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SNRAObPedGer > Pediatric Lecture 2A > Flashcards

Pediatric Lecture 2A Flashcards

1
Q 
Lung development continues into first decade of postnatal life:
 Begins \_\_\_\_\_\_\_\_
 Bronchial tree\_\_\_\_\_\_\_\_\_\_
 Terminal air sac\_\_\_\_\_\_\_\_\_\_
 Capillary networks\_\_\_\_\_\_
A

4 wks gestation
16-17 wks (gestation)
24 wks
26-28 wks

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2
Q

Formation of alveoli @_________

Alveoli form through @_________

A

36 wks gestation

8-10 yrs

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3
Q

At birth, neonatal lungs have
__________ not alveoli
 1/10th adult mature lungs

A

10-20 million terminal air sacs ; Alveoli

Saccules,

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4
Q

Brain removes what substance?

A

bicarbonate

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5
Q

Transition to extrauterine life (lungs) what happens

3 major changes in the lungs?

A

There is Rapid lung expansion
↑pulmonary Blood flow
Initiation of regular respiratory rhythm

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6
Q
  • Interruption of umbilical Blood Flow initiates→
  • Initial amniotic fluid removed by _______via_____
  • Residual amniotic fluid in lungs drained via______When?
A

-continuous, rhythmic breathing
-lung via upper airways
lymphatic/pulmonary channels; in first days of life

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7
Q

Changes in ______,_____ and _____→leads to what?

A

PaO2, PaCO2, and pH; acute decrease in PVR and increase in pulm. Blood Flow

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8
Q

Comment on LA pressure and RA pressure, pressure gradient and foramen ovale.

A

Increase in ↑LA pressure +↓RA pressure reverses pressure gradient across the Foramen ovale which causes a functional closure of THIS LEFT TO RIGHT one way flap valve.

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9
Q

Explain Control of respiration: Breathing is controlled by (3 factors) ? (IIO)

what provides afferent signaling?P_UC

A
  1. Input from sensors
  2. integration by central control system
  3. output to effector muscles

Afferent signaling provided by

  1. Peripheral arterial + central brainstem chemoreceptors
  2. Upper airway +intrapulmonary receptors
  3. Chest wall + muscle mechanoreceptors
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10
Q

-

A
  • Carotid bodies and Aortic bodies

- Carotid Greater role at sensing arterial chemical sensing of both PaO2 and pH

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11
Q

Central chemoreceptors responsive to __________and __________are thought to be located or near the ______________

A

Arterial CO2 tension and pH

 Ventral surface medulla

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12
Q

Nose, pharynx, larynx contain what?

what can they cause?

A

pressure, chemical, temperature, and flow receptors

 Can cause apnea, coughing, changes in ventilation

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13
Q

Pulmonary receptors in lung parenchyma
What kind of receptors are they ? aka_______
Where are they located?
What do they balance?
These receptors may be involved and Cause what reflex?
That reflex Prevents what?

A

 Slowly adaption receptors (stretch receptors)
 In airway smooth muscle
 Balance of inspiration/expiration
 Might cause Hering-Breuer reflex
 Prevents overdistention of lungs via vagal stimulation/ and prevents COLLAPSE OF THE LUNGS

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14
Q

Rapidly adapting receptors located where ?
Triggered by ___________
such as _____________

A

 Between airway epithelial
 Triggered by noxious stimuli
 Dust, smoke, histamine

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15
Q

Parenchymal receptors located __________

next _________

A

Juxtacapillary receptors

• Next to alveolar blood vessels

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16
Q

Parenchymal receptors respond to what? (3)

A

• Respond to hyperinflation, chemical stimuli in pulmn.

circ., interstitial congestion

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17
Q

Does not depress upper airway latency (medications)

A

Ketamine

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18
Q

Chest wall Receptors are
Located in?
Sense changes in
Also have

A
  • Mechanoreceptors
  • In muscle spindle endings and tendons of resp. muscles
  • Sense change in length, tension, and movement
  • Joint properioreceptors
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19
Q

Central integration of respiration by two centers

A

 Brainstem (involuntary)

 Cortical (voluntary)

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20
Q

Cerebral cortex
Influence?
Involve in ?

