Obstructive Lung Disease Flashcards
1
Q
What is shown on a chest xray that would suggest emphysema?
A
- Hyperlucency in the lung periphery suggests emphysema
- Bullae confirms emphysemsa (only a small percentage of pts with emphysema have bullae)
*abnormalities may be minimal even with severe COPD
2
Q
_______________ accounts for 95% of URIs
A
Infectious nasopharyngitis
3
Q
What are the most common viral pathogens?
A
- Rhinovirus
- Coronavirus
- Influenza
- Parainfluenza
- Respiratory syncytial virus (RSV)
4
Q
How are upper respiratory infections diagnosed?
A
Based on clinical symptoms
5
Q
Do we normally do cultures and lab tests to diagnose URI?
A
- They are impractical in a clinical setting
- Lack sensitivity, time consuming, expensive
6
Q
Most studies on URIs and anesthesia involve which population?
A
Pediatrics
7
Q
What are kids with URIs at higher risk for perioperatively?
A
Respiratory events:
- Hypoxemia
- Laryngospasm
- Breath holding
- Coughing
8
Q
What is the best way to diagnose COPD?
A
CT is much more sensitive for diagnoses than CXR
9
Q
What is multiorgan loss of tissue?
A
- phenotype of COPD
- associated with airspace enlargement, alveolar destruction, loss of bone, muscle and fat tissues
- carries higher rates of lung cancer
10
Q
Should surgery be postponed if a patient has had an URI for weeks with improving symptoms?
A
No, can continue with procedure
11
Q
What is the bronchitic phenotype associated with?
A
Bronchiolar narrowing and wall thickening and is usually accompanied by metabolic syndrome and cardiac disease
12
Q
When can a procedure be rescheduled if it was cancelled d/t an acute URI?
A
After 6 weeks
airway hyperreactivity may persist for that duration
13
Q
What is an inherited disorder associated with COPD that requires lifelong replacement therapy?
A
a1-antitrypsin deficiency
14
Q
What are some anesthesia management considerations for pts with URIs?
A
- Adequate hydration
- Reduce secretions
- Limiting airway manipulation
15
Q
____ should be measured in patients with uncontrolled COPD
A
Eosinophils
16
Q
What can be used to reduce upper airway sensitivity for patients with URIs?
A
Nebulized or topical LA on vocal cords
17
Q
High eosinophils indicate the need for ____ ____
Low levels are associated with increased risk of ____
A
- Inhaled glucocorticoids
- Risk of pneumonia
18
Q
What type of airway may reduce risk of laryngospasm in patients with URI?
A
LMA
18
Q
ABGs are often ___ until COPD is severe
A
Normal
19
Q
_________ extubation may allow for smoother emergence for patients with URIs
A
Deep
20
Q
What are potential adverse events in pts with URIs?
A
- Bronchospasm
- Laryngospasm
- Airway obstruction
- Post-intubation croup
- Desaturation
- Atelectasis
21
Q
With COPD, PaO2 doesn’t usually decrease until the FEV1 is ___ of predicted
PaCO2 may not increase until the FEV1 is ____
A
<50%
Even lower
22
Q
What is the first step in slowing progression for COPD?
A
Reducing exposure to smoke and pollutants
23
Q
How is intraop/ postop hypoxemia treated?
A
Common to occur in pts with URI→ Tx with supplemental O2
24
Smoking cessation can decrease COPD progression and lower mortality by how much?
18%
25
What is the first treatment for COPD?
Begins with long-acting inhaled muscarinic-antagonists
*if dyspnea persists, long-acting B2 agonists can be added
26
Chronic inflammation of the mucosa of the lower airways:
Asthma
27
Where does edema occur with asthma?
Airway edema→ esp in bronchi
28
What treatment for COPD is effective in patients with associated asthma, rhinitis, elevated eosinophils, and history of exacerbations?
Inhaled glucocorticoids
29
What can airway remodeling from asthma cause?
Thickening of basement membrane and smooth muscle mass
30
What are the main inflammatory mediators involved with asthma?
- Histamine
- PGD2
- Leukotrienes
31
What are some triggers that provoke asthma?
32
Diuretics could be helpful in treating COPD if what has developed?
RHF or CHF
33
What is meant by saying asthma is an episodic disease?
Acute exacerbations and asymptomatic periods
34
What are S/S of asthma?
- Exp wheezing
- Coughing
- Dyspnea
- Chest tightness
- Eosinophilia
*Most attacks are short lived lasting mins to hours*
35
What other treatments may be necessary during COPD exacerbations?
