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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
Neurocognitive Consequences of OSA
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
26
Metabolic Consequences of OSA
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
27
Most common sites of upper airway obstruction
Retropalatal and retroglossal regions of the oropharynx
28
Causes of Obstructions
Bony craniofacial abnormalities Excess soft tissue Acromegaly, thyroid enlargement, and hypothyroidism tonsils
29
Functional collapse
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
30
Collapsing forces
Intraluminal negative inspiratory pressure and extraluminal positive pressure
31
Dilating forces
Pharyngeal dilating muscle tone and longitudinal traction on the upper airway by increased lung volume Tracheal tug
32
Supine position enhances airway obstruction by....
Increases the effect of extraluminal positive pressure against the pharynx gravity
33
More collapsible upper airway r/t altered neuromuscular control causes
Inflammatory infiltrates and denervation changes overtime that makes the upper airway collapse
34
Respiratory-Related Arousal Response stimulated by
Hypercapnia Hypoxia Upper airway obstruction Work of breathing
35
most reliable stimulator of breathing
work of breathing = energy expended to inhale and exhale
36
Clinical Symptoms during the day
Dry mouth or headache upon waking, sleepiness, falling asleep during monotonous situations, subjective impairment of cognitive function
37
Clinical Symptoms during the night
Frequent awakening, awaking from own snoring w/ choking sensation, loud snoring, observed pauses in breathing during sleep, tachycardia, non-restorative sleep
38
Goals of CPAP
Eliminate all respiratory events, hypopnea, snoring, apnea so AHI decreases to less than 5 an hour and keep oxygenation > 90%
39
SX tx for OSA
Tonsillectomy – adults Maxillomandibular advancement (MMA)- reconstruction of jaw Uvulopalatopharyngoplasty (UPPP)- removal of extra tissue in the upper-airway Adenotonsillectomy – children
40
For every 1-point increase in the Mallampati score, the odds ratio for OSA is increased by.....
For every 1-point increase in the Mallampati score, the odds ratio for OSA is increased by 2.5
41
STOP-Bang
questionnaire that assess risk of OSA
42
Acute Upper Respiratory Tract Infection
Infectious (viral or bacterial) nasopharyngitis - 95% Noninfectious nasopharyngitis – 5% (Allergic or vasomotor in origin)
43
URI Symptoms
Nonproductive cough, sneezing, and rhinorrhea Bacterial infections Fever, purulent nasal discharge, productive cough, and malaise
44
URI Dx
Diagnosis - based on clinical signs and symptoms
45
Current URI = Delay surgery
Delay surgery - 6 weeks
46
URI Anesthetic Considerations
Adequate hydration, reducing secretions, and limiting airway manipulation Nebulized or topical local anesthetic applied to the vocal cords
47
Airway of choice with URI
LMA > ETT
48
Adverse respiratory events with URI and anesthesia
Bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis
49
Asthma
Reversible airflow 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
Status asthmaticus
life-threatening bronchospasm that persists despite treatment
51
Stimuli Provoking Asthma
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
Infiltration of the airway mucosa caused by
Eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes
53
Asthma Pathogenesis
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
Inflammatory mediators
Histamine, prostaglandin D2 and leukotrienes
55
Asthma Signs and Symptoms
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
Asthma Diagnosis
Airflow obstruction on pulmonary function testing that is at least partially reversible with bronchodilators Increase in airflow after bronchodilator inhalation
57
Asthma PFT
FEV1 < 35% of normal FRC - may increase substantially TLC - within normal range
58
Asthma ABG
Hypocarbia and respiratory alkalosis - most common Mild Normal PaO2 and PaCO2 Severe PaO2 <60 mm Hg on RA PaCO2 increases when the FEV1 < 25% of normal
59
Ashtma CXR
Mild/moderate – normal Severe - hyperinflation and hilar vascular congestion due to mucus plugging and pulmonary hypertension congested pulmonary hilum
60
Asthma ECG
RV strain or irritability, R axis deviation = moderate to severe changes
61
Short-acting bronchodilators - β2-agonists
Albuterol (Proventil), levalbuterol (Xopenex)
62
Inhaled corticosteroids
Budesonide (Pulmicort), fluticasone (Flovent)
63
Long-acting bronchodilators
β2-agonists – arformoterol (Brovana)
64
Combo inhaled corticosteroids + long-acting bronchodilators
Budesonide + formoterol (Symbicort) Fluticasone + salmeterol (Advair)
65
Leukotriene modifiers
Montelukast (Singulair)
66
Anti-IgE monoclonal antibody
Omalizumab
67
Methylxanthines
Theophylline, aminophylline
68
Mast cell stabilizer
Cromolyn
69
mechanical ventilation parameters for asthma
shorter inspiration and longer expiration avoid auto-peep/ air trapping by prolonging expiration permissive hypercapnia if needed to avoid barotrauma
70
Asthma preferred anesthetic / airway
Regional > GA stay out of the airway LMA > ETT suppress airway reflex; Fentanyl, remifentanil Induction – lidocaine, propofol, ketamine
71
Chronic Obstructive Pulmonary Disease
Progressive loss of alveolar tissue and progressive airflow obstruction that is not reversible α1-Antitrypsin deficiency
72
Emphysema characterized by
lung parenchymal destruction
73
Chronic bronchitis is characterized by
cough and sputum production
74
Risk factors for COPD
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
COPD Signs and Symptoms
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
COPD PFT
FEV1:FVC < 70% of predicted Increased RV, FRC, and TLC
77
COPD CXR
Hyperlucency (dark areas), hyperinflation, flattened diaphragm Bullae = air sacs= emphysema
78
COPD CT
More sensitive than CXR
79
COPD ABG
Relatively normal until COPD is severe PaO2 and PaCO2 … based on FEV1
80
COPD long-term oxygen treatment when.....
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
COPD Treatment
Long-acting β2-agonists, inhaled corticosteroids, and long-acting anticholinergic drugs Flu and pneumonia vaccinations Diuretics
82
treatment for COPD exacerbation
Antibiotics, systemic corticosteroids, and theophylline
83
Lung volume reduction surgery
Recommended if Not responsive to medical therapy Regions of overdistended/poorly functioning lung tissue Normal areas of lung tissue allowed expanding
84
typical albumin for COPD pts
Albumin <3.5 mg/dL
85
COPD anesthesia of choice
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
Bronchospasm treatment
Volatile anesthetic or propofol Short-acting bronchodilator Suctioning secretions IV corticosteroids and/or epinephrine
87
Tabacco use.....
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
Elimination half-life of carbon monoxide is ......
4-6 hours
89
Effects within in 12 hours of cessation of smoking
Within 12 hours P50 - 22.9 to 26.4 mm Hg Carboxyhemoglobin - 6.5% to 1%
90
Effects within in 6 weeks of cessation of smoking
Improved ciliary and small airway function and decreased sputum production Return of normal immune function and hepatic enzyme activity
91
Disadvantages of Smoking Cessation
Increased sputum production Patient fear of the inability to handle stress Nicotine withdrawal Irritability Restlessness Sleep disturbances Depression

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