PAH, PTX, alveolar collapse, atelectasis Flashcards by Linsley Lloyd

PH - rare incidence but more common in _____

obese

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PH mean pressure PAP ______

> 25 mmHg

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requires ______ to definitively diagnose

RHC

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5 main categories PH falls into

pulm arterial HTN
left heart disease with low EF
lung dz/chronic hypoxia
chronic thromboembolic
unknown etiologies

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PAH is an increase in ____

vascular tone

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increased proliferation of pulm ______ ______ ______

vascular smooth muscle

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initially reversible smooth muscle vasoconstriction progresses to ______ ______ _______ _____

irreversible smooth muscle hypertrophy

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right ventricular overload can lead to ____ ______ with decreased _______ perfusion

cor pulmonale
coronary

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_______ anesthetic if possible

regional

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if GA then avoid ______ _______ changes

major hemodynamic

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avoid _____ since it increases PVR

ketamine

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avoid any situation that would increase SNS output and increase PVR, such as:

hypoxemia
hypercarbia
acidosis
pain
hypothermia

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caution in surgery with potential for _____, _____, ______ embolism

air, fat, cement

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caution in surgery with ___ __________, ______, ________

[Anesthesia management of PH]

Elevated airway pressures, laparoscopic, tredelenburg position

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___ Hypotension
[PH management]

Avoid

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If hypotension fails to correct quickly, then suspect that the ____ may be from ___ and not a drop in ____.
[PH management]

Low BP, RV Failure, SVR

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Lung parenchyma tear or rupture allows air from inside of lung to escape between___and ___ ___, non-communicating with no atmospheric access, no shifting ___ or ___

[Characteristics, simple pneumo]

lung, visceral pleura, mediastinum, hemi-diaphragm

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Primary Pneumothorax:

absence of diagnosed lung disease, healthy

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Causes: (3)
[Primary Pneumothorax]

subpleural bleb, smoking, Birt-Hogg Dube’ syndrome speculated drop in atmospheric pressure

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Secondary Pneumothorax:

complication of lung disease

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Causes: (9)
[Secondary Pneumothorax]

COPD, emphysema, cystic fibrosis, metastasis, necrotizing bacterial lung infections, pneumocystis, TB, pneumonia, fungal, viral

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Traumatic pneumothorax: ___(closed/___) or ___ (open/___) ___ trauma (more common)

Blunt, non-communicating, penetrating, communicating, thoracic

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Iatrogenic:
[Traumatic Pneumo]

medical procedure induced

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Non-iatrogneic:
[Traumatic Pneumo]

External trauma

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____/___ (more common): [Traumatic Pneumo]

Communicating/open

___ penetrating injury, air comes from outside, with ___ ___ [Communicating Pneumo part 1]

External, atmospheric access

Atmospheric air enters and trapped between ___ ___and___ ___ during inspiration causing a ___ wound and exits chest cavity during ___ [Communicating Pneumo part 2]

parietal pleural, chest wall, sucking, expiration

___ moves away from ___ side during ___ and toward the ___ side during ___ (___ ___) [Communicating Pneumo part 3]

Mediastinum, affected, inspiration, affected, expiration, mediastinal flutter

___ air enters ___ chest wound during ___ [Tension Pneumo 1/4]

Atmospheric, external, inspiration

___ is not able to ___ chest cavity during ___ [Tension Pneumo 2/4]

Air, escape, expiration

Air in chest rapidly accumulates ___ lung on ___ side [Tension Pneumo 3/4]

collapses, affected

Continued ___ ___ builds [Tension Pneumo 4/4]

intrapleural pressure

___, ___, ___ shift to unaffected side [Tension Pneumothorax Physical Findings]

Heart, trachea, esophagus

Large vessels collapse and impede___ ___ into chest cavity resulting in ___ ___ ___ [Tension Pneumothorax Physical Findings]

venous return, decreased cardiac output

___ ___ ___ ___ (ventilated patient) [Tension Pneumothorax Physical Findings]

Increased peak inspiratory pressure

Increased ___ and ___ ___veins [Tension Pneumothorax Physical Findings]

