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Advance Anesthesia II > Pulmonary Pathophysiology I PPT > Flashcards

Pulmonary Pathophysiology I PPT Flashcards

EXAM 3

1
Q

Pulmonary Hypertension (PH) Definition:

A
  • A mean pulmonary artery pressure of at least 25 mmHg
  • A pulmonary capillary occlusion pressure of 15 mmHg or less.
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2
Q

Pulmonary Hypertension (PH) Etiology:

A
  • Drug effects
  • Connective tissue disorders
  • COPD
  • Sarcoidosis
  • Idiopathic/genetic factors
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3
Q

PAH 5 Main categories:

A
  • Pulmonary arterial hypertension itself (PAH)
  • PH due to left heart disease
  • PH due to lung diseases and/or hypoxia
  • Chronic thromboembolic pulmonary hypertension
  • Causes with unknown mechanisms
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4
Q

Treatment of Cor Pulmonale:

A
  • Diuretics to reduce cardiac workload; use cautiously to maintain adequate preload.
  • Use supplemental O2 to achieve PaO2 > 60 mmHg or Saturation > 90%.
  • Heart Lung Transplantation in severe cases.
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5
Q

Pre-operative Care for Cor Pulmonale:

A
  • Eliminate or control pulmonary infections.
  • Reverse bronchospasm.
  • Improve secretion clearance.
  • Expand collapsed/poorly ventilated alveoli.
  • Correct hydration and electrolyte imbalances.
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6
Q

Intra-operative Management for Cor Pulmonale:

A
  • Use regional anesthesia when high sensory levels aren’t needed.

Key points:

  • Avoid hypotension.
  • Volatile agents that decrease PVR are preferred.
  • