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Coexisting 2016 > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Characteristics COPD and asthma:

A

Chronic Obstructive diseases characterized by:

  • Chronic airway inflammation
  • Airway wall thickening (epithelial, submucosa and smooth muscle) → impairs gas exchange
  • Expiratory airflow obstruction
    • ​Asthma = reversible
    • COPD = not reversible or incompletely reversible​​
  • Airway hyperreactivity
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2
Q

Causes of asthma exacerbations:

A
  1. Allergens
  2. Exercise
  3. Nightime/sleep
  4. Chemicals (ASA/NSAIDs, VAs, irritants)
  5. Cold
  6. Infection
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3
Q

S/s of asthma:

A
  1. Wheezing
  2. Breathlessness/Air Hunger
  3. Chest tightness
  4. Early AM or nighttime cough
  5. Reversible airflow obstruction
  6. Tachypnea
  7. Prolonged expiratory phase
  8. Fatigue
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4
Q

Pre-op assessment of asthma:

A
  1. Triggers
  2. Severity (med requirements)
  3. Degree of reversibility w/ tx
  4. Current status, symptoms
  5. Prior anesthesia history
  6. Breath sounds
  7. general appearance, etc
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5
Q

Pre-op labs for asthma:

A
  1. PFTs
  2. ABG
  3. ECG (RH failure)
  4. CBC (eosinophils)
  5. CXR (hyperinflation of lungs)
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6
Q

Pre-op meds for asthmatics:

A
  1. Benzos
    1. anxiety can precipitate bronchospasm bronchospasm)
  2. Opioids
    • be sure to titrate carfully
  3. H2 antagonists
    • unopposed H1 antagonism may cause bronchoconstriction- Use Caution!
  4. Bronchodilators
    • albuterol) - 15-30 min before
  5. Pre-op steroids - prohylaxis
    • Hydrocortizone 100 mg q8h if FEV1 predicted
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7
Q

Overall goal for induction of anesthesia in asthmatics

A

GOAL= Blunt airway reflexes and avoid bronchoconstriction during airway instrumentation

  1. Consider Regional (good choice)
  2. Whenever possible, use LMA for smoother emergence/extubation
  3. GA should:
    1. ​depress airway reflexes
      • Lidocaine 1-1.5 mg/kg IV (consider LTA)
      • Opioids -judiciously (fentanyl and analogues)
    2. Avoid hyperreactivity
      • Use High MAC >1.5 for bronchodilation and bronchial reflex inhibition (Sevo and halothane are the least irritating)
      • ​AVOID desfluane/isoflurane - airway irritant
      • Propofol and ketamine is best for induction
        • <span>avoid Sodium metabisulfite prep </span>
        • <span>Higher end of induction doses</span>
      • Ketamine will increase secretions which may irritate the airway, but does bronchodilate - maybe give some glyco?
      • Maybe AVOID ketoralac/NSAIDS - increased leukotrienes via lipooxygenase pathway
    3. Treat bronchoconstriction
      • ​albuterol
      • sevoflurane
    4. AVOID histamine realease
      • ​​Sux, atricurium, mivicurium, D-tubo, morphine, demerol, thopental
    5. ​​​Neostigmine is ok for reversal, but MUST be given with anticholinergic - glycopyrolate
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8
Q

Maintenance of anesthesthesia in asthmatics:

A
  1. High concentration VA
    1. Sevo/halo are least pungent/irritating
  2. Avoid histamine releasers (sux, atra, miva)
  3. Avoid bronchospasm
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9
Q

Ventilation goals for asthmatics:

A

Ventilation

  1. Avoid PEEP !! →prone to air trapping
    • these pts may have intrinsic peep r/t air trapping
    • during an acute attack, may see “breath stacking”
  2. Decrease RR (8-10 bpm) - allows for adequate exhalation
  3. Longer I:E ratio
  4. Increase TV - to maintain Normal PaCO2
    1. TV and inspiritory flow rates are limited by excessive peak airway pressures
    2. Upper Limit - 40 cm H2O
  5. If you can choose a mode – consider using PCV over volume controlled ventilation
  6. Liberal hydration of pt and circuit
    • Place a humidifier in the breathing circuit
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10
Q

Treatment of intra-op bronchospasm:

A
  1. FiO2 to 100%
  2. Deepen anesthesia with VA or drugs
  3. Give a ß-agonist
  4. If no air movement:
    1. Epinephrine IV: 2-8 mcg/min (SQ 0.3-0.5mg q20-30min)
    2. Terbutaline (SQ)
    3. Corticosteroids: 1-2 mg of cortisol
  5. Other IV broncholilators
    1. Ketamine
    2. Propofol
    3. Lidocaine
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11
Q

