Obstructive Respiratory Disease (Exam IV) Flashcards
1
Q
What is OSA?
A
- Recurrent upper airway collapse during sleep leading to a reduced or complete cessation of airflow, despite ongoing breathing efforts.
2
Q
How is OSA diagnosed?
What 3 things do they look at?
A
Polysomnography recording
- Apnea
- Hypopnea
- Respiratory effort–related arousals
3
Q
Apnea is considered when there is _____% or more reduction in the amplitude of airflow signal as measured by an oral/nasal thermal sensor.
A
- 90%
4
Q
What are the classifications of apnea?
A
- Obstructive apnea event - patient is trying to breath
- Central apnea event - no breathing effort
- Mixed apnea event - starts at central apnea → OSA
5
Q
Apnea diagnosis is a duration of ____ seconds or more
A
- 10 seconds or more
6
Q
The recommended definition of hypopnea is a drop of ______% or more in the amplitude of the nasal pressure sensor that lasts for _____% or more of the event with a ______% drop in SpO2.
A
- 30%
- 90%
- 4%
7
Q
The alternative definition of hypopnea is a drop of _____% or more in the amplitude of the nasal pressure sensor that lasts ____% or more of the event associated with a ____% or more drop in SpO2 or _______ arousal.
A
- 50%
- 90%
- 3%
- EEG
8
Q
What is the Apnea-hypopnea index (AHI)?
A
- Number of apnea and hypopnea events per hour of sleep
9
Q
Respiratory Effort–Related Arousals
A
A limitation in the airflow followed by arousal on the EEG channel
10
Q
What is seen in Respiratory Effort–related Arousals
A
- Flattening of the airflow in a way that does not meet the criteria for apnea or hypopnea
- Increased respiratory effort
- Duration of 10 seconds or more
11
Q
What is the AHI score for a diagnosis of OSA?
A
- AHI of ≥ 15
12
Q
OSA diagnosis can also be made with an AHI of ≥ ______ PLUS clinical signs and symptoms present or associated medical and psychiatric disorders (ie: daytime sleepiness)
A
- 5
13
Q
Obstructive sleep apnea syndrome(OSAS)
AHI score?
How often will the patient have daytime somnolence?
A
- AHI of ≥ 5
- Daytime somnolence ≥ 2 days/week
14
Q
What will the AHI score be for mild OSA?
Moderate OSA?
Severe OSA?
A
- Mild (AHI 5–15)
- Moderate (AHI 15–30)
- Severe (AHI ≥ 30)
15
Q
Direct physiologic mechanisms of OSA
A
- Anatomic and functional upper airway obstruction
- Decreased respiratory-related EEG arousal response
- Instability of the ventilatory response to chemical stimuli
16
Q
Apnea episodes can be resolved by
A
- Increased muscular activity at the upper airway muscles (Jaw Thrust)
- Increased muscular activity at the thoracoabdominal respiratory muscles (deep breaths)
- EEG arousal (stimulate central respiratory centers)
17
Q
Neurocognitive Consequences of OSA (long list, but common sense)
A
- Slowing of the EEG
- Chronic sleep deprivation
- Excessive daytime sleepiness (EDS)
- Increased number of lapses in psychomotor vigilance task testing
- Decrease in cognition and performance
- Decreased quality of life
- Mood disorders
- Increased rates of motor vehicle collisions
18
Q
MetabolicConsequences of OSA (long list, common sense)
A
- Hypoxic injury
- Systemic inflammation
- ↑ SNS to counter the problems of OSA
- Alterations in the HPA function
- Hormonal changes
- Insulin resistance
- Glucose intolerance
- Dyslipidemia
- DM 2
- Central obesity
- Metabolic syndrome
19
Q
Most common sites of upper airway obstruction
A
- Retropalatal and retroglossal regions of the oropharynx
20
Q
What are physical obstructions that can cause the narrowing of an airway?
A
- Bony craniofacial abnormalities
- Excess soft tissue (this is most of what we will see)
- Acromegaly, thyroid enlargement, and hypothyroidism
- Overenlarged tonsils (usually in children)
21
Q
When will functional collapse occur?
A
When the forces that collapse the upper airway are greater than those keeping the upper airway open (dilating forces).