- Abx
- Corticosteroids
- Theophylline
36
What is a dangerous life-threatening bronchospasm that persists despite treatment?
Status asthmaticus
37
How is asthma diagnosed?
- Based off symptoms
- PFTs showing airflow obstruction that responds to bronchodilators
*Diagnosis can be suspected even with normal PFT results since the disease is episodic*
38
What can increase exercise capacity in pts with COPD?
Pulmonary rehab programs
39
What is asthma classification severity based off of?
- Duration of symptoms
- PFTs
- Medication usage
40
What is normal FEV1/FVC ration in healthy adults?
75-80%
41
When is long-term O2 recommended to decrease the risk of death in COPD patients?
- When the PaO2 is <55 mmHg
- Hct is >55%
- Evidence of cor-pulmonale
42
What is normal FVC for females and males?
Females: 3.7L
Males: 4.8L
43
What is normal FEV1?
80-120%
44
What is maximum voluntary ventilation?
Maximum amount of air that can be inhaled and exhaled within 1 min
45
What is the goal of supplemental O2 with COPD?
To achieve a PaO2 >60mmHg
46
What is diffusion capacity test (DLCO)?
47
How is supplemental O2 more effective than drug therapy?
- Decreasing PVR
- Decreasing pulmonary HTN
- Preventing erythrocytosis
48
What test can measure the severity of expiration obstruction in pts with asthma?
- FEV1 and FEF
- Symptomatic asthmatics FEV1 <35%
49
How does flow volume loop look in a patient with asthma?
Downward scooping on expiratory limb
50
Treatment for COPD chart:
51
What lung volumes can increase during moderate/severe asthma attacks?
- FRC can increase
- TLC remains normal
- DLCO remains normal
52
Treatment for COPD exacerbation chart:
53
T/F: After asthma attack subsides PFTs go back to normal
False→ Abnormal PFTs may persist several days after an attack
54
Which graph is showing healthy patient?
A
55
55
When might lung volume reduction surgery be necessary for treatment of COPD?
In patients with severe refractory COPD and overdistended lung tissue
56
What is graph B showing?
Bronchospasm
- FEV1 <80%
- FEF25-75% decreases
- Peak flow decreased
- FVC decreased
57
How does lung volume reduction surgery work?
How is it performed?
Removal of the overdistended areas allow normal lung tissue to expand
Most commonly performed via a median sternotomy or a video-assisted thorascopic surgery (VATS)
58
What disease is "O" showing?
Obstructive disease
59
Anesthesia considerations for lung volume reduction surgery:
- DLT
- Avoid N2O
- minimize high airway pressures
60
What disease is R(P) showing?
Parenchymal restrictive disease
61
Why is CVP an unreliable guide for fluid management during lung volume reduction surgery?
Surgical alterations affect intrathoracic pressures
62
Smoking and COPD are often associated with what comorbidities?
- DM
- HTN
- PVD
- Ischemic heart disease
- Heart failure
- dysrhythmias
- lung cancer
63
What is R(E) showing?
Extraparenchymal restrictive disease
64
What would you expect ABG to look like in a patient having an acute asthma attack?
- Respiratory alkalosis
- Tachypnea and hyperventilation from neural reflexes of the lungs (NOT HYPOXEMIA)
65
What are the most common ABG findings of symptomatic asthma?
- Respiratory alkalosis
- Hypocarbia
66
What happens with gas exchange when expiratory obstruction increases?
- V/Q mismatching increases
- Low PaO2
- PaCO2 increases when FEV1 < 25%
67
What contributes to hypercarbia in patients with asthma?
Fatigue of respiratory skeletal muscles
68
What is the goal of asthma treatment?
Control symptoms and reduce exacerbations
69
What findings are more predictive of pulmonary complications than spirometric tests?
Smoking, wheezing, productive cough
70
How long should inhalation therapies be continued before surgery?
Continued until the morning of surgery
71
Indications for preop pulmonary evaluation (9):
1) hypoxemia on room air or a need for home 02 without a known cause
2) a bicarbonate >33 mEq/L or PC02 >50 mmHg w/o diagnosed pulmonary dz
3) a history of respiratory failure d/t an existing problem
4) severe SOB attributed to respiratory disease
5) planned pneumonectomy
6) difficulty assessing pulmonary function by clinical signs
7) the need to distinguish causes of respiratory compromise
8) the need to determine the response to bronchodilators
9) suspected pulmonary HTN
72
What is the first line treatment for mild asthma?
