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PathoPhysiology Respiratory - CP > Obstructive Lung Disease > Flashcards

Obstructive Lung Disease Flashcards

1
Q 
Preoperative pulmonary testing is indicated for which of the following patients?
A. baseline NaHCO3 35 mEq/L
B. planned pneumonectomy
C. suspected pulmonary hypertension
D. hypoxemia on room air (PaO2 <60 mmHg)
E. all of the above
A

E. all of the above should have preoperative pulmonary testing.

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2
Q

What is obstructive lung disease?

A

pulmonary conditions characterized by airflow limitation (inside the lumen, bronchial wall, and peri-bronchial region) can be reversible (asthma) or irreversible (COPD)

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3
Q

What is OSA?

A

Obstructive Sleep Apnea
it is a mechanical obstruction of breathing that occurs during sleep when pharyngeal muscles relax that is more common in males and obese patients being the most precipitating factor

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4
Q

Obstructed airways lead to ___

A

chronic hypoxemia and hypercarbia

low FRC

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5
Q

Clinical features and hallmark signs of OSA

A

habitual snoring, fragmented sleep and daytime somnolence

present with comorbidities related to obesity and hypoxemia (systemic and pulmonary HTN, ischemic heart disease, CHF)

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6
Q

How is OSA diagnosed? and significance of AHI value

A

Polysomnography which records the number of abnormal respiratory events (apnea) per hour
AHI - hypo apnea index
>5 associated with sleep related symptoms
>15 moderate OSA
>30 severe OSA
Berlin or STOP BANG questionnaires

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7
Q

STOP BANG

A

Snore loudly, daytime Tiredness, Observed stop breathing, high blood Pressure, BMI > 35 kg/m2, Age >50, Neck circumference >40 cm, Gender - male

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8
Q

How would a flow volume loop look for a restrictive airway disease?

A

smaller volumes, same ratio, looks normal (just smaller)

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9
Q

How would a flow volume loop look for an obstructive airway disease?

A

“scooping” on exhalation, flow taking longer to get out, normal inspiration

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10
Q

Spirometry testing includes

A

Forced expiratory volume in 1 second (FEV1), Forced vital capacity (FVC), FEV1 to FVC ratio, FEV25-75%, MVV, DLCO

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11
Q

Normal FEV1 to FVC ratio

A

75-80%

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12
Q

Forced vital capacity (FVC)

A

volume of air forcefully exhaled after a deep inhalation

3.7 L in females, 4.8 L in males

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13
Q

Forced expiratory volume in 1 second (FEV1)

A

volume of air forcefully exhaled in one second (80-120% of predicted value)
obstructive disease usually <50% usually

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14
Q

FEV 25-75%

A

measurement of air flow at midpoint of a forced exhalation

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15
Q

Maximum voluntary ventilation (MVV)

A

max amount of air that can be inhaled and exhaled in 1 minute
males: 140-180, females: 80-120 L/min

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16
Q

Diffusing capacity (DLCO)

A

volume of carbon monoxide transferred across the alveoli into the blood per minute per unit of alveolar partial pressure
single breath of 0.3% CO and 10% helium held for 20 seconds
normal value 17-25 mL/min/mmHg

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17
Q

Acute upper respiratory infection

A

common cold

diagnosed based on S/S (nonproductive cough, sneezing, rhinorrhea)

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18
Q

bacterial URIs

A

more serious and include fever, purulent nasal discharge, productive cough, malaise, tachypneic, wheezing

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19
Q

Anesthetic considerations for acute URIs (pediatrics)

A

pediatric patients higher risk for complications (higher parasympathetic tone and more reactive airways), they are usually actively sick, have reactive airway disease, having their airway manipulated from ETT intubation and airway surgery

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20
Q

If surgery is cancelled when should surgery be rescheduled?

A

at least 6 weeks

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21
Q

Anesthetic management for acute URIs

A

hydration, reduce secretions, limit airway maniupulation, decision between LMA vs ETT

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22
Q

adverse respiratory events with acute URIs include

A

bronchospasm, laryngospasm, airway obstruction, postop croup, desaturation

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23
Q

Asthma

A

reversible airway obstruction characterized by bronchial hyperreactivity, bronchoconstriction, chronic inflammation of the lower airways

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24
Q

Pathophysiology of asthma

A

activation of the inflammatory pathway leads to infiltration of airway mucosa with eosinophils, neutrophils, mast cells, T and B cells and inflammatory mediators including histamine, prostaglandin and leukotrienes leading to airway edema and thickening of the basement membrane