A

 Influence or overrides involuntary rhythm generation

 Emotion, arousal, pain, speech, etc

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21
Q

Possible resp. rhythm generators ________and th _______________, neural circuits in the _____________
are though to be the rhythm generators
What do those groups of neurons do?

A

 Pre-Bötzinger complex and the retrotrapezoid
nucleus/parafacial respiratory group, neural circuits in the
ventrolateral medulla are thought to be the respiratory rhythm generators
- They fire in an oscillation patterns which is moderated by input from other resp. centers

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22
Q

Involuntary integration of sensory input occurs in various respiratory nuclei and neural complexes in the
pons and medulla that modify the

A

baseline pacemaker firing of resp. rhythm generators

 Involuntary integration of sensory input

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23
Q

Effectors of ventilation (4)

A

 Neural efferent pathways
 Muscles of resp.
 Bones/cartilage of chest wall + airway
 Elastic connective tissue

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24
Q

Upper airway patency is maintained by 2 things:

A

connective tissue

contractions of pharyngeal dilator muscles

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25
Q

Diaphragm produces most______During ________

A

volume during normal, quiet breathing

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26
Q

Provide →additional neg. pressure → more tidal volume

A

 Abdominal + intercostal muscles + accessory muscles

(sternocleidomastoid, neck muscles

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27
Q

Expiration is the

A

elastic recoil of lungs + thorax

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28
Q

Normally

  • Inspiration = ______
  • Expiration = _______
A

active

passive

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29
Q

 Vigorous breathing/obstruction

A

 Both active

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30
Q

Chest wall infants change in compliance?

A

↓ chest wall compliance

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31
Q

In Infants, the chest wall is more compliant therefore the __________Is not counterbalanced by _________
What breaks expiration?
_____>_____
What impairs that mechanism?

A

tendency of lung to collapse NOT counterbalanced by chest wall rigidity
 Inspiratory muscles brake expiration
 ERV > FRC
The braking mechanism is Impaired by anesthesia which can lead to airway closure and atelectasis

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32
Q

Component of assessment
 Assess for_____,_____,_____ pathology
 Consider
 which can be Impacted by

A

History, physical exam, evaluation of vital signs
Airway, musculoskeletal, neurologic
gas exchange
cardiac, hepatic, renal, or hematologic diseases

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33
Q

For pediatrics most important

A

O2 Saturation

Heart rate

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34
Q

 Risk factors for airway Issues

A
  1. resp. infection within 2 weeks
  2. wheezing during exercise
  3. > 3 wheezing episodes within 12 mo, nocturnal dry cough, eczema
  4. family Hx asthma, rhinitis (runny nose)
  5. Exposure to tobacco smoke
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35
Q

 Establish ______and ______of URI

 Precipitating factors of _______frequency, severity and ______Factors

A

timeframe, freq., severity
Antibiotics?
wheezing, frequency, severity, relieving factors

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36
Q

For Chronic pulm. Dz =

A

assess what causes acute exacerbations

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37
Q

In young infants, figure out:

A

Gestational age at birth, current postconceptual age,
neonatal resp. difficulties, NICU/prolonged
intubation

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38
Q

Premies at risk for

 R/T

A

apneic episodes
subglottic stenosis,
tracheomalacia (Weak cartilage)

prolonged intubation

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39
Q

For gross assessment

A

 Inspect from a distance

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40
Q

 Get baseline RR, SpO2, look for signs of accessory

A

respiratory muscle use (resp. distress)

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41
Q

 Weight important because
 Chronic pulm. Dz →
 Severe obesity →

A

malnourished, underweight, growth retardation

obstruction, sleep apnea

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42
Q

 Eczema + atopy (↑immune system) =

A

hyperreactive airway

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43
Q

 Auscultation 

 Tests:

A

Wheezes, rales, fine/coarse crepitus, altered breath sounds, cardiac murmurs
chest imagine, Hct, ABG, PFT, sleep study

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44
Q

PFTs include
________,________, _________ . done to find __________________
What does it measure about dysfunction ?
Nature or dysfunction as either?

