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Anesthesia II > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

If a patient has ongoing pulmonary disease, then they should really be cleared by

A

their pulmonologist or medical doctor prior to surgery

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2
Q

A person usually (underestimates/overestimates) how much they smoke per day?

A

Underestimates

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3
Q

During auscultation, patients should take ____ breaths first, and then ___ breaths

A

quiet, then deep

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4
Q

Describe bronchial breath sounds

A

Normal breath sounds of the tracheobronchial tree (large airways).

Heard best at: Trachea, sternoclaviular joint, and the right posterior interscapular space

Sounds like: High pitch and rapid/loud air movement

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5
Q

With bronchial breath sounds there is a ____ between inspiration and expiration

A

Pause

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6
Q

Describe vesicular breath sounds

A

Normal sounds you should hear over lung tissue
Softer and lower pitched than bronchial
No pause between inspiration and expiration.
Expiration is shorter (meaning we will hear more during inspiration)

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7
Q

When are bronchial breath sounds abnormal

A

Whenever they are heard somewhere they shouldn’t be (in the periphery)

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8
Q

What is lung consolidation?

A

Lung tissue that has been filled with liquid

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9
Q

What type of breath sounds should you hear in consolidation?

A

Low pitched-bronchial (more bronchial because the tissue that should be making vesicular sounds are not opening)

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10
Q

What is cavitary disease?

A

Disease where normal lung tissue is replaced by a cavity

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11
Q

What type of breath sounds should you hear in cavitary disease?

A

High pitched bronchial, because the lung tissue that should be making vesicular sounds is replaced by a cavity (essentially a large-airway).

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12
Q

When are crackles insignificant?

A

If they clear with deep breathing

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13
Q

What is wheezing?

A

Musical noise as air passes through constricted bronchioles. Usually heard on expiration (when the airways constrict), but can be heard on inspiration as well.

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14
Q

What is stridor?

A

High pitched sound on inhalation due to narrowing of the larynx. Think about how hard you would be truing to breathe in if your larynx was constricted!

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15
Q

Can PFTs be used alone to make a diagnosis?

A

No, they must be taken into consideration with other factors

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16
Q

What are PFTs used for?

A

Diagnosis
Evaluate disease progression and treatment
Assessing risk of pulm compliations

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17
Q

Who are good candidates for PFTs?

A 
COPD
Smokers with persistent cough
Wheezing or dyspnea on exertion
Morbid obesity (once they have pulm HTN or OHS)
Thoracic surgery patients (lung surgery)
Open upper abdominal procedures
Those > 70

Remember that PFTs are NOT routinely recommended. Just for those you questions how well they will do from a pulm standpoint post-op

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18
Q

Tests that assess abnormalities of gas exchange

A

ABG
Pulse-ox
Capnography

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19
Q

Spirometry

A

Tells you:
1) Volume (Normal is 80-120% of predicted value)

2) Flow (normal is 80-100% of predicted value)

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20
Q

Predicted values for spirometry are based on

A

Age
Height/weight
Gender
Race

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21
Q

Asthma is a disease of

A

inflammation

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22
Q

What happens to lung volumes in restrictive disease?

A

A proportional decrease in ALL lung volumes

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23
Q

What is the most commonly measured parameter in spirometry

A

Vital capacity

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24
Q

What is normal VC?

A

60-70mL/kg

Normal is >80% of predicted value

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25
Q

What is FVC?

A

Forced vital capacity (max inspiration followed by a FORCED expiration–meaning the patient has to cooperate with the test).

It graphs volume vs. time (meaning that it measures FLOW).

Test measures resistance to flow:
80-120% is normal
70-79% = mild
50-69% = moderate
<50% = severe
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26
Q

In COPD, FVC will be

A

Reduced (even if their VC is normal)

This is because the small airways close early and cause gas trapping

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27
Q

What is FEV1?

A

The amount of air you can forcefully expire in 1 second.

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28
Q

FEV1/FVC values

A 
70-80% = normal
60-75% = mild obstruction
50-59% = moderate obstruction
<50% = severe obstruction
29
Q

What is FEF25-75%?

A

Forced expiratory flow during the middle portion of FVC.
May reflect effort independent expiration and small airway status.
Sensitive in early stages of obstructive disease

30
Q

What is more reliable in early disease, FEF25-75% or FEV1/FVC?

A

FEF25-75%
- Remember that this is the effort independent portion and is sensitive to the status of small airways, especially early in disease

31
Q

Interpretation of FEF25-75% values

A

> 60% of predicted value = normal
40-60% = mild
20-40% = moderate
<10% = severe obstruction

32
Q

What is maximum voluntary ventilation (MVV)?

A

The largest volume of air a person is able to inhale and exhale in one minute (although test is only performed over 10, 12, or 15 seconds)

33
Q

MVV is ____ in obstructive disease

A

decreased

34
Q

MVV is ____ in restrictive disease

A

Normal (although someone with restrictive disease d/t to paralysis will have a decreased MVV)

35
Q

What information does FRC tell you?

A

Tells you about compliance and how well someone can tolerate apnea.

Someone with a low FRC will have a harder time maintaining their sats during apnea.

36
Q

How is FRC measured?

A

Nitrogen wash-out
Basically, someone breathes 100% O2 until the nitrogen analyzer attached to the spirometer detects a nitrogen concentration < 7%. Then all the nitrogen the person breathed out is added together to calculate FRC.