Short acting B2 agonist → only recommended if <2 exacerbations/ month
73
When in doubt, ____ can be sufficient to assess lung disease
Spirometry with FEV1
74
What can be used in after B2 agonist to improve asthma symptoms?
Daily inhaled corticosteroids improve symptoms, reduce exacerbations, and decrease risk of hospitalization
75
Major risk factors for development of postoperative pulmonary complications:
76
What treatments can be used if short acting B2 agonists and inhaled steroids don't control asthma symptoms?
- Daily inhaled B2 agonist
- Inhaled muscarinic antagonists
- Leukotriene inhibitors
- Mast cell stabilizers
77
Strategies to reduce post-op complications:
78
___ of smokers undergo GA annually
5-10%
79
When do we use systemic steroids to treat asthma?
Reserve systemic steroids for SEVERE asthma that is uncontrolled with inhalation meds
80
SQ _____________ decreases use of long term medication use in athmatics
Immunotherapy
81
What is the only nonpharmacologic treatment for refractory asthma?
Bronchial thermoplasty
82
What does the procedure of a bronchial thermoplasty involve?
- Bronchoscopy used to deliver radio-frequency ablation of airway smooth muscles to all lung fields except right middle lobe
- 3 sessions
- Intense heat used (risk of airway fire)
- Reduction of airway muscle mass is thought to reduce bronchconstriction
83
What test is used to monitor response to bronchial thermoplasty?
- Serial PFTs
- When FEV1 improved to 50% normal pt usually have little/no symptoms
84
When is the max benefit of smoking cessation seen?
Not seen until 8 weeks
85
What classifies acute severe asthma?
Bronchospasm that does not resolve despite usually Tx
86
What is emergency treatment for acute severe asthma?
- High dose short acting B2 agonists and systemic corticosteroids
- Inhaled B2 agonists can be administered every 15-30 min for several doses
- IV corticosteroids administered early because onset takes several hours
- Supplement O2 to maintain >90%
- Magnesium and oral leukotriene inhibitors
87
The adverse effects of carbon monoxide on O2-carrying capacity and of nicotine on the CV system are ____
short-lived
88
What are the most common IV corticosteroids given for acute severe asthma?
- Hydrocortisone
- Methylprednisone
89
Treatment of acute severe asthma:
90
____________ has been reported in 0.2-4.2% of asthmatic undergoing GA
Bronchospasm
91
What is the risk of bronchospasm in asthmatic pts correlated with?
- Type of surgery→ higher with upper abdominal and oncologic surgery
- How recent last attack occurred
92
What are general anesthesia mechanisms that increase airway resistance?
- Depression of cough reflex
- Impairment of mucociliary function
- Reduction of palatopharyngeal muscle tone
- Depressed diaphragmatic function
- Increased fluid in the airway wall
- Airway stimulation w/ intubation
- PNS activation
- Release of inflam mediators (substance P and neurokinins)
93
What should be addressed in the preop assessment in a patient with asthma?
- Disease severity
- Effectiveness of current treatment
- Need for additional therapy before surgery
- How frequent are exacerbations
- Recent hospitalizations/intubations
- Previous anesthesia tolerance
- Physical appearance/ accessory muscle use
- Auscultate for wheezing/crackles
- PFTs before/after bronchodilator may be indicated
94
What is the elimination half-life of carbon-monoxide?
4-6 hours
95
What happens to the PaO2 with 50% saturation 12 hours after smoking is stopped?
What happens to plasma levels of carboxyhemoglobin?
- PaO2 increases from 22.9-26.4 mmHg
- Carboxyhemoglobin decreases from 6.5-1%
96
What does smoking interfere with?
Normal immune function and the ability to respond to pulmonary infection following surgery
97
How long is required to have return of normal immune function after abstinence from smoking?
6 weeks
98
Some components of cigarette smoke stimulates ___ ____
Liver enzymes
99
How long does it take after smoking cessation for hepatic enzyme activity to return to normal?
6 weeks
100
What is the optimal timing of smoking cessation before surgery to reduce postop pulmonary complications?
6-8 weeks (max benefit @ 8 weeks)
101
What are some things that can help with smoking cessation?
- Nicotine replacements - patches, inhalers, nasal spray, lozenges, gum
- Sustained released Buproprion - typically started 1-2 weeks before smoking is stopped
102
What are the disadvantages in smoking cessation in the immediate preop period?