22
Q
What are the collapsing forces?
A
- Intraluminal negative inspiratory pressure
- Extraluminal positive pressure
23
Q
What are the dilating forces
A
- Pharyngeal dilating muscle tone
- Longitudinal traction (Tracheal Tug)
24
Q
______ position enhances airway obstruction.
Why does this position enhance airway obstruction?
A
- Supine
- Supine position will Increase the effect of extraluminal positive pressure against the pharynx
25
Patients with OSA have a more collapsible upper airway with altered neuromuscular control. Their upper airway muscles have ________ and __________ changes, which might decrease their ability to dilate the airway during sleep.
* Inflammatory infiltrates
* Denervation
26
Respiratory-Related Arousal Response is stimulated by what factors?
What will be the most reliable stimulator of arousal?
* Hypercapnia (let patient's ETCO2 climb to take a breath)
* Hypoxia
* Upper airway obstruction
* **Work of breathing** (most reliable stimulator of arousal)
27
OSA clinical symptoms during the day
* Dry mouth or headache upon waking
* Sleepiness
* Falling asleep during monotonous situations
* Subjective impairment of cognitive function
28
OSA clinical symptoms during the evening
* Frequent awakening
* Awaking from own snoring w/ choking sensation
* Loud snoring
* Observed pauses in breathing during sleep
* Tachycardia
* Non-restorative sleep
29
OSA Associated Comorbidities (long list/ common sense)
* HTN
* CAD
* Myocardial infarction
* Heart failure
* Atrial fibrillation
* CVA
* DM-2
* ESRD
* Graves disease
* Hypothyroidism
* Acromegaly
* Nonalcoholic steatohepatitis (NASH)
* Polycystic ovarian syndrome
30
Risk Factors for OSA
* Increased age
* Obesity
* Non-Caucasian race
* Upper airway narrowing
* Male gender
* Pregnancy
* Craniofacial abnormalities
* Smoking
31
Treatment options for OSA.
What is the gold standard treatment?
* **Positive airway pressure device (CPAP)- gold standard**
* Oral appliances
* Surgery
* Hypoglossal Nerve Stimulator
* Weight reduction
32
What are surgical procedures for OSA?
* Tonsillectomy – adults
* Maxillomandibular advancement- *good if done right.*
* Uvulopalatopharyngoplasty (UPPP) - *very useless*
* Adenotonsillectomy – children
33
Goals for CPAP.
AHI:
O2:
* AHI < 5
* O2 > 90%
34
For every 1-point increase in the Mallampati score, the odds ratio for OSA is increased by _______.
* 2.5
35
Induction considerations for OSA
* Elevate HOB
* Pre-oxygenation
* Consider difficult mask ventilation or intubation
* Minimize opioid use
36
Which anesthesia is preferred for OSA patients: Regional or GA?
* Regional
*If GA is used, secure the airway.*
37
STOP-BANG questions.
* 0-2 (Low Risk for OSA)
* 3-4 (Moderate Risk for OSA)
* 5+ (Severe Risk for OSA)
38
Infectious (viral or bacterial) nasopharyngitis accounts for about _______% of all URIs, with the most common responsible viral pathogens being rhinovirus, coronavirus, influenza virus, parainfluenza virus, and respiratory syncytial virus (RSV).
* 95%
***Noninfectious nasopharyngitis** can be allergic or vasomotor in origin accounts for the other **5%** of URI.*
39
URI Symptoms and Diagnosis
* Nonproductive cough, sneezing, and rhinorrhea
* Bacterial infections - fever, drainage, cough
* Dx will be made based on clinical signs and sx
*If patients show sx URI w/o fever, you may proceed with surgery. If there is a URI w/ **FEVER** do not go to surgery.*
40
How long should surgery be delayed if the patient has a current URI
* 6 weeks
41
URI for several days or weeks. Can the patient have surgery?
* If stable or improving condition – proceed to surgery
42
URI anesthetic considerations
* Adequate hydration
* Reducing secretions
* Limiting airway manipulation
* Nebulized or topical LA applied to the vocal cords
* LMA > ETT
43
Adverse respiratory events of URI
* Bronchospasm
* Laryngospasm
* Airway obstruction
* Postintubation croup
* Desaturation
* Atelectasis
44
Asthma is a disease of **reversible** airflow obstruction characterized by these three things.
