Obstructive Lung Disease Flashcards by Leonardo Fajardo III

Obstructive respiratory diseases are divided into what four groups based on anesthetic management?

Acute upper respiratory tract infection (URI)
Asthma
Chronic obstructive pulmonary disease (COPD)
Miscellaneous respiratory disorders

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Acute upper respiratory tract infections are common in what population?

Surgical

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Infections nasopharyngitis accounts for what percent of URIs?

95%

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What are the 5 most common viral pathogens listed in the lecture related to URIs?

1.Rhinovirus
2.Coronavirus
3.Influenza
4.Parainfluenza
5.Respiratory Syncytial Virus (RSV)

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When we diagnose a URI what is it usually based on?

The patient’s clinical symptoms

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Why don’t we use viral cultures and lab tests when diagnosing URIs?

Lack Sensitivity
Time consuming
Expensive
honestly, impractical in a busy clincial setting

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Most studies on URI’s in anesthesia involve what patient population?

Pediatric patients

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What respiratory events will we see with our pediatric patients perioperatively?

*hypoxemia
*laryngospasm
*breath holding
*coughing

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If you cancel your surgery because of an acute URI, how long should you wait before rescheduling, and why?

6 weeks
- Airway hyperreactivity may persist for that duration

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When can we safely manage a patient with URI without having to postpone the surgery?

A patient who has had a URI for weeks and is STABLE OR IMPROVING

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Anesthetic management of patients with URI should include what 3 main things?

Adequate hydration
Reducing secretions
Limiting airway manipulation

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What can we use on the vocal cords in URI to reduce upper airway sensitivity?

Nebulized or topical Local Anesthetic

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What can we substitute during induction of patients with URI that could reduce the risk of laryngospasm?

We can use an LMA rather than an ETT

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When we consider induction and maintenance of URI patients, they are similar to what other Obstructive lung disease?

Asthma

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When would be the best time to extubate a patient with acute URI ?

DEEP extubation may allow for smoother emergence!

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Name a few adverse respiratory events in patients with URI’s:

“B-LAPD”
B-ronchospasm
L-aryngospasm
A-irway Obstruction
A-telectasis
P-ostintubation Croup
D-esaturation

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Intraoperative and postoperative hypoxemia in acute URI are common and treatable with what?

Supplemental O2

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What is the definition of Asthma?

CHRONIC inflammation of the mucosa of the LOWER airways

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The inflammatory casade in Asthma involves infiltration of the airway mucosa with what? and what could this result in?

-inflammatory mediators
-results in airway edema, especially in the BRONCHI

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What leads to thickening of the basement membrane and smooth muscle mass in Asthma?

Airway remodeling

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What are the three main inflammatory mediators implicated in asthma?

Histamine
Prostaglandin D2
Leukotrienes

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List the pharmacologic agents that are considered asthma provoking stimulators:

Aspirin
B antagonists
some NSAIDS
Sulfiting agents

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When is Exercise a more prominent asthmatic provoking stimulator?

Attacks typically follow exertion rather than occurring during it

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Endorphins and vagal meditation are what form of asthma-provoking stimulator?

Emotional stress

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What are two other asthma provoking stimulators that have not been mentioned?

1. Allergens 2. Infections : respiratory viruses

Asthma is an ________ disease with acute exacerbations and _________ periods.

episodic, asymptomatic

What are a few symptoms you would see with Asthma patients?

"CDE" C-oughing C-hest tightness D-yspnea E-XPIRATORY wheezing E-OSINOPHILIA

With Asthma how long do most attacks last?

Usually short-lived, lasting minutes to hours

What is status asthmaticus?

DANGEROUS!! life-threatening bronchospasm that persists despite treatment

How would we diagnose Asthma?

1. Patient's Symptoms!! 2. PFTs showing airflow obstruction that responds to treatment with BRONCHODILATORS

What does the classification of Asthma severity depend on?

-Patients symptoms -PFT's -and medication usage (how often are these patients needing rescue meds?)

What does Forced EXPIRATORY volume in 1 second measure?

FEV1 and FEF (Forced expiratory flow) measure the severity of EXPIRATORY obstruction

The typical symptomatic asthmatic has an FEV1 of what percent?

<35%

Flow-volume loops show a _______ scooping on the _______ limb.

Downward expiratory

During moderate/ severe attacks what happens to the FRC and TLC?

FRC--> Increases substantially TLC--> remains normal

Would the DLCO (diffusing lung capacity for Carbon Monoxide) PFT change with Asthma patients?

No, it is not changed

How long will abnormal PFTs persist after an asthma attack?

Several days

During an asthma attack, which symptoms are caused by neural reflexes of the lungs rather than by hypoxemia?

Tachypnea Hyperventilation

What are the two most common ABG findings of symptomatic asthma?

1. HYPOcarbia 2. Respiratory ALKALOSIS

As expiratory obstruction of Asthma increases, V/Q mismatching increases, resulting in low _______.

PaO2

The PaCO2 on ABG increases when the FEV1 is below what percent of predicted?

<25%

In asthmatic patients, fatigue of the respiratory skeletal muscles contributes to the development of what?

HYPERcarbia

What is the primary aim of asthma treatment?

To control Symptoms and reduce exacerbations

What is the first-line treatment for mild asthma?

A short-acting inhaled β2 agonist

When are short-acting inhaled β2 agonists recommended only?

Only if <2 exacerbations/month

After using a short-acting B2 agonist, daily _______ _________ improves symptoms, reduces exacerbations, and decreases the risk of hospitalization.

inhaled corticosteroids

What could be required daily if an asthma patient's symptoms remain uncontrolled?

Inhaled B2 agonist

What are three other medical treatments recommended in the lecture for Asthma patients?

1. Inhaled muscarinic antagonists 2. Leukotriene inhibitors 3. Mast cell stabilizers

What drug is reserved for severe asthma, uncontrolled with inhalational medications?

Systemic corticosteroids

What can the asthma patients take to decrease the use of long-term medications?

SQ immunotherapy

What is Bronchial thermoplasty?

The ONLY nonpharmacologic tx for refractory asthma

What diagnostic procedure is used to deliver radiofrequency ablation of airway smooth muscles to all lung fields except the right middle lobe?

Bronchoscopy

Why does the ablation of airway smooth muscle help the refractory asthmatic patient?

Reduction in airway muscle mass is thought to reduce bronchoconstriction

How many sessions is bronchial thermoplasty performed in, and what do you use alongside bronchoscopy?

3 sessions uses intense heat, which carries risk of airway fire

What is used to monitor a patients response to bronchial thermoplasty treatment?

Serial PFTs

When does the patient experience little to no symptoms if the FEV1 improves to what percent of normal?

FEV1 improves to 50% of normal

In ACUTE severe asthma _______ does not resolve despite usual treatment.

Bronchospasm

What is the emergency treatment for acute severe asthma attacks?

1. High-dose, short-acting B2 agonists 2. Systemic corticosteroids

How frequently can β2 agonists be administered during acute severe asthma attacks?

every 15-20 min for several doses

Why are IV corticosteroids administered early in acute severe asthma patients?

Onset takes several hours

What are the two most common IV corticosteroids used in Acute Severe Asthma?

1. Hydrocortisone 2. Methylprednisone

Supplemental O2 in Acute severe asthma is to maintain a SpO2 of what?

>90%

What are two other drugs that are used in severe cases of asthma?

1. Magnesium 2. Oral leukotriene inhibitors

Bronchospasm has been reported in what percent of asthmatics undergoing general anesthesia?

0.2-4.2%

The risk of bronchospasm is correlated with what two things?

-Type of surgery -How recent the last attack occurred

What are the two common surgeries mentioned in the lecture that contribute to a higher risk of bronchospasm?