CVP, distended neck

Dyspnea, ___, ___, ___ [Tension Pneumothorax Physical Findings]

respiratory distress, cough, tachypnea

___or absent ___breath sounds [Tension Pneumothorax Physical Findings]

Decreased, ipsilateral

___(most common sign) [Tension Pneumothorax Physical Findings]

Tachycardia

___ chest pain [Tension Pneumothorax Physical Findings]

Ipsilateral

Hyp__emia [Tension Pneumothorax Physical Findings]

Hypoxemia

Hyp___tension [Tension Pneumothorax Physical Findings]

Hypotension

Hyp___carbia… but ETCO2 ___due to ___ CO!! [Tension Pneumothorax Physical Findings]

Hypercarbia, decreased, low

Tension Pneumothorax Treatment (3)

Observation only Decompression of Pleural Space Supplemental Oxygen

___ or ___ then observation only [Tension Pneumothorax Treatment]

Asymptomatic, < 15%

Decompression of pleural space ___ angiocath, ___ syringe, 3 ___ ___ Insert at ___intercostal space ___ Or… Insert at ___intercostal space laterally [Tension Pneumothorax Treatment]

14 g. , 50 cc, way stopcock, 2nd, anteriorly, 4th-5th, laterally

Supplemental oxygen ___ ___ ___ [Tension Pneumothorax Treatment]

accelerates air reabsorption

Inhalation of high concentrations of oxygen may speed the ___ of a pneumothorax by reducing the partial pressure of ___ in the pulmonary capillaries,. This should increase the pressure gradient between the pleural cavity, and pleural capillaries, so increasing the absorption of ___ from the pleural cavity [Tension Pneumothorax Treatment]

resolution, nitrogen, air,

Optimizes ___ delivery and ___ ___ [Tension Pneumothorax Treatment]

oxygen, gas exchange

Inflammatory condition caused by ___ or ___ Most frequent bacteria: ___ [Pneumonia]

bacteria, virus, pneumococci

Alveoli membrane becomes ___ & ___ [Pneumonia]

inflamed, porous

Consolidation: Alveoli fills with ___, ___ ___. Entire lobes can become ___ [Pneumonia]

fluid, cell material, consolidated

Reduction in ___-___ surface area [Pneumonia]

gas-exchanging

V/Q ratios decrease: What does this mean? Increased shunt or deadspace? Hypoxemia, Hypercapnia or both? [Pneumonia]

Shunt, Both

Treatment: ___, ___, ___ ___ [Pneumonia]

Antibiotics, Resp Rx, VC breaths

A reduction or absence of air in parts of the lung resulting in the collapse of ___, loss of ___ ___, ___-___ shunt and diminished gas exchange. [Atelectasis]

alveoli, lung function, intra-pulmonary

___ reduction or absence of air in parts of the lung resulting in the ___ of alveoli, ___ ___lung function, intra-pulmonary ___ ___ gas exchange.

Atelectasis, collapse, loss of, shunt, diminished

Oxygen concentration:

the fraction or percentage of inspired oxygen delivered (FiO2).

General Anesthesia causes ___

Atelectasis

General Anesthesia causes Atelectasis Estimated incidence between ___-___.

50-100%

“The prevalence of atelectasis has been estimated to be as high as ___ in patients undergoing ___ ___”

100%, general anesthesia.

Average ___, can exceed ___ collapsed lung [General anesthesia causes atelectasis]

3-4%, 20%

Difficult to ___postoperatively [General Anesthesia causes Atelectasi]

reverse

Reduced inspiratory volumes and chest wall expansion resulting from ___ ___ ___ and a reduced ___tone [General Anesthesia causes Atelectasi]

deeper anesthesia depth, muscle

___ ___ due to artificial creation of a significantly higher A-a gradient than ___ [General Anesthesia causes Atelectasi]

Absorption atelectasis, normal

Anesthesia= FRC Decreased, Lung Compliance Decreased, Airway Resistance Increased --> Loss of tone, smaller volume, reduced ___ ___ --> ___ ___ atelectasis [General Anesthesia and Lung Volume]

airway dimensions, airway closure

Pressure of abdominal contents and resulting FRC Initial upright position ___ Supine position ___ Induction of anesthesia ___