* Bronchial hyperreactivity
* Bronchoconstriction
* Chronic airway inflammation
45
Causes and Risk Factors of Asthma
* Hereditary
* Family history
* Maternal smoking during pregnancy
* Viral infections
* Limited childhood exposure to highly infectious environments (Bubble Child)
46
Status asthmaticus
* Life-threatening bronchospasm that persists despite treatment
47
Stimuli Provoking Asthma
*ASA can cause respiratory alkalosis → hyperventilation → asthma attack.*
48
The pathophysiology of asthma is a specific chronic inflammation of the mucosa of the lower airways. Activation of the inflammatory cascade leads to infiltration of the airway mucosa. This results in airway edema, particularly in the bronchi. The inflammatory mediators implicated in asthma include what three mediators?
* Histamine
* Prostaglandin D2
* Leukotrienes
*Typically, there are simultaneous areas of inflammation and repair in the airways.*
49
Asthma Signs and Symptoms
* Wheezing
* Productive or nonproductive cough
* Dyspnea
* Chest discomfort or tightness (air hunger)
* Eosinophilia
* Episodic disease… acute exacerbations interspersed w/ symptom-free periods
* Short-lived attacks lasting minutes to hours
50
When the history is being given by someone with asthma, attention should be paid to what specific factors?
* Previous intubation
* Admission to ICU
* 2 or more hospitalizations for asthma in the past year
* Presence of significant co-existing diseases
51
Asthma is diagnosed when a patient reports sx of wheezing, chest tightness, or shortness of breath and demonstrates airflow obstruction on pulmonary function testing (PFT) that is at least partially reversible with _______.
* Bronchodilators
*If the use of bronchodilators increases airflow, the patient will then be diagnosed with asthma. Yay -_-*
52
What three factors determine asthma severity?
* Clinical symptoms
* Results of PFT
* Frequency of medication usage
53
**PFT Dx for Asthma**
FEV1
FRC
TLC
FEV1 < 35% of normal
FRC - may increase substantially
TLC - within normal range
54
Mild asthma is usually accompanied by a _____ PaO2 and PaCO2.
_____ and _____ are the most common arterial blood gas findings in the presence of asthma.
* Mild asthma is usually accompanied by a **normal** PaO2 and PaCO2.
* **Hypocarbia** and **respiratory alkalosis** are the most common arterial blood gas findings in the presence of asthma.
55
As the severity of expiratory airflow obstruction increases, the associated V/Q mismatching may result in a PaO2 of less than ______mmHg while breathing RA.
The PaCO2 will likely increase when the FEV1 is less than _____% of the predicted value.
* PaO2 less than **60 mmHg** on RA
* PaCO2 will increase when FEV1 is less than **25%** of predicted value
56
Patients with **severe asthma** may have what characteristics on their CXR?
* Hyperinflation
* Hilar vascular congestion d/t mucus plugging
* Pulmonary hypertension.
*CXR in a patient with **mild or moderate asthma** is **often normal.***
57
Patients with asthma will have what characteristics on their EKG?
* RV strain or irritability (moderate to severe asthma)
* Right Axis Deviation
58
First-line treatment for Asthma
* Short-acting bronchodilators - β2-agonists
* Albuterol (Proventil), levalbuterol (Xopenex)
*Goal is to prevent bronchial inflammation and bronchospasms.*
59
Long-term treatment of Asthma.
* Inhaled corticosteroids:
* Long-acting bronchodilators:
* Combo inhaled corticosteroids + long-acting bronchodilators:
* Leukotriene modifiers:
* Anti-IgE monoclonal antibody:
* Methylxanthines:
* Mast cell stabilizer:
* Inhaled corticosteroids: Budesonide (Pulmicort), fluticasone (Flovent)
* Long-acting bronchodilators: β2-agonists
Arformoterol (Brovana)
* Combo inhaled corticosteroids + long-acting bronchodilators: Budesonide + formoterol (Symbicort) Fluticasone + salmeterol (Advair)
* Leukotriene modifiers: Montelukast (Singulair)
* Anti-IgE monoclonal antibody: Omalizumab
* Methylxanthines: Theophylline, aminophylline
* Mast cell stabilizer: Cromolyn
60
Status Asthmaticus Treatment
61
The preoperative evaluation aims to formulate an anesthetic plan that prevents or blunts expiratory airflow obstruction for asthmatic patients. What factors do you want to evaluate?
