine 1-1.5mg/kg 1-3 minutes prior to intubation suppresses airway reflexes * Narcotics prevent increased airway resistance * The depth of anesthesia during maintenance should depress hyperactive airway reflexes * __________ is a bronchodilator * Consider an LMA as it is less irritating to the airway

* brittle asthmatic * airway secretions * Sevoflurane

Management of Anesthesia – Intraoperative Ventilation * A __________ inspiratory flow rate produces optimal distribution of ventilation and perfusion * Allow sufficient time for ________ to avoid air trapping * Humidify the airway in patients with exercise induced asthma * Liberal administration of fluids to keep the secretions in the airway less viscous Avoid muscle relaxants that cause histamine release Attempt to extubate the patient while airway reflexes are suppressed “________” If a deep extubation is not safe, make sure the airway reflexes are suppressed * Intravenous lidocaine * Pretreatment with inhaled bronchodilators - albuterol

* slow * exhalation * deep extubation

# Asthma Intraoperative Bronchospasm * Make sure you have ruled out other causes of bronchospasm * Mechanical obstruction of the breathing circuit, the airway, or the ETT * If the bronchospasm is caused by asthma * Deepen the anesthetic with a volatile agent, ketamine, propofol, lidocaine or a combination * Administer 100% O2 * Consider B2-agonist treatment (Albuterol) * In severe cases, administer intravenous or subcutaneous ________ (________) * Corticosteroid administration – ______________ 2-4 mg/kg * Consider ___________, if long term postoperative mechanical ventilation is needed

* epinephrine 10 mcg/kg * Hydrocortisone * aminophylline

# Tracheal Obstruction * Can be caused by a foreign body, _______ after a prolonged intubation, or compressing masses (I.e., an enlarged thyroid or a malignant mass) * _______ and ________ stridor is present * Abnormal inspiratory and expiratory flow volume curves * No response to _________ ## Footnote * Develops after a ____________ * The _____________ may progress to destruction of the cartilaginous rings and circumferential constricting scar formation * The use of ___________, ____________ ETT cuffs is preferred * The patient becomes symptomatic when the lumen of the adult trachea is less than _________ mm in diameter * The patient may have audible stridor * Flow-volume loops have: * The stenosis is relieved with tracheal dilation or tracheal resection of the stenotic trachea

* stenosis * Inspiratory and expiratory * bronchodilators ## Footnote * prolonged intubation * tracheal ischemia * high-volume; low pressure * 5 * flattened inspiratory and expiratory curves

# Restrictive diseases Restrictive diseases are those in which expansion of the lung is restricted by alterations in the _________, ________, ________, or __________. Restrictive diseases are characterized by a reduction in all _______, decreased ___________, and preservation of __________

* lung parenchyma, diseased pleura, the chest wall, or a neuromuscular disease * lung volumes, lung compliance, expiratory flow rates

# Restrictive Diseases Diffuse Interstitial Pulmonary Fibrosis * Principle feature is _________ of the alveolar wall * Infiltration with _____ - _______> a cellular exudate consisting of ________ and other mononuclear cells is seen within the alveoli > the alveolar architecture is destroyed and scarring occurs which cause multiple air-filled cystic spaces formed by ________ and _________ called “honeycomb lung” * Cause of the disease is _______

* thickening of the interstitium * lymphocytes and plasma cells * macrophages * dilated terminal and respiratory bronchioles ## Footnote unknown

# Restrictive Diseases Pulmonary Function Test 1. Spirometry reveals a restrictive pattern 1. The FVC is ______, but the gas is exhaled so quickly that even though the FEV1 is also _______, the FEV/FVC% may _______ normal value 1. All lung volumes are reduced, the ______,_____, and ______ 1. The fibrous tissue reduces the dispensability of the lung 1. The lung volumes are ______ and _________ are needed to distend the lungs 1. The airway resistance is _______

1. - 2. reduced, low, exceed 3. TLC, FRC, and RV 4. - 5. small, large pressures 6. normal or decreased

