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obstructive pulmonary dz Flashcards

1
Q

Obstructive Sleep Apnea is

A

Recurrent upper airway collapse duringsleepleading to reduced or complete cessation of airflow, despite ongoing breathing efforts

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2
Q

Polysomnography recording assesses

A

Apnea
Hypopnea
Respiratory effort–related arousals

all are a form of obstructive apea that can be dx on a PSG.

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3
Q

Most common type of sleep dysfunction

A

Obstructive Sleep Apnea

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4
Q

Apnea is ……

A

90% or more reduction in the amplitude of airflow signal as measured by an oral/nasal thermal sensor

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5
Q

Classifications of apnea

A

Obstructive apnea event- breathing effort during apnea
Central apnea event
Mixed apnea event

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6
Q

Obstructive apnea event

A

breathing effort during apnea

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7
Q

Central apnea event

A

no breathing effort happening

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8
Q

Mixed apnea event

A

apnea starts at central and ends as obstructive

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9
Q

Time of apnea to be dx

A

Duration of 10 seconds or more

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10
Q

Hypopnea recommended def

A

A drop of 30% or more in the amplitude of the nasal pressure sensor that lasts for 90% or more of the event

Associated with a 4% or more drop in Spo2

Airflow as measured by nasal pressure sensor and Spo2

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11
Q

Hypopnea Alternative definition

A

A drop of 50% or more in the amplitude of airflow as measured by nasal pressure sensor that lasts 90% or more of the event

Associated with either a 3% or more drop in Spo2or EEG arousal

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12
Q

EEG arousal

A

abrubt shift in EEG lasting more than 3 seconds preceded by 10 seconds of normal waves

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13
Q

Apnea-hypopnea index (AHI)

A

Number of apnea and hypopnea events per hour of sleep

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14
Q

Medicaid accepts what definition

A

Recommended definition

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15
Q

hypopnea time diagnosis

A

Duration of 10 seconds or more

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16
Q

Respiratory Effort–related Arousals

A

A limitation in the airflow followed by an arousal on the EEG channel

Flattening of the airflow in a way that does not meet the criteria for apnea or hypopnea

Increased respiratory effort

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17
Q

Apnea-hypopnea index (AHI) diagnosis of OSA

A

AHI of ≥ 15 per hour of sleep

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18
Q

AHI > 5 plus …….

A

AHI of ≥ 5 plus clinical signs and symptoms present or associated medical and psychiatric disorders correlates to OSA

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19
Q

S/s of OSA

A

Associated sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, or observed apnea

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20
Q

risk factors for OSA

A

HTN, CAD, MI, CHF, AF, CVA, DM, cognitive dysfunction, or mood disorder

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21
Q

Obstructive sleep apnea syndrome(OSAS) dx

A

AHI of ≥ 5
Daytime somnolence ≥ 2 days/week

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22
Q

Severity of OSA

A

Mild (AHI 5–15)
Moderate (AHI 15–30)
Severe (AHI ≥ 30)

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23
Q

Direct physiologic mechanisms for sleep apnea

A

Anatomic and functional upper airway obstruction
Decreased respiratory-related EEG arousal response
Instability of the ventilatory response to chemical stimuli

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24
Q

The way Apnea episodes are resolved …….

A

Increased muscular activity at the upper airway muscles= increased muscular tension

Increased muscular activity at the thoracoabdominal respiratory muscles

EEG arousal

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25
Q

Neurocognitive Consequences of OSA

A

Slowing of the EEG
Chronic sleep deprivation
Excessive daytime sleepiness (EDS)
Increased number of lapses on psychomotor vigilance task testing
Decrease in cognition and performance
Decreased quality of life
Mood disorders
Increased rates of motor vehicle collisions

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26
Q

MetabolicConsequences of OSA

A

Hypoxic injury
Systemic inflammation
Increased sympathetic activity
Alterations in hypothalamic-pituitary-adrenal function
Hormonal changes
Insulin resistance
Glucose intolerance
Dyslipidemia
DM 2
Central obesity
Metabolic syndrome

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27
Q

Most common sites of upper airway obstruction

A

Retropalatal and retroglossal regions of the oropharynx

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28
Q

Causes of Obstructions

A

Bony craniofacial abnormalities
Excess soft tissue
Acromegaly, thyroid enlargement, and hypothyroidism
tonsils

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29
Q

Functional collapse

A

Forces that can collapse the upper airway > the forces that dilate the upper airway

collapsing forces ….intraluminal negative inspiratory pressures, extraluminal positive pressure outside the lumen contribute to collapsing

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30
Q

Collapsing forces

A

Intraluminal negative inspiratory pressure and extraluminal positive pressure

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31
Q

Dilating forces

A

Pharyngeal dilating muscle tone and longitudinal traction on the upper airway by increased lung volume
Tracheal tug

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32
Q

Supine position enhances airway obstruction by….