* Onset age: childhood or adult
* Triggers: environment
* Accessory muscle use, wheezing or crepitations, eosinophil counts
* Chest physiotherapy, antibiotics, and bronchodilators
* Evaluate stress dose steroids
62
What kind of anesthesia is preferred for asthma patients: Region or GA?
* Regional
*Best bet is to say out of the airway if you can.*
63
What drugs will be given to asthma patients to suppress airway reflexes?
* Fentanyl
* Remifentanil
64
Induction drugs for asthma patients.
* Lidocaine
* Propofol - often used for induction in a hemodynamically stable asthmatic patient.
* Ketamine - preferred induction drug in a hemodynamically unstable patient with asthma.
65
What kind of NMBD do you want to avoid in Asthma patients?
* Avoid histamine-releasing drugs
* Atracurium
66
What is Chronic Obstructive Pulmonary Disease
* Progressive loss of alveolar tissue and progressive airflow obstruction that is not reversible
67
________deficiency is an inherited disorder associated with the premature development of COPD.
* α1-Antitrypsin
68
Emphysema is characterized by _________destruction
* Lung parenchymal
69
Chronic bronchitis characterized by _________.
cough and sputum production
70
Chronic Obstructive Pulmonary Disease is a disease of ________.
* small airways
71
Risk Factors of COPD (long list, common sense)
* 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
72
COPD causes pathologic deterioration in _______ within the lung parenchyma.
COPD causes pathologic changes that decrease the rigidity of __________ and thus predispose them to collapse during exhalation.
* Elasticity/recoil
* Bronchiolar wall
73
COPD will cause an ____________, which lowers the pressure inside the bronchioli and further favors airway collapse;
COPD will cause active ________ and ______resulting from increased pulmonary secretions.
COPD will cause the destruction of _______, _________ of air sacs, and the development of ____________.
* COPD will cause an **increased gas flow velocity in narrowed bronchioles**, which lowers the pressure inside the bronchioli and further favors airway collapse;
* COPD will cause active **bronchospasm** and **obstruction** resulting from increased pulmonary secretions.
* COPD will cause the destruction of **lung parenchyma** , **enlargement** of air sacs, and the development of **emphysema**.
74
COPD Signs and Symptoms
* Dyspnea on exertion or at rest
* Chronic cough
* Chronic sputum production
75
As COPD expiratory airflow obstruction increases in severity, ________ and a ________ time are evident. Breath sounds are likely to be decreased, and expiratory wheezes are common.
* As COPD expiratory airflow obstruction increases in severity, **tachypnea** and a **prolonged expiratory** time are evident. Breath sounds are likely to be decreased, and expiratory wheezes are common.
76
COPD PFT Findings:
FEV1:FVC
RV:
FRC:
TLC:
**PFT for COPD**
FEV1:FVC <70% of predicted
RV: ↑
FRC: ↑
TLC: ↑
77
COPD CXR Findings:
* Hyperlucency - dark areas on CXR
* Hyperinflation
* Bullae (air sacs) = emphysema
*CT is more sensitive than CXR.*
78
Arterial blood gas measurements often remain relatively normal until COPD is ______.
The PaO2 does not usually decrease until the FEV1 is less than ____% of predicted, and the PaCO2 may not increase until the FEV1 is even lower.
* severe
* less than 50%
*COPD must be very severe to see significant ABG changes.*
79
Long-term oxygen administration (home oxygen therapy) is recommended if the PaO2 is less than _____ mm Hg, the hematocrit is above ____%, or there is evidence of _______.
* 55 mmHg
* 55%
* Cor Pulmonale
*Supplemental oxygen administration aims to achieve a **PaO2 greater than 60 mm Hg***.
80
Smoking cessation benefits for COPD patients
* Decreases disease progression
* Diminishes symptoms of chronic bronchitis
* Eliminates accelerated loss of lung function
81
What drugs are often used and recommended to treat COPD?