# Gas Exchange Restrictive diseases * The arterial PaO2 and PCO2 are typically ______ and the pH is _______ * __________ is mild at rest until the disease is advanced * In the advanced stages of the disease physiologic _______ and _______ are increased * These patients typically have ______ ________ breathing pattern

* reduced; normal * hypoxia * dead space and shunt * shallow rapid

# Other types of Restrictive diseases **Sarcoidosis** 1. Characterized by the presence of __________ _______ and can occur in other organs such as the lymph nodes, heart, lungs, skin, eyes, spleen, and lungs 2. Cause is unknown but one possibility is that an unknown antigen is recognized by _________ and it results in the activation of ___________ and the production of __________. 3. There are 4 stages in sarcoidosis - The restrictive pattern is seen in stages ______ and _____ ## Footnote 4. All lung volumes are ______ 5. Lung _______ is reduced 6. The __________ is reduced is low and often falls considerably with exercise

1. Granulomatous tissue 2. alveolar macrophages; T-lymphocytes, interleukin-2 3. 2 and 3 ## Footnote 1. small 2. compliance 3. resting PaO2

# Other types of Restrictive diseases **Hypersensitivity pneumonitis** 1. Also known as ____________ 2. It’s a hypersensitivity reaction affecting the _________ that occurs in response to inhaled organic dust such as _____,______, and ______/______ material. 3. Example “_______ lung” 4. The alveolar walls are thickened and infiltrated with _______, _________, and occasional _________ that together with collections of ________, which cause the formation of ________. ## Footnote Signs and symptoms * Dyspnea and cough __-___ hours after inhalation of the antigens * Chest x-ray shows: * _________ develops after multiple episodes

1. extrinsic allergic alveolitis 2. lung parenchyma ; fungi, spores, and animal or plant material 3. farmers 4. lymphocytes, plasma cells, eosinophils. histiocytes, small granulomas ## Footnote - 4-6 - pulmonary infiltrates - Pulmonary fibrosis

# Restrictive diseases Management of Anesthesia – Preoperative * Patients usually present with ______ and ________ cough * _________ may be present Chest X-ray * _______ or _______pattern * ABG will show hypoxemia with normocarbia * PFT will show a restrictive pattern * A vital capacity less than 15mL/kg indicates severe pulmonary function

* dyspnea; nonproductive * Cor pulmonale

# Restrictive disease Management of Anesthesia – Intraoperative These patient do not tolerate apneic periods * Small FRC and low oxygen stores ______, ______, and _______ ventilation all contribute to further decreases in FRC Uptake of inhaled agents is _________ in these patients because of the decrease in FRC Inhalation induction is quicker Keep peak airway pressures as low as possible to prevent barotrauma

- GA, supine position, and controlled - faster

# Restrictive disease Diseases of the Pleura Diseases of the Chest Wall Neuromuscular Disorders

Diseases of the Pleura Pneumothorax Tension pneumothorax Pleural effusion Diseases of the Chest Wall Scoliosis Ankylosing Spondylitis Neuromuscular Disorders Guillain-Barre syndrome Amyotrophic lateral Sclerosis Myasthenia gravis Muscular dystrophies

Diseases of the pleura **Pneumothorax** The pressure in the intrapleural space is subatmospheric as a result of the elastic recoil forces of the lung and chest wall When air enters the space, the lung ______ and the rib cage _________ ___________ pneumothorax usually occurs in young males due to high mechanical stress that occurs in the upper zone of the upright lung * Symptoms are: * Breath sounds are reduced on the _______ side and its diagnosed by chest x-ray

- collapses, springs out - Spontaneous - pain on one side accompanied by dyspnea - affected

**Tension pneumothorax** * When air enters the intrapleural space during inspiration but cannot escape during expiration * It causes a large pneumothorax in which pressure may _______ atmospheric pressure and it interferes with _________ in the thorax * It’s a medical emergency * It can cause respiratory distress, tachycardia and signs of mediastinal shift such tracheal deviation Treatment * Chest tube

- exceed; venous return

# Restrictive Diseases Scoliosis: Refers to lateral curvature of the spine and kyphosis to posterior curvature Can be caused by ________ or __________ ## Footnote Signs and symptoms Depends on the severity of the curvature;

bony tuberculosis or neuromuscular disease ## Footnote Dyspnea on exertion Rapid and shallow breathing Hypoxemia worsens with increased severity of curvature which leads to CO2 retention and cor pulmonale

# Restrictive Diseases PFTs will reveal a reduction in all lung volumes In advanced disease the patient has a reduced ventilator response to ________, respiratory muscles are ______, the vascular bed is restricted causing a rise in _____________.