- increase in sputum
- anxiety
- irritability
- nicotine withdrawal
103
What is bronchiectasis?
Irreversible airway dilation, inflammation, chronic bacterial infection
104
Prevalence of bronchiectasis is highest in which patients?
>60 with chronic lung disease such as COPD, asthma, and women
105
_______ count can mirror the degree os airway inflammation from asthma
Eosinophil
106
Symptoms of bronchiectasis:
- Chronic productive cough with purulent sputum
- Hemoptysis
- Clubbing
107
What FEV1 and FVC values are associated with an increased risk for perioperative respiratory complications?
- Reduction in FEV1:FVC ratio <65% of predicted
- Reduction in FVC <70% of predicted
- Reduction of FEV1 <70% of predicted
108
What happens if you have poor mucociliary activity?
Recurrent bacterial infection causing further inflammation, bronchial dilation, airway collapse, airflow obstruction, and inability to clear secretions
109
What should the peak expiratory flow rate be in a person with asthma prior to surgery?
>80% of predicted or their best value
110
With bronchiectasis, once a bacterial superinfection is established, it is nearly impossible to eradicate and causes what?
Daily excessive sputum production persists
111
What can be given in preop to improve reversible components of asthma?
- Chest physiotherapy
- Abx
- Bronchodilators
112
List of characteristics of asthma to be evaluated in preop:
113
How is bronchiectasis diagnosed?
- baseline CXR and PFT should be obtained
- Sputum culture should be checked for any active infection
- CT is the gold standard for diagnosis
114
What does a CT show with bronchiectasis?
Dilated bronchi
115
What is the main treatment for bronchiectasis?
Antibiotics and chest physiotherapy
116
COPD is a disease of chronic airflow _________
Obstruction
117
What are other treatments for bronchiectasis?
- Flu vaccine
- Bronchodilators
- Corticosteroids
- O2 therapy
118
What are symptoms of COPD?
- Emphysema w/ lung parenchymal destruction
- Chronic bronchitis
- Dyspnea
- Productive cough
- Sputum production
119
What causes cystic fibrosis?
Caused by a mutation in the cystic fibrosis transmembrane conductance regulator gene
120
What is typical upon auscultation of a pts lungs with COPD?
- Decreased breath sounds
- Expiratory wheezes
121
What causes the loss of pulmonary elastic recoil in COPD?
Bronchio-alveolar destruction
122
How does the CFTR mutation lead to production of abnormally thick mucus?
CFTR produces a protein, which aids in salt and water movement in and out of cells
123
COPD has a prevalence of 10% world wide and is the _____ leading cause of death
3rd
124
What are risk factors for development of COPD?
- Smoking
- Exposure to dust/chemicals
- Asbestos
- Gold mining
- Biomass fuel
- Genetic factors
- Age
- Female
- Poor lung development
- Low birth weight
- Recurrent childhood resp infections
- Low SE class
- Asthma
125
What are 5 things discussed in lecture that COPD can lead to?
1) Deterioration of elasticity or recoil of the lung parenchyma, which normally keeps the airways open
2) Decreased bronchiolar wall structure, allowing collapse during exhalation
3) Increased velocity through the narrowed bronchioli, lowering intrabronchial pressure, favoring collapse
4) ↑pulmonary secretions, leading to bronchospasm and obstruction
5) Parenchymal destruction, enlarged air sacs, and emphysema
126
What are other symptoms of cystic fibrosis?
- Dehydrated viscous secretions
- luminal obstruction
- destruction and scarring of various glands and tissues
- can lead to severe organ damage
127
What is the definitive way to diagnose COPD?
Spirometry
128
What do PFTs show in a patient with COPD?
- Decreased FEV1:FVC ratio (<70%)
- Greater decrease in FEF by decreased VC
- Increased FRC and TLC
- Reduced DLCO
- Increased RV (slow expiratory flow)
129
What is the primary cause of morbidity and mortality in cystic fibrosis?
Chronic pulmonary infection
130
What causes enlarged airway diameter in COPD?
- Increase in RV and FRC
- Greater work of breathing at higher lung volumes
131
With cystic fibrosis, exocrine pancreatic insufficiency leads to what?
Malabsorption of fats and fat soluble vitamins
132
How is cystic fibrosis diagnosed?
- Sweat chloride concentration >60 mEq/L
- DNA analysis can identify CFTR mutation
- malabsorption with a response to pancreatic enzyme treatment is evidence of pancreatic exocrine insufficiency associated with CF
133
How does VC, TLC, RV, and FRC change with obstructive lung diseases?