Upper abdominal surgery Oncologic surgery

List the many general anesthesia mechanisms that can 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 on intubation - PNS activation - release of inflammatory mediators such as Substance P and neurokinins

What is the point of doing an asthma preoperative assessment?

finding out the disease severity, effectiveness of current tx, and the need for additional therapy before surgery

What other important factors would we note as anesthesia providers in the pre op assessment of asthma?

- What are the frequency of exacerbations? - Has there been a need for hospitalization/ intubation? - What has been their previous anesthesia tolerance?

Should you skip physical appearance in your preop assessment?

NO, assess physical appearance and use of ACCESSORY muscles.

What will you need to listen for while assessing your asthma patient preop?

Wheezing or crackles

_______ counts often mirror the degree of airway inflammation.

EOSINOPHIL

What will be indicated before and after bronchodilator therapy?

PFTs (especially FEV1)

A reduction in which PFT test result is a risk for perioperative respiratory complications in patients with asthma?

A reduction in FEV1 or FVC to <70% of predicted, and or FEV1:FVC ratio <65%

What can you do as the anesthesia provider preoperatively to improve reversible components of asthma?

"ABC" A-ntibiotics B-ronchodilators C-hest physioitherapy

What two classes of drugs should we continue until induction when you are caring for a patient with asthma?

Anti-inflammatories Bronchodilators

If the Asthma patient has been on systemic corticosteroids within the past 6 months, what drug would be indicated?

A stress dose hydrocortisone or methylprednisolone is indicated

Patients should have a Peak Expiratory Flow Rate (PEFR) greater than what percent of predicted before surgery?

>80% or their personal best value

What is COPD defined as?

It is a disease of chronic airflow obstruction

What are symptoms of COPD?

- Emphysema characterized by lung parenchymal destruction - chronic bronchitis - dyspnea - productive cough - sputum production

As far as breath sounds, what would you hear in COPD patients?

decreased BS Expiratory wheezes

Why is pulmonary elastic recoil lost in COPD patients?

bronchial-alveolar destruction

Worldwide, COPD has a prevalence of _______ percent and is the _____ leading cause of death.

10% 3rd

Recall the long list of Risks of COPD:

Smoking Exposure to dust and chemicals Asbestos Gold mining Biomass fuel Genetic factors Age Female gender Poor lung development Low birth weight Recurrent childhood respiratory infections Low socioeconomic class ASTHMA

COPD can lead to what five things mentioned in the lecture?

1. Deterioration of elasticity of the lung 2. Decreased bronchiolar wall structure 3. Increased velocity through the narrowed bronchioli 4. Increased pulmonary secretions 5. Parenchymal destruction, enlarged air sacs, and emphysema

What is the role of the elastic recoil of the lung in its normal function?

Keeps the airway open normally

What is the normal function of the bronchiolar wall structure in the lungs?

It normally allows for collapse during exhalation

What do increased pulmonary secretions lead to in COPD?

Bronchospasm and obstruction

What does the increased velocity through the narrowed bronchioli lead to in COPD patients?

Lowers intrabronchial pressure, favoring collapse

Definitive diagnosis of COPD is made with what?

Spirometry

What do the PFTs show in our COPD patients?

Decrease in FEV1: FVC ratio and an even greater decrease in the FEF between 25-75% of vital capacity

What specific common findings would we see with our COPD patients on the PFT results?

- FEV1: FVC <70% - Increased FRC and TLC - Reduced DLCO (diffusing lung capacity for carbon monoxide)

Why do we see an increase in residual volume with our COPD patients?

it is due to slow expiratory airflow and gas trapping behind prematurely closed airways

The compensated increase in RV and FRC in COPD patients leads to what?

an ENLARGED airway diameter

With COPD patients you will see ________ work of breathing at ______ lung volumes.

greater higher

How is the VC different in normal v. obstructive patients?

It goes from normal to DECREASED

How is the TLC different in normal v. obstructive patients?

It goes from normal to INCREASED

How is the RV and FRC different in normal v. obstructive patients?

Both are INCREASED

How is the RV:TLC ratio different in normal v. obstructive patients?

It INCREASES

What is the only thing that decreases in COPD patients ?

Vital Capacity decreases