CO2; inefficient; pulmonary artery pressures

# Restrictive diseases Diseases of the Chest Wall **Ankylosing Spondylitis** * The disease has an unknown etiology * There is a ________ onset of immobility of the __________ and fixation of the ________ * The movement of the chest wall is ___________. * There is a reduction in FVC and TLC, but the FEV1/FVC and the airway resistance are normal * Chest compliance is reduced

* gradual; vertebral joints; ribs * reduced

# Restrictive diseases Disorders of the Mediastinum - Mediastinal mass have various causes: Large mediastinal masses may be associated with: - airway obstruction, - loss of lung volumes, - pulmonary artery or cardiac compression, and - superior vena cava obstruction

-Lymphoma, thymoma, teratoma, and restrosternal goiter

# **Superior vena syndrome** Develops when the mass obstructs venous drainage in the ________. Leads to: - dilation of collateral veins in the thorax and neck, edema of the face, neck, and upper chest, edema of the conjunctiva, - increased ____________ to include headaches and altered mental status - _______ is common - Usually caused by a __________

* upper thorax * intracranial pressure * Dyspnea * cancerous mass *

Management of Anesthesia – Mediastinal Mass Preoperative evaluation should include a chest x-ray, measurement of a flow-volume loop, chest imaging studies, and clinical evaluation for evidence of _______. Must assess the size of the mass to predict whether airway difficulties will be expected A ____________ technique is the best anesthetic choice for a diagnostic tissue biopsy The patient may be asymptomatic when awake but may develop _________ under anesthesia in the supine position Symptomatic patients may need to be induced in the _____ position Topical anesthesia of the airway with/without sedation to facilitate ___________. An ________ induction with maintenance of spontaneous ventilation

* tracheobronchial compression * local anesthetic * airway obstruction * sitting; fiberoptic laryngoscopy * inhalation

# Restrictive diseases Neuromuscular disorders Neuromuscular disorders that interfere with the transfer of central nervous system input to the skeletal muscles necessary for inspiration and exhalation can result in restrictive disease All of the diseases below can lead to dyspnea and respiratory failure (4) The patient’s inability to take a _______ breath leads to reduced FVC, TLC, inspiratory capacity, and FEV1. These patients usually do not complain of dyspnea until the ________ is involved These diseases are usually monitored by FVC and blood gases ## Footnote Management of Anesthesia Avoid or limit drugs with prolonged respiratory depressant effects In patients with a pneumothorax, avoid N2O Regional anesthesia is a good choice for peripheral operations as long as the sensory block is below _____ Mechanical ventilation should facilitate optimal ventilation and oxygenation Since the lungs have poor compliance, higher __________ may be needed Postoperative mechanical ventilation should be considered in patients with advanced restrictive lung disease

Guillian Barre syndrome Amyotropic lateral sclerosis (ALS) Myesthenia gravis Muscular dystrophies - deep - diaphragm ## Footnote - T10 - inspiratory pressures

Pulmonary edema 1. An abnormal accumulation of fluid in the ____________ spaces and ________ of the lung 1. It’s a complication of a variety of _____ and ________ diseases and may be life-threatening 1. It’s due to leakage of intravascular fluid into the __________ of the lungs and into the _______ ## Footnote 1. It can be caused by:

1. extravascular, tissues 2. heart and lung 3. interstitium; alveoli ## Footnote - increased capillary pressure (hydrostatic or cardiogenic pulmonary edema) or - by increased capillary permeability