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25
Q

Signs and Symptoms of asthma

A

episodic disease
wheezing, productive and nonproductive cough, dyspnea and chest discomfort, eosinophilia

status asthmaticus = persists despite treatment

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26
Q

Pulmonary function testing in asthma

A 
FEV1 <35% of normal
downward scooping of expiratory limb on loop
FRC increases
TLC remains normal
DLCO unchanged (not a diffusion disease)
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27
Q

ABGs in asthma

A

mild - normal ABG
can see hypocarbia and respiratory alkalosis but once accessory muscle use fatigues = acidosis
severe - PaO2 <60 mmHg, rise in PaCO2 (shunt conditions)

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28
Q

Chest X-Ray and EKG for asthmatics

A

cxray - may be normal in mild cases but will have hyperinflation and hilar congestion d/t mucus plugging and pulmonary HTN in severe cases

ekg - RV strain d/t increase pulmonary pressures = inferior changes (II, III, aVF) ST depression

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29
Q

Treatment for asthma

A

treat inflammation and bronchospasm
corticosteroids, long acting bronchodilators, leukotriene modifiers, anti-IgE monoclonal antibody, methylxanthines, mast cell stabilizers

get PFT after treatment to see how responsive they are!

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30
Q

Status Asthmaticus

A

EMERGENCY

administer B2 agonist, IV corticosteroids, supplemental oxygen, IV Mag, oral leukotriene inhibitor

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31
Q

if resistant to treatment for bronchospasm what are your next thoughts?

A

airway edema and secretions

32
Q

Anesthetic considerations for asthma

A

get thorough history and determine severity of disease
eosinophil counts (indication of inflammation)
PFT results (FVC <70% or FEV1/FVC ratio <65% = increased periop risk!)
use regional whenever possible/safest
use lidocaine!
use Sevoflurane
avoid histamine releasing drugs! (atracurium and succinylcholine)
deep extubation
hydrate
avoid anticholinesterase drugs

33
Q

What is one ventilator strategy for asthmatics?

A

increase PEEP and increase expiration (ratio 1:2-3)

34
Q

COPD

A

nonreversible loss of alveolar tissue and progressive airway obstruction

35
Q

risk factors of COPD

A

cigarette smoking, occupational exposure, pollution, recurrent respiratory infections, low birth weight, a1-antitrypsin deficiency

36
Q

Emphysema

A

characterized by enlargement of air spaces distal to the terminal bronchiole with destruction of walls, loss of alveoli and damage to capillaries, small airways are thin, tortuous and atrophied

37
Q

Centriacinar emphysema

A

more in apex of lungs

38
Q

panacinar emphysema

A

no regional preference, but usually more distally and deals with the a1-antitrypsin deficiency

39
Q

Chronic bronchitis

A

disease characterized by excessive sputum production

40
Q

hallmark findings of chronic bronchitis

A

hypertrophy of mucus glands of large bronchi, inflammatory changes in small airways, granulation of tissue, smooth muscle increases, peri bronchial fibrosis

41
Q

COPD PFTs

A

decrease in FEV1/FVC ratio (<70% and not reversible with bronchodilators)
decrease in FEV25-75%
increase in FRC, RV, and TLC
Severity is determined by GOLD spirometric criteria

42
Q

COPD treatment goals

A

relieve symptoms and slow progression
smoking cessation
oxygen administration (2 LPM NC) especially if PaO2 <55, Hct >55%, cor pulmonale

43
Q

COPD drug treatment

A

long acting B2 agonists
inhaled corticosteroids
long acting anticholinergic drugs

44
Q

Severe cases of COPD

A

may need to have lung volume reduction surgery
increases elastic recoil, decreases amount of hyperinflation, improved diaphragmatic and chest wall movement, decrease in abnormal V/Q

45
Q

anesthetic considerations for a lung volume reduction surgery

A

double lumen tube
avoid nitrous oxide
avoid excessive positive pressure ventilation

46
Q

Examples of who needs PFT

A

hypoxemia or need for home o2 with no known cause
NaHCO3 > 33 mEq/L
PaCO2 > 50 mmHg
Hx of respiratory failure d/t persistent problem
Severe SOB
Planned pneumonectomy
Difficulty assessing pulmonary status
Differential diagnosis needed
Need to determine response to bronchodilators
If they have pulmonary hypertension

47
Q

Risk of postoperative complications for COPD

A

> 60 y/o, ASA III or IV, current smoker, CV involvement (RV function), low albumin <3.5, active S/S (wheezing, low SpO2, edema, crackles)

48
Q

How long ideally should someone stop smoking before surgery?