VC= Normal to decreased
TLC= Normal to increased
RV= increased
FRC= increased
RV: TLC ratio= increased
134
How many stages of COPD are there and what is the criteria for each stage?
135
136
What can a bronchoalveolar lavage show in cystic fibrosis?
High percentage of neutrophils - a sign of airway inflammation
137
What else is present in virtually all CF patients?
COPD
138
Treatment for cystic fibrosis:
- Antibiotics
- Chest physiotherapy
- Bronchodilators
- Pancreatic enzyme replacement
- O2 therapy
139
What treatment for cystic fibrosis can increase sputum clearance?
Recombinant human deoxyribonuclease
140
What is primary ciliary dyskinesia?
Congenital impairment of ciliary activity in respiratory tract, epithelial cells and sperm tails and ciliated ovary ducts
141
Impaired ciliary activity can lead to what 4 things?
- chronic sinusitis
- recurrent respiratory infections
- bronchiectasis
- infertility
142
What is Kartagener syndrome a triad of?
- Chronic sinusitis
- Bronchiectasis
- Situs inversus (chest organ position is inversed
143
Approximately ___ patients with congenitally nonfunctioning cilia have situs inversus
1/2
144
Isolated dextrocardia is almost always associated with what?
Congenital heart disease
145
What is the main preop concern with primary ciliary dyskinesia?
Ensure active infection is treated, determine if organ inversion is present
146
What anesthesia is preferred with primary ciliary dyskinesia?
RA preferable to GA to decrease postop pulmonary complication
147
When would you choose left IJ for CVC placement over right?
If the pt has inversion of the great vessels
148
How would uterine displacement change if a patient has organ inversion?
Normally it's to the left to avoid vena cava syndrome, but with inversion displacement is to the right
149
How would intubation with a double lumen tube change with pulmonary inversion?
Typically L DLT is preferred because right mainstem is shorter and RUL more easily obstructed - pulmonary inversion may indicate R DLT placement
150
Why do you avoid nasal airways with primary ciliary dyskinesia?
High incidence of sinusitis
151
What is bronchiolitis obliterans?
Epithelial inflammation leading to bronchiolar destruction and narrowing
152
What are some risks for bronchiolitis obliterans?
- Viral lung infections
- Toxin exposures
- lung transplants
- stem cell transplant
153
What are symptoms of bronchiolitis obliterans?
Nonspecific, including dyspnea and nonproductive cough
154
What does PFTs show with bronchiolitis obliterans?
Obstructive disease, reduced FEV1 and FEV1:FVC ratio that is unresponsive to bronchodilators
155
What does CT show with bronchiolitis obliterans?
Air trapping and bronchiectasis in severe cases
156
What does central airway obstruction include?
Obstruction of airflow in the tracheal and mainstem bronchi
157
What percent of lung cancer patients can be affected by airflow obstruction?
20-30%
158
What can cause central airway obstruction?
- Tumors
- Granulations
- airway thinning
159
Tracheal stenosis can develop after ___ ____
prolonged intubation
160
Tracheal ischemia can progress to ___ ____
Scar formation
161
How can you minimize tracheal ischemia?
Using high-volume, low pressure cuffs on ETTs
162
When does tracheal stenosis becomes symptomatic?
When lumen decreased to <5mm
163
When are accessory muscles used with central airway obstruction?
throughout all phases of the breathing cycle
164
What do flow-volume loops show with central airway obstruction?
Flattened inspiratory and expiratory curves - shows fixed airway obstruction
165
What does a CT show with central airway obstruction?
Tracheal narrowing
166
What can be used to treat tracheal stenosis?
- Tracheal dilation
- tracheobronchial stent
167
How can tracheal dilation be done?
Can be done bronchoscopically using balloon dilators, surgical dilators or laser resection
168
What is the most successful treatment for tracheal stenosis?
Surgical resection and reconstruction
169
What is necessary for tracheal resection and reconstruction?
A translaryngeal intubation is necessary
170
How is a translaryngeal intubation done?
The distal trachea is opened, and ETT inserted and attached to the anesthetic circuit
171
What type of ventilation can be helpful for tracheal stenosis?
High-frequency ventilation
172
What can be added to the inspired gases to facilitate anesthesia with tracheal stenosis?
Helium - decreases the density of gas mixture and may improve flow through the area of tracheal narrowing