2300 ml, 1400 ml, 950 ml

Atelectasis forms regardless of ___ ___

patient position

Causes of Atelectasis under General Anesthesia (3)

Mechanical compression Absorption of Alveolar Gas Surfactant dysfunction

Mechanical Compression: ___ ___ tone reduced ___ movement cephalad [Causes of Atelectasis under General Anesthesia]

Thoracic muscle, Diaphragmatic

Absorption of Alveolar Gas: Under-ventilated airways narrow and close. Air in alveoli rapidly diffuses into capillary. Alveoli ___but ___ continues. Accelerated with ___ ___. [Causes of Atelectasis under General Anesthesia]

collapses, perfusion, higher FiO2

Surfactant dysfunction: Positive___ and ____anesthetics [Causes of Atelectasis under General Anesthesia]

pressure, volatile

How does a high oxygen concentration cause atelectasis?

Accelerates alveolar absorption

Due to oxygen’s rapid diffusing capacity and the pressure difference across the membrane, gas is ___ ___ of the alveolus until it ___…re-opening of the ‘sticky’ atelectasis requires positive pressure of ___ cmH2O

‘sucked out’, collapses, 30–35

No ___ splint and a large ___ gradient promotes ___ ___ [Delivery 100% O2, PAO2~600 mmHg, 0% Nitrogen, PaO2(v) 40, PaO2 (a) 500]

nitrogen, A-a, alveoli collapse

In less than ___minutes alveoli can ___ or ___collapse. [Delivery 100% O2 PaO2 (v) 40, PaO2 (a) 0)]

5, partially, totally

___ ___remains with a reduced A-a gradient causing a ___ in alveoli collapse [Delivery of 40% O2, PAO2 250mmHg, >50% Nitrogen, PaO2 (v) 40, PaO2 (a)200]

Nitrogen splint, delay

In PACU: Oxygen sat 92-94%, Combined with shallow respirations, from residual paralysis, residual ___/___. Now sat drops to mid 80s ***___of pts transferred from OR to PACU without oxygen dropped their saturation to ___ [Results of 100% oxygen in OR, Unrecognized atelectasis]

anesthesia/opioids, 30%, <90%.

Upper airway obstruction requiring intervention (___ ___, __ ___ or nasal airway) [PACU Respiratory Events]

jaw thrust, oral airway

Mild-moderate hypoxemia (SpO2=___ ___) on 3L NC Oxygen that was not improved after active interventions (increasing O2 flows to >3L/min, application of ___-___ ___ ___ verbal requests to ___ ___, ___ ___.) [PACU Respiratory Events]

93%-90%, high-flow face mask, breathe deeply, tactile stimuli

Severe hypoxemia (SpO2___) on 3L nasal cannula O2 that was not improved after active interventions (___ ___ ___, application of ___-___ ___ ___ verbal requests to ___ ___, ___ ___.) [PACU Respiratory Events]

<90%, increasing O2 flows to >3L/min, high-flow face mask, breathe deeply, tactile stimuli

Signs of respiratory distress or impending ___ ___ (respiratory rate ___, accessory muscle use, ___ ___) [PACU Respiratory Events]

ventilatory failure, >20 bpm, tracheal tug

Inability to___ ___ when requested to by the PACU nurse [PACU Respiratory Events]

breathe deeply

Patient complaining of symptoms of___ or ___ ____ ____ ___(difficulty breathing, swallowing or speaking) [PACU Respiratory Events]

respiratory, upper airway muscle weakness

Patient requiring ___ in the PACU [PACU Respiratory Events]

reintubation

Clinical evidence or suspicion of ___ ___ after tracheal ___ (gastric content observed in the ___ and ___) [PACU Respiratory Events]

pulmonary aspiration, extubation, oropharynx, hypoxemia

most common cause of early post op hypoxemia is ______ and ______ ______ leading to right to left intrapulmonary shunting

hypoventilation and lobar atelectasis

atelectasis can remain for _____

days

post op day 1 patient remains on ______ _____ at __/___

nasal cannula 2L/min

post op atelectasis can show low grade _____

fever

post op atelectasis - coughing up _______ _____ and CXR can show ______ infiltrates

yellow sputum bilateral infiltrates

post op atelectasis - start ______ and resp rx

antibiotics

post op atelectasis may result in __-__ extra days inpatient stay

2-3

these post op atelectasis symptoms are indicative of _____ _____ _____

postoperative pulmonary complication (PPC)

is PPC rare?