37
Q

Appearance of the flow/volume loop in obstructive disease

A

Scooped out expiration d/t air trapping

38
Q

FV Loop in restrictive disease

A

Basically a normal loop, but skinnier d/t reduced volumes (volume is on the x axis)

39
Q

Flattened upstroke in a FV loop indicates

A

Some sort of upper airway obstruction such as tracheal stenosis.
In the anesthetized patient, this could be a mucus plus, kinked ET tube, etc.

40
Q

PA, Pa, and Pv pressures and Lung Zones

A

Zone 1: PA > Pa > Pv
Zone 2: Pa > PA > Pv
Zone 3: Pa > Pv > PA

41
Q

Does Zone 1 type V:Q normally occur in the awake and spontaneously breathing patient?

A

NO! Normally, we should have enough BP to force blood into the apices.
However, this type of V:Q may occur if BP drops or alveolar pressure increases (like in PPV!)

42
Q

Does Zone 3 type V:Q normally occur in the awake and spontaneously breathing patient?

A

NO! Normally a nice deep breath should provide enough PA to overcome the arterial and venous pressures.

43
Q

Zone 3 is an example of a

A

Shunt. Because there is a lot of blood flow, but little ventilation.

44
Q

In the awake and spontaneously breathing patient, where is ventilation the smallest?

A

At the highest portion of the lung

45
Q

In the awake and spontaneously breathing patient, where is ventilation the best?

A

In the more dependent parts of the lung. Here, the alveoli are compressed d/t gravity and the lung tissue has good compliance.

46
Q

Pulmonary risks of PPV

A

Atelectasis (if not enough TV)
Increased blood flow to the dependent lung
Increased ventilation in the independent lung
(^^ above two cause worsened V:Q mismatch)
Dead space (apparatus)
Potential for barotrauma

47
Q

How to counteract the pulm risks of PPV

A

Set PAW pressures to 15cm above what their normal PAW is
Deliver an adequate TV (to prevent atelectasis)
Maintain BP to perfuse the lung well
PEEP (prevent atelectasis)
FiO2

48
Q

CV risks of PPV

A

Decreased preload and BP
(decreased preload will decrease CO, which decreases BP)

Can cause right to left shunt if the person has an atrial-septal defect

Counteract these effects with positioning, fluids, alpha and beta stimulants, and inotropes

49
Q

Who may cancel a case if the patient has been smoking?

A

Plastics or ortho, because it will interfere with wound healing.

50
Q

How to maximize pulm function before surgery?

A

Smoking cessation
Mobilize secretions and treat infections
Treat bronchospasm
Improve motivation ad stamina

51
Q

Effects of smoking cessation

A

12-24 hours = carboxyhemoglobin levels return to normal, and patient is able to oxygenate better
2-3 weeks = mucociliary function returns and the patient has an increase in secretions and airway irritability
4 weeks = secretions reduce
8 weeks = rate of post-op pulmonary complications decrease** ideal amount of time to stop smoking before surgery

52
Q

How can we help mobilize secretions?

A

Hydrate!!
Vibration/percussion
Aerosol therapy
Mucolytic agents?? (may increase secretions and cause irritable airways)

53
Q

Meds used to treat/prevent bronchospasm

A

B2 agonists
Anticholinergics (atrovent)
Methylxanthines
Corticosteroids (will probably need a booster dose of this before surgery)

54
Q

Point to note with FRC and restrictive disease

A

FRC will be reduced, so less safe apnea time. Be careful with your pre-op sedation.

Also, this decrease in FRC accelerates uptake of inhaled agents

55
Q

Restrictive disease and regional anesthesia

A

Be careful of block > T10. This will cause loss of accessory muscles that they need to breath!!

56
Q

Restrictive disease and PPV

A

Expect increased PAW pressures
Decrease TV to 4-8 mL/kg
Increase RR to 14-18 (to normalize MV)
Give PEEP (but remember this will decrease preload)

57
Q

Affect of anesthesia on FRC

A

Normally, there is a 10-15% decrease in supine position
Additional 5-10% with GA
Plateau of FRC occurs after 10 minutes, regardless of ventilation
Can take up to 3-7 days for FRC to recover after upper abdominal surgery

58
Q

VC may have up to a ___% reduction after an upper abdominal procedure, and take up to __ days to return to normal

A

40%
14 days
And this is for a healthy patient! Will be even worse for someone with pulmonary disease

59
Q

How can we reduce airway reactivity?

A

Aggressive bronchodilator therapy
High alveolar concentrations of inhaled anesthetics (remember that IAs are bronchodilators!!)
IV opioids/lidocaine prior to AW manipulation
Single-dose corticosteroids

60
Q

Vent management for obstructive disease

A

Large TV (remember their lung volumes are increased!)
Slow resp rate
Longer exp-time
Keep PIP below 40cmH20

Intrinsic PEEP may occur due to air trapping

61
Q

In obstructive disease, MVV is

A

reduced

62
Q

In restrictive disease, MVV is

A

normal

although it depends on cause, obviously someone with muscle disease will have reduced MVV

63
Q

What does FRC tell you about?

A

Safe apnea time and pulmonary compliance

64
Q

Effect of obstructive disease on FEF25-75%

A

Reduced

Remember that this test tells you about the small airways, and small airways close early in obstructive disease

65
Q

When may zone 1 occur?

A

PPV or drop in BP

66
Q

In PPV, you get increased ventilation to the ______ lung

A

Independent

67
Q

Vent settings for restrictive disease

A

Lower TV (4-8mL/kg)
Increased RR (14-18bpm)
Give PEEP
Expect high peak airway pressures

68
Q

In obstructive disease, we should avoid PIP above

A

40

Remember that their airways have thinned, and we want to avoid high pressures.

Anesthesia II (11 decks)

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