Emergence/post-op care for asthma:

A
  1. Smooth emergence - ETT promotes bronchoconstriction and airway resistence
  2. Pre-emptive albuterol, IV lido 10-15 minutes prior to wake up
  3. Deep extubation if possible
  4. If not, try to get patient to SV as early as possible
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12
Q

Characteristics of COPD:

A
  • Progressive airway obstruction
  • Chronic bronchitis and/or emphysema
  • Smoking #1 risk factor
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13
Q

COPD staging:

A
  1. Stage 1: FEV1 > 50% predicted
  2. Stage 2: FEV1 35-49%
  3. Stage 3: FEV 1 < 35%
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14
Q

“Blue bloaters”:

A
  1. Chronic bronchitis
  2. Copious secretions cause obstruction
  3. Cough
  4. Diminshed breath sounds
  5. PaO2 →cyanosis and dusky appearance
  6. PaCO2 > 45
  7. Pulmonary hypertension d/t HPV
  8. Marked cor pulmonale/righ sided heart failure
  9. Overweight
  10. CXR: increased bronchovascular markings
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15
Q

“Pink puffers”:

A
  1. Emphysema
  2. Obstruction due to loss of recoil
  3. Severe dyspnea
  4. PaO2 > 60
  5. Normal PaCO2
  6. Very diminished breath sounds
  7. Tend to be thin
  8. anxious, pursed lips
  9. CXR: hyperinflation with a low diaphragm
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16
Q

Smoking cessation timeline:

A
  1. 12-24 hours:
    • decreased carboxyhemoglobin levels to normal
  2. 2-3 weeks:
    • ciliary function improves, increased airway secretions, hyperreactivity
  3. 4 weeks: PFTs improve
  4. 8 weeks:
    • decreased rate of postoperative complications
    • immune, metabolic function normalizes

​(if patient cannot quit for four weeks before surgery, it is better to only have them quit for 24 hours before)

17
Q

Induction in COPD patients:

A

GOAL= minimize risk of post op respiritory failure

  1. Caution with pre-medication
    • They don’t tolerate respiratory depressant effects of drugs (medulla is “reset” d/t chronic hypercarbia, so these pts are less sensitive to ↑ levels of CO2)
    • Hold opioids until the pt is hooked to monitors and with oxygen on
  2. Ketamine is good for pts who tolerate the CV effects, otherwise propofol
  3. Regional is a good choice: Avoid levels > T6
  4. Depress airway reflexes/reactivity
    • Lidocaine 1-1.5 mg/kg IV (consider LTA)
    • Opioids -judiciously (fentanyl and analogues)
    • Consiter comorbitities for other agents (Heart failure??)
    • Sevo may be best for bronchodilation (least irritating)​
    • AVOID desfluane/isoflurane - airway irritant​
    • albuterol
  5. AVOID histamine realeasers
    • ​Sux, atricurium, mivicurium, D-tubo, morphine, demerol, thopental
  6. Use Short acting NMB-
    1. monitor with TOF so you know you are able to reverse
  7. ​Neostigmine is ok for reversal, but MUST be given with anticholinergic - glycopyrolate
18
Q

Maintenance in COPD patients:

A
  1. Cautious with N2O;
    1. Given in high concentration→limits the amount of oxygen delivery
    2. can cause rupture of bullae from emphysema→ pneumothorax
  2. VAs bronchodilate ​but also attentuate Hypoxic Pulmonary Vasoconstriction reflex
  3. Increased gradient between PaCO2 and ETCO2
    • ​ this is r/t air-trapping & ↑deadspace ventilation
  4. Opioids - less useful than VA’s for maintenance phase b/c can be associated w/prolonged depression of ventilation & delayed emergence
  5. ​​Humidification
19
Q

Ventilation goals in COPD patients:

A
  1. No PEEP
  2. Large TVs (10-15ml/kg)
    • Large TV’s = ↓ likelihood of turbulent airflow and help maintain optimal VQ matching
  3. low RR (6-10 bpm)
    • sufficient time for venous return;
  4. Humidifier in circuit
  5. Consider patient’s baseline CO2 and tolerate hypercarbia based on it
    • are they a blue bloater or pink puffer?
  6. Monitor for air trapping
    • ​monitor for intrinsic PEEP or dynamic hyperinflation r/t air-trapping (expiratory volume never reaches baseline again, so next breath starts out at a higher baseline volume)
20
Q

Emergence and post-op management in COPD patients:

A

Postoperative ventalitory status is the Priority issue

  1. May need to stay intubated/ventilated for prolonged period (they are susceptible to acute respiratory failure during post-op pd (d/t atelectasis, hypercapnia, hypoxemia, retention of secretions, bronchospasm​)
    • esp. after abdominal/thoracic surgeries →but the goal is to get them extubated as <strong>soon as possible</strong>, they wil do better!
    • <strong>Education</strong> →Post op ventilation is NOT a complication, but rather an expected result
  2. Adjust vent based on blood gasses
  3. Adequate pain control
    • allows for pain free breathing and improved coughing & to avoid splinting → reduced atelectasis risk
21
Q

Causes of reduced lung compliance:

A

Normal compliance = 100-200ml/cmH​2O

  1. Increased fibrous tissue
    • long-standing COPD, sarcoidosis, bleomycin toxicity
  2. Alveolar edema
    • sepsis, re-expansion pulm edema, negative pressure pulm edema
  3. Low lung volumes
    • atalectasis
  4. Increased pulm venous pressure
    • pulm HTN secondary to chronic Hypoxic Pulmonary Vasoconstriction
22
Q

Four types of restrictive lung disorders with examples:

A
  1. Acute intrinsic (pulm edema, ARDS, aspiration pneumonitis)
  2. Chronic intrinsic (pulm fibrosis, sarcoidosis)
  3. Chronic extrinsic (chest wall/ab/neuromusc diseases, obesity, kyphosis)
  4. Disorders of pleura/mediastinum (tumors, pneumothorax, pleural effusions)
23
Q

Describe re-expansion pulm edema:

A

Acute Intrinsic restrictive disorder

Occurs after rapid evacuation of > 1L from pneumothorax/effusion that’s > 24 hours old, due to enhanced capillary membrane permeability

  1. Treament:
    1. O2
    2. PEEP
    3. no diuretics unless volume overload is primary issue
24
Q

Describe negative pressure pulmonary edema:

A

Acute Intrinsic restrictive disorder

Occurs minutes to 2-3 hours after acute upper airway obstruction (in a spontaneously breating patient)

  1. Highly negative intrapleural pressure causes:
    • decreased interstitial hydrostatic pressure
    • increased venous return
    • increased LV afterload
    • incerased SNS outflow→HTN and displacement of blood volume
    • Acute pulmonary edema
  2. Most often caused by:
    • post-extubation laryngospasm
    • attempting to breath against closed airway- muscle guys
    • Obstructve sleep apnea, hiccups, epiglotitis, tumors
  3. self-limiting to 12-24 hour duration
  4. Treatment:
    • O2
    • airway monitoring/maintinence (C-Pap if needed)
    • mechanical ventilation + PEEP if needed
25
Q

Aspiration Pneumonitis s/s and treatment:

A

Acute Intrinsic restrictive disorder

Gastric Acid aspirate is rapidly distributed through the lungs it destroys surfactant producing cells and injures lung epithelium

  1. Results in capilary permability/atelectesis
  2. s/s:
    • arterial hypoxemia (decreased sats)
    • Tachypnea
    • Bronchospasm
    • Pulmonary vascular constriction can causel pulmonary HTN
    • X-ray shows changes 6-12 hours later
  3. Treatment:
    • Increase FiO2
    • PEEP
    • B2 agonists (albuterol) bronchodilation
    • Bronchoscopy if suspect solid material
    • generally abx and steroid use is not used
26
Q

sarcoidosis

  • what is it?
  • how do these patients present?
  • what are the anesthetic considerations?
A

Chronic Intrinsic restrictive disorder

Systemic granulomas disorder that leads to pulmonary fibrosis leading to cor pulmonale and pulmonary hypertension

  • Laryngeal sarcoid = Decrease diameter of airway (smaller tube and difficultairway/intubation)
  • Myocardial sarcoid = heartblocks, dysrhythmias, restrictive cardiomyopathy → cardiac involvement
  • Liver, spleen, unilateral optic and facial nerves palsey

  1. Often present w/ dyspnea, cough & rapid shallow breathing
  2. Cor pulmonale and pulm HTN are likely
  3. Decreased alveolar diffusion capacity
  4. Often haveng a mediasinoscopy →lymph node biopsy
  5. Often times on corticosteroids→STRESS DOSE!
  6. Check electrolytes; check for hyperclacemia r/t metabolism of granulomas
27
Q

Consiterations with chronic extrinsic lung disease:

A
  1. Chest wall disorders
    • decreased lung voume corespond with increased airway resistence
  2. Neuromuscular disorders -
    • Inefective cough/clearance of secretions
    • prone to infection/pneumonia
    • high risk for aspiration d/t ineffective swallowing.
  3. Mediastinal tumors
    • ​​can compress the pumonary artery, myocardium or SVC
    • can occulde airway if given a muscle relaxant
28
Q