A

Increases the effect of extraluminal positive pressure against the pharynx

gravity

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33
Q

More collapsible upper airwayr/t altered neuromuscular control
causes

A

Inflammatory infiltrates and denervation changes overtime that makes the upper airway collapse

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34
Q

Respiratory-Related Arousal Response stimulated by

A

Hypercapnia
Hypoxia
Upper airway obstruction
Work of breathing

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35
Q

most reliable stimulator of breathing

A

work of breathing = energy expended to inhale and exhale

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36
Q

Clinical Symptoms during the day

A

Dry mouth or headache upon waking, sleepiness, falling asleep during monotonous situations, subjective impairment of cognitive function

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37
Q

Clinical Symptoms during the night

A

Frequent awakening, awaking from own snoring w/ choking sensation, loud snoring, observed pauses in breathing during sleep, tachycardia, non-restorative sleep

38
Q

Goals of CPAP

A

Eliminate all respiratory events, hypopnea, snoring, apnea so AHI decreases to less than 5 an hour and keep oxygenation > 90%

39
Q

SX tx for OSA

A

Tonsillectomy – adults

Maxillomandibular advancement (MMA)- reconstruction of jaw

Uvulopalatopharyngoplasty (UPPP)- removal of extra tissue in the upper-airway

Adenotonsillectomy – children

40
Q

For every 1-point increase in the Mallampati score, the odds ratio for OSA is increased by…..

A

For every 1-point increase in the Mallampati score, the odds ratio for OSA is increased by 2.5

41
Q

STOP-Bang

A

questionnaire that assess risk of OSA

42
Q

Acute Upper Respiratory Tract Infection

A

Infectious (viral or bacterial) nasopharyngitis - 95%
Noninfectious nasopharyngitis – 5% (Allergic or vasomotor in origin)

43
Q

URISymptoms

A

Nonproductive cough, sneezing, and rhinorrhea
Bacterial infections
Fever, purulent nasal discharge, productive cough, and malaise

44
Q

URI Dx

A

Diagnosis - based on clinical signs and symptoms

45
Q

Current URI = Delay surgery

A

Delay surgery - 6 weeks

46
Q

URIAnesthetic Considerations

A

Adequate hydration, reducing secretions, and limiting airway manipulation
Nebulized or topical local anesthetic applied to the vocal cords

47
Q

Airway of choice with URI

A

LMA > ETT

48
Q

Adverse respiratory events with URI and anesthesia

A

Bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis

49
Q

Asthma

A

Reversibleairflow obstruction characterized by bronchial hyperreactivity, bronchoconstriction, and chronic airway inflammation

Hereditary

Family history, maternal smoking during pregnancy, viral infections, and limited childhood exposure to highly infectious environments

50
Q

Status asthmaticus

A

life-threatening bronchospasm that persists despite treatment

51
Q

Stimuli Provoking Asthma

A

allergens
pharm agents; asa, beta antagonist, NSAID, sulfiing agens
infections; respiratory viruses
exercise; attacks follow exertion rather than occurring during it
emotional stress; endorphins and vagal mediation

52
Q

Infiltration of the airway mucosa caused by

A

Eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes

53
Q

AsthmaPathogenesis

A

Specific chronic mucosal inflammation in lower airways
Activation of the inflammatory cascade
Infiltration of the airway mucosa
Bronchi… airway edema
Basement membrane… thickened
Airway walls… thickened and edematous
Inflammatory mediators
Simultaneous areas of inflammation and repair in the airways

54
Q

Inflammatory mediators

A

Histamine, prostaglandin D2and leukotrienes

55
Q

Asthma Signs and Symptoms

A

Wheezing, productive or nonproductive cough, dyspnea, chest discomfort or tightness (air hunger), and eosinophilia

Episodic disease… acute exacerbations interspersed w/ symptom-free periods

Short-lived attacks lasting minutes to hours

Previous intubation or ICU admission, ≥ 2 hospitalizations in the past year, and the presence of significant co-existing diseases

56
Q

AsthmaDiagnosis

A

Airflow obstruction on pulmonary function testing that is at least partially reversible with bronchodilators
Increase in airflow after bronchodilator inhalation

57
Q

Asthma PFT

A

FEV1< 35% of normal
FRC - may increase substantially
TLC - within normal range

58
Q

Asthma ABG

A

Hypocarbia and respiratory alkalosis - most common

Mild
Normal PaO2and PaCO2

Severe
PaO2<60 mm Hg on RA
PaCO2 increases when the FEV1< 25% of normal

59
Q

Ashtma CXR

A

Mild/moderate – normal
Severe - hyperinflation and hilar vascular congestion due to mucus plugging and pulmonary hypertension

congested pulmonary hilum

60
Q

Asthma ECG

A

RV strain or irritability, R axis deviation = moderate to severe changes

61
Q

Short-acting bronchodilators - β2-agonists

A

Albuterol (Proventil), levalbuterol (Xopenex)