PPCs occur in as much as _____ of patients undergoing major non-thoracic sx

30%

_______ is a locus for infection

atelectasis

atelectasis and _____ account for majority of PPCs

pneumonia

incidence of atelectasis following abdominal sx is as high as _____

69%

PPCs are a leading cause of ______, ______, and extended ______

mortality, morbidity, and extended hospitalization

we can prevent atelectasis at induction with the use of ______

CPAP

CPAP has been shown to reduce atelectasis formation even if using _____ _____

high FiO2

CPAP may increase _______ risk with gastric insufflation

aspiration

semi recumbent vs supine: no ______ in _____

no reduction in atelectasis

maintain thoracic and diaphragmatic muscle tone by (3)

1. spontaneous breathing 2. avoid paralytics 3. ketamine use to preserve muscle tone

there is evidence that the level of PEEP required to reopen airways may not be high enough to reopen ______ ______

collapsed alveoli (may need recruitment manuever)

PEEP of ______ with BMI < 25

6 cmH2O

PEEP of ______ with BMI up to 30

8 cmH2O

PEEP applied _______ _______ of atelectasis may prevent it

BEFORE formation

PEEP of ______ consistently opened collapsed lung tissue

10 cmH2O

_____ and ______ maintains open gas exchanging units

PEEP and oxygenation

PEEP and oxygenation improves resp mechanics and oxygenation in the _____ _____

morbidly obese

PEEP prevents _______ after an alveolar recruitment manuever (ARM)

de-recruitment

what is a sigh breath?

double tidal volume breath

with sigh breaths, amount of atelectasis is ________

unchanged

single sigh breath vs sustained ARM =

new surfactant released

ARM - sustained inflation with airway pressure _______

40 cmH2O

ARM - 2 goals

1. open airways 2. keep them open

ARM - sustained for __-__-__ seconds

7-10-15

ARM - MUST be followed by ______ to remain open

PEEP

ARM - releases ______ to alveolar wall and terminal bronchiole

surfactant

avoid _____ ______

100% oxygen

8 RCTs indicated that use of 100% FiO2 during GA resulted in: (4)

1. accelerated atelectasis formation 2. increased atelectatic areas of lung 3. increased intra-pulmonary shunting 4. worsening gas exchange

100% FiO2 resulted in atelectasis in less than ___ ______

5 minutes

5 RCTs indicated that using lower FiO2 during GA resulted in reduced _______ and ________ of absorption atelectasis

formation and magnitude

atelectasis development delayed on average by as much as an hour when less than ____ FiO2 was used

50%

_____ FiO2 improves gas exchange during general anesthesia

40%

100% FiO2 at the end of GA promotes post op atelectasis regardless of _____

VCM (vital capacity manuever)

very little atelectasis developed with ____ FiO2 after induction

30%

a vital capacity manuever followed by 40% oxygen ______ _______ post op atelectasis formation

completely prevented

high FiO2 is the main mechanism responsible for _______

atelectasis

Multiple studies performed to assess optimal FiO2: creating the least amount of absorption atelectasis. Maintain ___ ___. Maintaining acceptable ____.

Nitrogen splint, SaO2

current evidence does not indicate that the possible benefits of the use of high ___ ___can overcome the detrimental consequences of postoperative pulmonary complications.”

oxygen concentrations,

Ventilation during anesthesia should be done with a moderate fraction of inspired oxygen (e.g., FiO2 of ___ to ___) and should be ___ only if arterial ___ is compromised

0.3 to 0.4, increased, oxygenation

Avoiding preoxygenation using 30% FiO2 eliminated atelectasis formation during ___ and subsequent ___

, induction, anesthesia

FiO2 100% averaged ___-___ atelectatic lung tissue [Preoxygenation & Atelectasis Formation]