S/s of pneumothorax:

A
  1. Acute dyspnea
  2. Ipsilateral chest pain
  3. Decreased PaO2
  4. increased PaCO2
  5. Hypotension
  6. Tachycardia
  7. Uneven/decreased chest wall movement
  8. Hyperresonant percussion
  9. Decreased or absent breath sounds
29
Q

Regional anesthesia in restrictive lung disease:

A
  1. AVOID > T10 level = loss of accessory muscles
    • vital esp in spont breathing patients
  2. Good to note they don’t tolerate sedation well so regional may be benificial for post op pain control
30
Q

Induction in restrictive lung disease:

A
  1. Pre-meds: Titrate pre-meds carefully to avoid respiratory depression (lose accessory muscle function easily)
    • they need high minute vent to compensate for low volumes
  2. Pre-oxygenation critical d/t reduced FRC & decreased safe apnea time
  3. Will have a shorter apnea time - work efficiently
  4. Use nitrous with caution - risk for barotrauma!!
  5. May need etomidate if CV comorbidities
  6. Use short actinng NMB
31
Q

Maintenance in restrictive lung disease:

A
  1. AVOID nirtrous due to risk of barotrauma!!
  2. Volitile agents have accelerted uptake
    • decreased FRC and increased RR
  3. Mechanical ventilation:
    1. USE: ETT (LMA not a good choice→loss of accessory mucsle and inability to maintain oxygenation)
    2. Decreased Tidal Volume (4-8 mL/kg)
    3. Increased RR (14-18 breaths per minute)
    4. Expecct higher peak airway pressures but the goal is to keep 2O
    5. Consider the risk for barotrauma → high risk!!!
    6. Avoid excessive FiO2
32
Q

Pre-operative assessment and optimization for patients with restrictive lung disease

A

Assessment:

  1. What is their exercise tolerance & baseline dyspnea
  2. Can use PFTs, flow volume loops & ABGs to grade the severity of the restrictive disease
  3. Increased risk:
    • Decreased Vital Capacity < 15 ml/kg (70 ml/kg is normal)
    • Resting Hypercarbia

Optimization (5 things)

  1. Treat any active pulmonary infection
  2. Improve sputum clearence
  3. Treat cardiac dysfunction
  4. IS- to improve respiratory muscle strength & stamina
  5. Smoking cessation
33
Q

Respiratory criteria for extubation

A

Respiratory Criteria for extubation

  1. PaO2 > 60 mmHg
  2. SaO2 > 90%
  3. PaCO2 <50 mmHg
  4. Respiratory Rate <30 breaths/minute
  5. Tidal Volume > 300 mL (6 ml/kg)
  6. Vital capacity > 10-15 mL/kg (or SV of 2-3 ml/kg)
  7. Full reversal of NMB
  8. Return of laryngeal reflexes
  9. Adequate LOC & muscle strenght (head lift >5 sec)
34
Q

Post anesthethetic management for restrictive lung diseases

A

Have a lower threshold for:

  1. Post -op mechanical ventilation
  2. Monitoring in a postoperative bed & maybe a slow wean in ICU

High Risk of Post-op respiratory failure!!d/t ↓ lung volumes & impaired cough

  1. Transport to PACU with supplimental O2
  2. treat pain adequately, but avoid respiratory depression
    • ​​regional comes in handy
    • consiter the surgical site - thoracis surgery - you don’t want splinting but try to avoid atelectasis

​remember, pts present with:

  1. ​decreasde lung volumes and impaired cough
  2. rapid shallow breathing pattern
  3. abdominal impingement of diaphram
35
Q

Anesthetic management of ACUTE restrictive disease in critically ill Patients

A
  1. If the surgery is elective →CANCEL IT!
  2. If emergency surgery indicated
    1. Use diuretics for fluid overload
    2. vasodilators and inotropes for cardiac failure
    3. Consider drainage of pleural effusions/ascites pre-op
    4. May need an ICU vent -(for the propper settings)
    5. AGGRESSIVE hemodynamic monitoring
      • art line, CVP, +/- PA catheter
36
Q

Pharmacologic treatment for Asthma and COPD

A

BOTH Asthma and COPD

  • Inhaled ß-agonists (albuterol) - bronchodilation
  • Inhaled and systemic corticosteroids - decrease inflammation
  • Mast cell Stabilizers (Cromolyn) - decrease histamine release
  • Phosphodiesterase inhibitors - bronchodilation via increased cAMP (Thophyline/methyxanthines)

COPD - parasympatholytics - (atropine inhalers)

ASTHMA - leukotriene inhibitors (singulair)

Coexisting 2016 (12 decks)

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