A

dynamic studies, measurement of static lung
volumes, diffusing capacity
 Finds mechanical resp. dysfunctions
 Quantifies dysfunction  Defines nature of dysfunction  Obstructive, restrictive, mixed

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45
Q

Dynamic studies
Spirometry
What is FEV/ FVC

A

 Measures volume of air inspired and expired
 Forced exhalation after maximal inhalation = forced vital
capacity (FVC)
 Fraction of volume exhaled in the first second = forced
expiratory volume (FEV1)

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46
Q

Dynamic studies include

A

Spirometry
Flow volume loops
Peak expiratory flow

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47
Q

Obstructive PFT  Obstruction =

A

decreased velocity of flow through airways

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48
Q

 Normally should be able to exhale

more than

A

80% of FVC in 1 second

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49
Q

Normal FEV1/FVC =

A

0.8 or 80%

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50
Q

 If exhalation over first second divided by total FVC is less than _______=

A

< 80 % =airway obstruction

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51
Q

Restrictive PFTs

Decreased__________  Both FEV1 and FVC _______

A

lung volume ↓ equally 

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52
Q

Diagnosis of PFTs

A

FVC < 80% of normal
Normal or increased FEV1/FVC
 Loss of lung tissue or inability to expand

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53
Q

 Obstructive = more common in children is

Other examples

A

Asthma

Airway lesions, congenital subglottic webs, vocal cord dysfunction

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54
Q

Improvement in FEV1 of ____% is considered a response

A

12%; positive

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55
Q

Mixed problems with FEV, FVC 3 conditions

A

Cystic fibrosis
sickle cell disease
bronchopulmonary dysplasia

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56
Q

Restrictive

there is Limitations of_______ for example in _____,_____ and _______

A

chest wall movement

Deformities, scoliosis, pleural effusions

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57
Q

Restrictive: Space-occupying intrathoracic lesions

A

Large bullae or congenital cysts

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58
Q

Restrictive :Alveolar filling defects Examples

A

 Pneumonia

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59
Q

Other use of PFTs

A

 Differentiate fixed from variable airway obstruction
 Localize obstruction above or below thoracic inlet
 Fixed central airway obstruction
Tumor, stenosis
Obstructs both inspiration and expiration
Pancake flow-volume loop

60
Q

Other variable obstructions?
Affect ______
During Inhalation = Chest ______ and airway are_______
What obstructs inhalation?
During exhalation = Chest _______, intrathoracic airway __________
What obtructs exhalation?

A 
Variable obstructions 
Only affects one part of vent. Cycle
 Inhalation = chest expands and
airways are drawn open  Variable extrathoracic lesions
obstruct inhalation
 Exhalation = chest collapses,
intrathoracic airways close  Variable intrathoracic lesions
obstruct exhalation
61
Q

Upper Respiratory Infection

Viral vs. bacterial?

A

 Viral
 Short-lived, self-limiting
 ↑airway sensitivity/reactivity/secretions for several weeks
severe coughing, and breath holding

62
Q

What can a respiratory infection affect?

A

 Can decrease FVC, FEV1, peak expiratory flow, and diffusion capacity

63
Q

URI potential MOA

A

mucosal invasion, chemical mediators, altered
neurogenic reflexes
↑ laryngospasm, bronchospasm, arterial hemoglobin desaturation,

64
Q

Runny nose with no fever kids—>

A

Ok to proceed

65
Q

Elective surgery postponed if more severe symptoms
present: (3)
in between consider?

A

 Mucopurulent secretions, lower respiratory tract signs
(wheezing), pyrexia >100.4°F (38°C), ∆ behavior/activity
 In between?
 Consider comorbidities, type of surgery/anesthetic,
contamination risk factor, ability to admit postoperatively

66
Q

 Proceed c/general anesthesia what to do?

Deep extubation ?

A

 Depth of anesthesia must be adequate for airway
manipulation
 Incidence of desaturation higher in awake children

67
Q

Only 2 times to extubate

A

DEEPLY SEDATED

WIDE AWAKE

68
Q

AVOID _______ and _______if possible because

A

airway stimulation  Avoid ETT if possible

 ↑complications esp. young children

69
Q

most effective, lest harmful way to provide anesthesia

A

Face mask

70
Q

 Facemask =

A

smallest airway complications 

LMA could be a good intermediate

71
Q

For URI Postpone elective cases

A

2-4 weeks

72
Q

Wait that long for URI because it Allows for balancing of:

A

 Time to ↓airway reactivity, periop. resp. risk, need to

perform surgery

73
Q

Propofol vs sevo for laryngospasms

A

 Propofol causes less laryngospasms than sevoflurane

74
Q

What is LTA

A

LTA ( Laryngeal tracheal anesthesia ) insert, put lidocaine than remove and put ETT

75
Q

No evidence to support LTA< but what does help?