A

at least 6 weeks

benefits are seen in as little as 4 hours

49
Q

Malnutrition increases risk of

A

pleural leaks after lung surgery

50
Q

What can be a complication with interscalene blocks in COPD patients?

A

causes ipsilateral phrenic nerve palsy which can be bad for COPD patients because it can put them into respiratory failure

51
Q

Why should nitrous oxide be avoided in COPD patients?

A

it attenuates HPV which will worsen the V/Q mismatch

52
Q

mechanical ventilation considerations for COPD patients

A 
humidification
avoid dynamic hyperinflation
Vt 6-8 mL/kg
PIP < 30 mmHg
FiO2 to maintain Spo2 >90% or their baseline
53
Q

What can result from positive pressure ventilation without sufficient expiration?

A

increased intrathoracic pressure (decreases venous return) and increased pulmonary artery pressure = right heart strain!

54
Q

How does air trapping present?

A

capnography shows sloped carbon dioxide concentration

expiratory flow does not reach baseline before next breath

55
Q

Treatment for bronchospasm

A

deepen anesthetic, deliver short acting bronchodilator, suction, IV steroids, epinephrine

56
Q

bronchiectasis

A

irreversible airway dilation and collapse resulting from inflammation d/t chronic infection
can have significant hemoptysis

57
Q

Distinguishing factors of bronchiectasis

A

Finger clubbing!, hemoptysis, history of chronic cough w/ purulent sputum, and pleuritic chest pain

58
Q

General anesthesia with ETT in bronchiectasis considerations

A

double lumen tube (to prevent cross contamination from one lung to the other)
frequent suctioning
avoid nasally intubating

59
Q

cystic fibrosis

A

autosomal recessive disorder from chromosome 7
prevents chloride transport and movement of salt and water in and out of cells = abnormally thick sputum production outside of epithelial cells

60
Q

primary cause of morbidity and mortality in cystic fibrosis is

A

chronic pulmonary infection

61
Q

diagnosis of cystic fibrosis

A

sweat chloride concentration >70 mEq/L
chronic purulent sputum production
malabsorption with response to pancreatic enzyme therapy, bronchoalveolar lavage high in neutrophils

62
Q

presence of normal sinuses is strong evidence that

A

Cystic fibrosis is NOT present

63
Q

treatment of cystic fibrosis

A

alleviate symptoms

clearance of secretions, correction of organ dysfunction, nutrition, prevent intestinal obstruction, gene therapy?

64
Q

anesthetic considerations for cystic fibrosis

A 
delay until optimized (controlling infection and removing secretions)
vitamin K
GA with volatile agents
avoid anticholinergic meds
awake extubation!
adequate pain control
65
Q

What may you need to do if you use volatile agents in cystic fibrosis?

A

SUCTION their airway after turning gas on

66
Q

primary ciliary dyskinesia

A

congenital impairment of ciliary activity in respiratory tract epithelial cells and sperm cells

67
Q

Kartagener’s syndrome triad of

A

chronic sinusitis
bronchiectasis
situs inversus (organs reversed)

68
Q

anesthetic considerations for primary ciliary dyskinesia

A

regional anesthesia preferred
reverse ECG leads if have organ reversal
do a left IJ cannulation for central line insertion
if pregnant place in right uterine displacement
avoid nasal pharyngeal airways (risk of sinusitis)

69
Q

bronchiolitis obliterans

A

disease of the small airways and alveoli in children from respiratory syncytial virus (RSV)

70
Q

adults can develop bronchiolitis obliterans from

A

viral pneumonia, collagen vascular disease (RA), inhalation of nitrogen dioxide (Silo filler’s disease), graft vs host disease post-transplant

71
Q

Bronchiolitis obliterans organizing pneumonia (BOOP) shares features of

A

interstitial lung disease and bronchiolitis obliterans

72
Q

tracheal stenosis

A

occurs following prolonged intubation or over inflation of ETT cuff = ischemia of tracheal mucosa = scarring

73
Q

symptomatic tracheal stenosis in adults

A

when tracheal diameter < 5 mm (dyspnea at rest, use of accessory muscles in all phases)

74
Q

what would a flow loop look like for tracheal stenosis?

A

flattened inspiratory and expiratory curves

“fixed obstruction”

75
Q

treatment for tracheal stenosis

A

tracheal dilation (temporary measure) with balloon or stent
laser scarred tissue
tracheal resection with anastomosis (best treatment)

76
Q

anesthetic considerations with tracheal stenosis

A 
translaryngeal intubation (below stenosis)
volatile anesthetics (ensures max inspired oxygen concentration)
helium (decreases density of gas mixture and improves flow through narrowing)

PathoPhysiology Respiratory - CP (4 decks)

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