# ** Pulmonary edema It typically manifest as _____________on X-ray (see next slide). A _________ distribution (________ pattern) of the lung opacity is common; seen with increased _____________ The presence of ___________ on chest x-ray suggest increased permeability pulmonary edema

* bilateral symmetrical opacities * perihilar; butterfly; capillary pressure * air bronchograms

Various causes of pulmonary edema Aspiration ___________ problems Opioid overdose High-altitude pulmonary edema ____________ of collapsed lung Upper airway obstruction (negative-pressure)

- Neurogenic - Re-expansion

Pulmonary edema – Preoperative 1. Elective surgery should be delayed in patients with _______ pulmonary edema 1. Large __________ may need to be drained 1. Persistent hypoxemia may require mechanical and PEEP ## Footnote Pulmonary edema – Intraoperative These patients are critically ill The ICU management should continue into the operating room Have an intraoperative plan for ventilation To avoid barotrauma and hemodynamic compromise it is reasonable to ventilate with ________ tidal volumes (_______ mL/kg) with a compensatory ________ in ventilator rate (____-___ mL/kg) Attempt to maintain the PIP less than _____ cm H2O In patients with severe ARDS, a more sophisticated ventilator (i.e., HFOV or HFJV) may be needed

1. acute 2. pleural effusions ## Footnote 1. low, 6 2. increase; 14-16 3. 30

# Vascular diseases PE is a condition that is preventable and potentially life-threatening Most pulmonary emboli arise from detached portions of venous thrombi that have formed in the deep veins of the lower extremity, right side of the heart, and pelvic area Non-thrombotic emboli such air, fat, and amniotic fluid can also occur Factors that lead to venous thrombi formation: ## Footnote Pulmonary embolus Diagnosis is difficult; it can mimic other cardiopulmonary illnesses Clinical manifestations of PE are nonspecific The most consistent symptom of acute PE is __________. ________-________ are the most common signs of PE but are nonspecific Other symptoms Wheezing, fever, ________, pleural rub, a loud pulmonic component of the second heart sound, a ______ ventricular shift, and bulging neck veins

* Stasis of blood * Alterations in the blood coagulation system * Abnormalities of the vessel wall ## Footnote - acute dyspnea - Tachypnea and tachycardia - rales, right

ABG * Could be normal or demonstrate arterial _________ and __________ ## Footnote In the presence of PFO or ASD * Severe hypoxemia * ECG findings are ST-T wave changes and _________ axis deviation * Peaked ________ waves, _______, and ________ may be present if the PE causes acute cor pulmonale

* hypoxemia, hypocapnia ## Footnote - right - P, atrial fibrillation, and RBB

Pulmonary embolus Manifestations under general anesthesia may be nonspecific: (4) The ECG and CVP may indicate onset of pulmonary HTN and RV dysfunction ## Footnote Capnography will demonstrate a _________ in ETCO2 Lab test * A _____________ strongly suggest a thromboembolism is present * _______ levels may be elevated * **Pulmonary arteriography is the gold standard for the diagnosis of PE**

Unexplained arterial hypoxemia Hypotension Tachycardia Bronchospasm ## Footnote - decrease - positive D-dimer - Troponin

Pulmonary embolus Treatment Anticoagulation, thrombolytic therapy, inferior vena cava filter placement, and surgical embolectomy _________ remains the cornerstone of treatment of acute PE An intravenous bolus of _____ to _______ followed by an intravenous infusion should be administered if patient is considered to have a high likelihood of PE In patients with significant bleeding after anticoagulation or reoccurrence of PE will have a vena cava filter placed ## Footnote _________ caused by the PE will require treatment Inotropes such as dopamine or dobutamine Vasoconstrictor such as norepinephrine Pulmonary vasodilator to control pulmonary HTN Pulmonary artery embolectomy is reserved for patients who are unresponsive to medical therapy or who cannot receive thrombolytic therapy