A

Lubing LMA with lidocaine jelly, nasal vasoconstrictors

to reduce secretions

76
Q

3 Lower respiratory diseases:

A

 Asthma
 Cystic fibrosis
 Sickle Cell disease

77
Q

Chronic disorder characterized by variable/recurring symptoms, ______, ______ and ________
 Associated with____________ hypersensitivity

A 
airway obstruction,
inflammation, and hyperresponsiveness
immunoglobulin E (IgE)-mediated hypersensitivity
78
Q

 Rare perioperative complications of asthma

A

1.Anaphylaxis
2. adrenal crisis
3. ventilatory barotrauma (pneumothorax or
pneumomediastinum)

79
Q

Presentation ASTHMA:

A

wheezing, chest tightness or discomfort, persistent dry cough, and dyspnea on exertion

80
Q

Signs of Severe resp. distress:

A

chest wall retraction, use of accessory muscles, prolonged expiration, pneumothorax, and progression to respiratory failure and death

81
Q

Problems with asthma

A

Permanent airway changes = airway remodeling = nonresponsive to therapy

82
Q

Problems with DIAGNOSIS of asthma

A

 Coughing, wheezing, and bronchospasm are NOT exclusive to asthma = hard to diagnose

83
Q

 Asthma involves interaction of

A 
host factors (genetics) and environmental exposures (smoking) which occur during an
important time in immune system development
84
Q

Chronic cough =_______

 not required to diagnose asthma_______

A

most common manifestation of asthma in children

Wheezing

85
Q

Acute vs Chronic airway

A

know difference

86
Q

Potential perioperative complications for

Assess for

A

 Bronchospasm, pneumonia, pneumothorax, death
 Assess severity and control before surgery
 Note presence of nocturnal dry cough, > 3 wheezing episodes in past 12 mo, Hx eczema

87
Q

Treatments of asthma

A
  • Albuterol
  • ICS
  • Increased ICS, manipulate mixture of SABA and ICS, and Also LABA, and theophylline.
88
Q

For asthma , do we discontinue meds preop

A

NO

89
Q

KETAMINE and ASTHMA

A

Ketamine IV induction agent of choice  Bronchodilation!

90
Q

Desflurane and ASTHMA →

A

↑risk of bronchospasm  Avoid in asthmatics

91
Q

 Surgical stimulation can trigger

A

bronchospasm if not deep enough

92
Q

Indication of Intraoperative bronchospasm

A

 Polyphonic expiratory wheezing
 Prolonged expiration
* Increased PEAK airway pressures (MOST IMPORTANT)
 Expiration with increased respiratory effort
 Slow upslope ETCO2 waveform
 ↑ETCO2
 ↓O2

93
Q

Most important indication of Intraoperative bronchospasm?

A

increased PEAK AIRWAY PRESSURE

94
Q

Treating intraoperative bronchospasm
_____Anesthesia, FiO2, PEEp, expiratory time
which does what?

A 
 Remove triggering stimulus if possible
 Deepen anesthesia
 ↑FiO2
 ↓PEEP (Remove if able)
 ↑expiratory time
 Minimizes alveolar trapping
95
Q

Meds to treat intraoperative bronchospasm

steroids?

A 
 Inhaled β-agonists
 4-8 puffs
 More bronchodilation c/coadministration of ipratropium
 Corticosteroids
 Chronic use = adrenal crisis
96
Q

I: E ratio should be appropriate

A

Expiratory 2 seconds (best alveoli exchange)

97
Q

Are you able to put albuterol in anesthesia circuit

A

yes

98
Q

_____________preferred over tracheal administration

Dose_______ may be repeated, followed by ________

A
  • IV salbutamol (albuterol) (because patient is not breathing well so IV route is better)
  • 10 mcg/kg  May be repeated, followed by 5 -10 mcg/kg per minute for first hour until improvement
99
Q

Epinephrine is an effective__________ (least favored)

A

bronchodilator

Dose: 0.05-0.5 mcg/kg/min

100
Q

Status asthmaticus
Beware of _________ and
Signs of ___________
Other signs include