* Long-acting β2-agonists
* Inhaled corticosteroids,
* Long-acting anticholinergic drugs
* Flu and pneumonia vaccines
* Diuretics
*Meds will improve FEV1, and dyspnea, and reduce exacerbation of COPD by up to 25%.*
82
In selected patients with severe COPD who are not responding to max medical therapy and have regions of overdistended, poorly functioning lung tissue, _______ may be considered.
* Lung reduction surgery
83
What does surgical removal of overdistended lung areas allow?
* More normal areas of the lung to expand
84
What improvements should be seen with lung volume reduction surgery?
* Increases elastic recoil
* Decrease in the degree of hyperinflation
* Improved alveolar gas exchange/ventilation
85
COPD Pre-Op Evaluation (long list, common sense)
* Smoking history (any amount, any time)
* Current medications
* Co-morbidities
* Evidence of RV failure
* Exercise tolerance (METs)
* Exacerbations
* Prior hospitalizations
* Optimized before surgery
* Albumin should be >3.5 mg/dL
* PFTs/ABGs
* Ventilation
86
When will COPD patients need a pre-op consultation? (Again, it's a long list. Use common sense)
* Hypoxemia on RA or the need for home O2 therapy w/o known cause
* Bicarbonate > 33 mEq/L or PCO2 > 50 mm Hg
* History of respiratory failure resulting from an existing problem
* Severe SOB r/t respiratory disease
* Planned pneumonectomy
* Difficulty in assessing pulmonary function by clinical signs
* Need to distinguish potential causes of significant respiratory compromise
* Need to determine the response to bronchodilators
* Suspected pulmonary HTN
87
COPD Peri-Op Risk Reduction Chart
*Ignore post-op for this exam*
88
Regional anesthesia is preferred over general anesthesia in patients with COPD. This technique can decrease the risk of what adverse events?
* Laryngospasm
* Bronchospasm
* Barotrauma
* Hypoxemia
* Lower intraabdominal
* Peripheral extremities procedures
* Minimally invasive
* Avoid interscalene lock
89
When will a COPD patient use General Anesthesia?
* General anesthesia is the usual choice for upper abdominal and intrathoracic surgery.
*Regional anesthesia is suitable for lower intraabdominal surgery, peripheral extremity procedure, or minimally invasive procedures.*
90
What kind of regional block do you want to avoid with COPD patients?
* Interscalene block
*Risk of diaphragmatic paralysis.*
91
General Anesthesia Considerations for COPD Patients
* Minimze use of benzos and opioids (less is more)
* Use of low gas flows/ keep airways humidified
* Avoid the use of Nitrous
* Sevoflurane > Desflurane
* Watch for bronchospasm
92
What do you do if your COPD patient develops bronchospasm during general anesthesia?
* ↑ Volatile anesthetic or propofol
* Use a short-acting bronchodilator
* IV corticosteroids and/or epinephrine
* Suction secretions
93
When should patients stop tobacco use before surgery?
* 8 weeks before surgery (Minimum 6 weeks)
94
Those who have smoked more than 60 pack-years have _____ the risk of any pulmonary complication and _____ the risk of pneumonia compared with those who have smoked less than 60 pack-years.
* 2x the risk of any pulmonary complication
* 3x the risk of pneumonia
95
Cardiac Effects of Smoking
Respiratory Effects of Smoking
Other Organ System Effects of Smoking
*Long list, common sense.*
96
The adverse effects of carbon monoxide on oxygen-carrying capacity and of nicotine on the cardiovascular system are short-lived. The elimination half-life of carbon monoxide is approximately _____ hours when breathing room air.
* 4–6 hours
97
Within ______hours after cessation of smoking, the **P50 increases from 22.9 to 26.4 mmHg**. **The carboxyhemoglobin level decreases from 6.5% to about 1%.**
* 12 hours
98
It will take at least ______ weeks of smoking cessation to see improved ciliary and small airway function, decreased sputum, and improved immune function and hepatic enzyme activity.
* 6 weeks (8 weeks for max benefit)
99
Disadvantages of Smoking Cessation.
What will be most concerning for anesthesia?
* **Increased sputum production (most concerning for anesthesia)**
* Patients fear the inability to handle stress
* Nicotine withdrawal
* Irritability
* Restlessness
* Sleep disturbances
* Depression