62
Q

Inhaled corticosteroids

A

Budesonide (Pulmicort), fluticasone (Flovent)

63
Q

Long-acting bronchodilators

A

β2-agonists – arformoterol (Brovana)

64
Q

Combo inhaled corticosteroids + long-acting bronchodilators

A

Budesonide + formoterol (Symbicort)Fluticasone + salmeterol (Advair)

65
Q

Leukotriene modifiers

A

Montelukast (Singulair)

66
Q

Anti-IgE monoclonal antibody

A

Omalizumab

67
Q

Methylxanthines

A

Theophylline, aminophylline

68
Q

Mast cell stabilizer

A

Cromolyn

69
Q

mechanical ventilation parameters for asthma

A

shorter inspiration and longer expiration

avoid auto-peep/ air trapping by prolonging expiration

permissive hypercapnia if needed to avoid barotrauma

70
Q

Asthma preferred anesthetic / airway

A

Regional > GA
stay out of the airway

LMA > ETT

suppress airway reflex; Fentanyl, remifentanil

Induction – lidocaine, propofol, ketamine

71
Q

Chronic Obstructive Pulmonary Disease

A

Progressive loss of alveolar tissue and progressive airflow obstruction that isnot reversible

α1-Antitrypsin deficiency

72
Q

Emphysema characterized by

A

lung parenchymal destruction

73
Q

Chronic bronchitis is characterized by

A

cough and sputum production

74
Q

Risk factors for COPD

A

Smoking
Occupational exposure to dust and chemicals (coal mining, gold mining, and textile industry)
Indoor and outdoor pollution
Recurrent childhood respiratory infections
Low birth weight
Lung development during gestation and childhood
Lower socioeconomic class
Asthma
Age
Female sex

75
Q

COPD Signs and Symptoms

A

Dyspnea on exertion or at rest, chronic cough, and chronic sputum production

Exacerbations… acute worsening airflow obstruction
Tachypnea and prolonged expiratory time
Decreased breath sounds, expiratory wheezes

76
Q

COPD PFT

A

FEV1:FVC < 70% of predicted
Increased RV, FRC, and TLC

77
Q

COPD CXR

A

Hyperlucency (dark areas), hyperinflation, flattened diaphragm

Bullae = air sacs= emphysema

78
Q

COPD CT

A

More sensitive than CXR

79
Q

COPD ABG

A

Relatively normal until COPD is severe
PaO2and PaCO2 … based on FEV1

80
Q

COPD long-term oxygen treatment when…..

A

PaO2< 55 mm Hg, hematocrit > 55%, or cor pulmonale
Goal - PaO2> 60 mm Hg

relief of arterial hypoxemia w/ o2= effective in decreasing PVR and Pulm htn then drug therapy.

81
Q

COPDTreatment

A

Long-actingβ2-agonists, inhaled corticosteroids, and long-acting anticholinergic drugs
Flu and pneumonia vaccinations
Diuretics

82
Q

treatment for COPD exacerbation

A

Antibiotics, systemic corticosteroids, and theophylline

83
Q

Lung volume reduction surgery

A

Recommended if Not responsive to medical therapy
Regions of overdistended/poorly functioning lung tissue

Normal areas of lung tissue allowed expanding

84
Q

typical albumin for COPD pts

A

Albumin <3.5 mg/dL

85
Q

COPD anesthesia of choice

A

Regional anesthesia > GA for Lower intraabdominal
Decreases the risk of laryngospasm, bronchospasm, barotrauma, and hypoxemia

Avoid interscalene block- because it can cause hemidiaphragm paralysis

less benzo and opioids

humidity inspired gas

avoid Nitrous oxide= Enlargement or rupture of bullae…pnx

Sevoflurane > Desflurane

86
Q

Bronchospasm treatment

A

Volatile anesthetic or propofol
Short-acting bronchodilator
Suctioning secretions
IV corticosteroids and/or epinephrine

87
Q

Tabacco use…..

A

Cessation > 8 weeks prior to surgery
Minimum 6 weeks

> 60 pack-years= 2 ppd x 30 yrs
2x the risk of any pulmonary complication
3x the risk of pneumonia

88
Q

Elimination half-life of carbon monoxide is ……

A

4-6 hours

89
Q

Effects within in 12 hours of cessation of smoking

A

Within12 hours
P50 - 22.9 to 26.4 mm Hg
Carboxyhemoglobin - 6.5% to 1%

90
Q

Effects within in 6 weeks of cessation of smoking

A

Improved ciliary and small airway function and decreased sputum production

Return of normal immune function and hepatic enzyme activity

91
Q

Disadvantages of Smoking Cessation

A

Increased sputum production
Patient fear of the inability to handle stress
Nicotine withdrawal
Irritability
Restlessness
Sleep disturbances
Depression

HA (15 decks)

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