A 
 Beware of drowsy, silent child with quiet chest
 Imminent respiratory arrest
 Other signs: 
paradoxical thoracoabdominal movement
bradycardia
absence of pulsus paradoxus
101
Q

Stats asthmaticus treatment

A

Requires emergent intubation

IV magnesium may be helpful

102
Q

Bronchospasm compared to anaphylaxis differentiated from asthma by systemic signs

A

 Angioedema, flushing, urticaria, CV collapse

103
Q

Atopy-associated asthma =

A

↑risk of anaphylaxis c/NMB, antbx, latex

104
Q

What not to do in an attempt to treat asthma

A 
What NOT to do:
 Antibiotics
 Aggressive hydration (unless dehydrated ped)
 Mucolytics
 Chest physiotherap
105
Q

Cystic fibrosis is a _________Disorder on chromosome

A

Autosomal recessive

7

106
Q

Cystic Fibrosis is
Affect regulation of __________ in ________ surface
Impacts ______, _____, ______< _____

A

Affects regulation of chloride and other ion fluxes at epithelial surfaces
• Impacts sweat ducts, airways, pancreatic ducts, intestine, biliary tree, vas deferens

107
Q

In cystic fibrosis there is __________concentration,

A

• Increased sweat chloride concentrations
viscous mucus production, lung Dz, intestinal obstruction, pancreatic insufficiency, biliary cirrhosis
• Multisystem disease

108
Q

Pulmonary issues with cystic fibrosis
MOST major problem is (caps) , impaired _________ ____
Organisms involved
exacerbation

A
  • MUCUS PLUGGLING, chronic infection, inflammation, epithelial injury, increased secretions, impaired ciliary clearance → infection
  • Staph. Aureus, H. influenza
  • Exacerbations of cough/sputum production
109
Q

Pulsus Paradoxus

A

Change in pressure when they take breaths

110
Q

Recurrent exacerbations

A

→progressive airway obstruction, bronchiectasis, emphysema, V/Q mismatching, hypoxemia  Hemoptysis (growth of vessels with bronchiectasis)

111
Q

Bronchial reactivity/airway resistance = common

 Bullae formation =

A

pneumothorax

112
Q

In Cystic Fibrosis , PFTs reflect ______pattern

A

PFTs reflect obstructive pattern (↑FRC, ↓FEV1/VC , ↓PEF)

113
Q

Cystic Fibrosis end stage

A

cor pulmonale –> Cardiomegaly, fluid retention, hepatomegaly

114
Q

More hemoglobin S than

A

A

115
Q

Anesthesia complications for Cystic Fbrosis
Assess.
They have problem with___________

A

Assess severity, current state, progression, current
therapies, order advanced diagnostics if you suspect
major organ dysfunction
 Problem with mechanical ventilation
 Breathing in non-warmed, un-moisturized air

116
Q

For rate of O2, considered high flow

A

4L high flow

117
Q

Anesthesia complications Other lower structures have to expend energy warming

A

 Less effectively, more likely to dehydrate, mucus gets thicker

118
Q

Inhaled anesthetics directly impairs (3)

A

mucociliar escalator
blunts cough response
decreases ventilatory

119
Q 
Anesthesia consideration:
 Nebulized saline treatment up until surgery
 HME (Keep moisture in the circuit )
 Clear secretions
 Can increase \_\_\_\_\_\_\_\_\_\_\_
 Extubate after\_\_\_\_\_\_\_\_\_
 Sitting up 30-40°
A

as needed but don’t over do it
- fully reversing NMB
airway resistance

120
Q

Postop for Cystic Fibrosis :

A

continue humidification, initiate physiotherapy PRN,

careful titration of narcotics, early mobilization

121
Q

Sickel Cell disease is
 Mutation @
Gene codes_______ instead of______

A

Inherited hemoglobinopathy
chromosome 11
hgb S; hgb A

122
Q

Sickle cells characterized by

A

 Characterized:
Acute episodes of pain, acute and chronic pulmonary disease, hemorrhagic and occlusive stroke, renal
insufficiency, and splenic infarction,

123
Q

Mean life expectancy of sickle cell patients

A

shortened to just over 3 decades

124
Q

 Acute chest syndrome (ACS)
- Lung damage  Diagnosis: chest infiltrate c/ chest pain, fever 101.3°F (38.5°C), tachypnea, wheezing, cough
 Etiologies: infection, fat embolism after bone marrow infarction, pulmonary infarction, and surgical
procedures
 Associated with younger pts, ↓ body temp, and greater blood loss