* Heparin * 5,000 to 10,000U ## Footnote - Hypotension

Pulmonary embolus When life threatening PE occurs the goal is to support vital function The patient who comes to the operating room for the treatment of life-threatening PE * Patients is usually intubated and mechanically ventilated * Monitor cardiac filling pressures * Use right atrial pressures to guide fluid administration * Cardiac output may need to be supported with inotropic drugs - Dopamine, dobutamine, amrinone, milrinone ## Footnote Induction and maintenance: Avoid arterial hypoxemia, hypotension, or pulmonary HTN Maintain anesthesia with any drug that does not cause ___________ Avoid N2O as it may increase _______ Use a muscle relaxant that does not release __________

## Footnote - myocardial depression - PVR - histamine

# Respiratory failure Acute respiratory failure is the inability to provide adequate arterial oxygenation and/or elimination of CO2 Diagnosis * PaO2 is less than _______ mmHg despite oxygen supplementation in the absence of a right to left shunt * A PaCO2 higher than _______ mmHg in the absence of respiratory compensation for respiratory alkalosis * pH is ____________ It is often accompanied by a decrease in ____ and _________

* 60 * 50 * decreased ## Footnote - FRC and lung compliance

# Adult Respiratory Distress Syndrome It is caused by an inflammatory injury to the lung and is manifested clinically by acute hypoxemic respiratory failure Pathogenesis * Manifest as rapid onset of __________ accompanied by ____________ refractory to treatment * There is an influx of ___________ into the alveoli as a result of increased alveolar capillary membrane permeability * ______________ may be produced locally in the lungs * In some patients it progresses to ____________ with persistent arterial hypoxemia and decreased lung compliance

* respiratory failure; arterial hypoxemia * protein-rich edema fluid * Proinflammatory cytokines * fibrosing alveolitis

# ARDS Signs and Symptoms * Arterial hypoxemia resistant to treatment with ______ is the first sign * _________ can lead to right sided heart failure * Death from ARDS is usually caused by multiple organ failure or sepsis ## Footnote Diagnosis * Acute _________ hypoxemia * _____________ of chest x-ray * PCWP of less than ________ mmHg

* O2 * Pulmonary HTN ## Footnote * refractory * Diffuse infiltrates * 18

# ARDS Treatment * Treatment is directed at supporting oxygenation and ventilation Goals * Correcting hypoxemia * Removing excess carbon dioxide * Securing a patent airway * Find and treat the cause of ARDS for example an infection * Adequate nutrition * Prevent GI bleeding and thromboembolism * Inhaled b-agonist ## Footnote Treatment – Tracheal intubation and ______ Initial steps in treatment is to secure the airway Keep inspired oxygen concentration to maintain the PaO2 between 60-80 mmHg Avoid barotrauma by maintaining peak airway pressures below 35-40 cm H2O

## Footnote - PEEP

# ARDS Application of PEEP * Helps prevent alveolar collapse at end expiration and increases lung volumes, especially FRC * Improves ventilation/perfusion matching * Decreases the magnitude of right to left intrapulmonary shunting * PEEP is indicated when high concentrations of inspired oxygen (FIO2 > _____) are needed to maintain PaO2 * High levels of PEEP decrease cardiac output and cause barotrauma * PEEP is added in increments of 2.5-5 cm H2O until the PaO2 is at least ____ mmHg with an FiO2 of less than 0.5

- 0.5 - 60

# ARDS Treatment – Fluid and hemodynamic management The rational for restricting fluids in patients with ARDS is to decrease the risk of ____________ Maintain urine output at 0.5-1 mL/kg/hr Diuresis with furosemide may help with excessive fluid administration The goal of fluid therapy is to maintain the intravascular fluid volume at the lowest level consistent with adequate organ perfusion as assessed by metabolic acid-base balance and renal function ## Footnote Treatment Removal of airway secretions * Adequate hydration and humidification of inspired gases Infection * Antibiotic therapy based on sputum culture and sensitivity testing Nutritional support * Its important to prevent muscle weakness * Hyperalimentation

- pulmonary edema

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Module 9: Anesthetic Management of Patients with Respiratory Disease Flashcards

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