15-20%

FiO2 80% averaged __ ___ atelectatic lung tissue [Preoxygenation & Atelectasis Formation]

less than 2%

FiO2 60% nearly___ atelectatic lung tissue [Preoxygenation & Atelectasis Formation]

eliminated any

FiO2 30% = ___atelectatic lung tissue [Preoxygenation & Atelectasis Formation]

The final disaster…___ ___ should not be done routinely [Oxygen at Emergence]

post oxygenation

Running 100% FiO2 just prior to the end of anesthesia resulted in ___ of lung even following a ___of lung by a vital capacity maneuver [Oxygen at Emergence]

derecruitment, re-expansion

Running ___ FiO2 just prior to the end of anesthesia kept the lung open following a ___ ___ ___ [Oxygen at Emergence]

40%, vital capacity maneuver

Oxygen consumption equation, VO2

VO2= Fi02-Fe02 x Vm /weight in kg

O2 Content of Blood Equation

CaO2=(hgb x oxyhgb x 1.39)+(.003 x PaO2)

Oxygen delivery equation

DO2= CaO2 (mls/dL) x CO(mls/min)/kg/100

Does using 100% Oxygen Significantly Improve the Amount of Oxygen Delivered to the Tissues?

No Assuming the patient has normal cardiac output & Hgb Using FiO2 21% = delivers ≈ 11.7mlsO2/kg/min Using FiO2 50% delivers ≈ 12.3mlsO2/kg/min Using FiO2 100% delivers ≈ 13.0mlsO2/kg/min

The ___ ____ that is the limiting factor in delivery of O2 to the tissues [Why Does Oxygen Delivery Not Change Much?]

cardiovascular system

___ is the vehicle and ____is the cargo [Why Does Oxygen Delivery Not Change Much?]

Hemoglobin, oxygen

Lower ___promotes higher ___ and O2 delivery [Why Does Oxygen Delivery Not Change Much?]

Vt , CO

If sat is near 100% then ___ FiO2 may have___effect on oxygen delivery [Why Does Oxygen Delivery Not Change Much?]

increasing, little

O2 consumption ___ [What is the Point about FiO2?]

3.4 mlsO2/kg/min

Oxygen Delivery on room air: ___ (mlsO2/kg/min) Nearly ___ more than consumed/need [What is the Point about FiO2?]

11.7 mlsO2/kg/min, 4x

No compelling reason to use ___ FIO2 unless indicated [What is the Point about FiO2?]

higher

Superphysiologic doses of blood oxygen do not result in a significant ___ in tissue ___ [What is the Point about FiO2?]

increase, oxygen

Better to run slightly___sat and keep ___ ____ [What is the Point about FiO2?]

lower, alveoli open

2017 WHO recommended ___FiO2 in colon surgery to reduce ___ ____ ____ [Where are We Today Regarding FiO2?]

high , surgical site infections (SSI)

___guidelines generated controversy [Where are We Today Regarding FiO2?]

WHO

____Guidelines recommend ___ FiO2 for colon surgery [Where are We Today Regarding FiO2?]

ERAS, high

…___ Fio2, compared to the ___ ____ Fio2, under the perioperative conditions at this trial site does not meaningfully change clinical outcomes [Where are We Today Regarding FiO2?]

80%, lowest feasible

No Proof of ___surgical site infection in patients receiving ____ O2 [Where are We Today Regarding FiO2?]

reduced, 80%

CPAP during ____/____ can ____ atelectasis formation

preoxygenation/induction, decrease

____ can prevent ____ formation but use it before ____develops

PEEP, atelectasis, atelectasis

___ ____ ___ recruits collapsed alveoli followed by ___to prevent reoccurrence

Alveolar recruitment maneuver, PEEP

Avoid ___ ETT at emergence

suctioning

Follow ___ ____ ERAS-based guidelines

your institution’s

___FiO2 worsens atelectasis and ___ while less than 50% prevents atelectasis and reduces ___

100%, PPCs, PPCs

Use between____and ___FiO2 during____ ____when not contraindicated

40%, 60%, general anesthesia

If you must use ___ oxygen use it only with ___

100%, PEEP

Emerge on less than ___ if not contraindicated

100%

Pulse Oximetry does not tell the CRNA about the ___ of ___ formation

degree, atelectasis

Less than ___ oxygen saturation is acceptable

100%