A

due to SCD

125
Q

Diagnosis:

A

chest infiltrate c/ chest pain, fever 101.3°F (38.5°C), tachypnea, wheezing, cough

126
Q

 Etiologies of SCD

Associated with younger pts, ↓ body temp, and greater blood loss

A

infection, fat embolism after bone marrow infarction, pulmonary infarction, and surgical
procedures

127
Q

Sickle cell do not let these patients get

A

COLD

128
Q

Chronic = sickle cell lung disease  Manifestations: 

A

Obstructive pattern in children, restrictive in adults
 Later stages:  Both VC + TLC↓, gas diffusion impaired,
pulmonary fibrosis, pulmonary artery hypertension, right
-sided cardiomyopathy, and progressive hypoxemia

129
Q

Get a CXR and look for

A

 Decreased distal pulmonary vascularity
 Diffuse interstitial (eventually pulmonary) fibrosis
 Cardiomegaly

130
Q

Perioperative management Cystic Fibrosis
Transfusion to
Goal:__________
 ↑risk
 High risk: children c/risk or hx of stroke
 Risk factors: low hgb, HTN, male gender
 Commonly develop postop atelectasis
 Fine line with pain medicine
 Too much = atelectasis, not enough =

A

PRBC transfusion to decrease risk of periop ACS
correct anemia to Hct 30%
-hypoventilation…atelectasis

131
Q

 Anesthesia goals for SCD

A

regional when possible, nonopioid
analgesics, incentive spirometry, early mobilization,
good pulmonary toilet
 Support gas exchange: supplement O2, positive
pressure, bronchodilators, correction of anemia

132
Q

Key points: neonates alveoli ______and _______

A

Fewer and smaller

133
Q

Key points: Neonates lung compliance and chest wall?

A

Fewer and smaller alveoli reduce lung compliance

CHEST WALL is very compliant

134
Q

Key points: Because there is _______in lung compliance and _______in chest wall compliance, those two things promote 2 things

A

Chest wall collapse during inspiration

Low residual volume at expiration

135
Q

Key Points : The low residual volume, FRC is __________which limit _______Reserve when there is ______ such as when there is an intubation attempt, therefore, it predisposes neonates to _________and _________

A

Lower; O2 reserve; Apnea; Atelectasis and hypoxemia

136
Q

Key Points: These features make them NOSE BREATHERS up until what age____? Nwrrowest part ?

A

Larynx : anterior and cephaload
Epiglottis: longer
Trachea and neck: shorter
Cricoid

137
Q

Key Points: Cardiac SV is _________ because of ______and noncompliant _______ventricle in neonates and infant.Therefore ______is very sensitive to changes in HR

A

fixed; immature ; left

138
Q

Key points: Why do pediatric are at risk for greater heat loss to environment?

A

Thin skin, low fat, greater surface area in relation to weight

139
Q

Key points: Hypothermia put the pediatric patient at risk for

A

Delayed awakening
Arrhythmias
Respiratory depresswion
Increased PVR.

140
Q

Neonates, infants and children have

A

GREATER ALVEOLAR VENTILATION

REDUCED FRC

141
Q

Key points: Because neonates and kids have greater ventilation (MV) to FRC ration what does it lead to ___________ combined with greater ____________ there is ________ _______

A

Rapid increase in alveolar anesthetic concentration; Greater blood flow to the brain ; Speed inhalation induction

142
Q

Key points: Viral infection

A

Viral infection within 2-4 weeks before anesthesia/ ETT appears to put at increased risk for pulmonary complications including, wheezing, laryngospasm, HYPOXEMIA, and ATELECTASIS

143
Q

How can you avoid laryngospasm in the pediatric patient?

A

Extubating while awake
OR
Extubating while deeply sedated

144
Q

Children and succynylcholine

A

At higher risk for adverse effects related to SUCC.

145
Q

Pediatric Scoliosis due to ______ ______ are predisposed to

A

Muscular dystrophy: arrhythmia, MH , untoward effect of succinylcholine.

146
Q

Children not pre-medicated with atropine may experience __________with succinylcholine

A

Profound Bradycardia

SNRAObPedGer (25 decks)

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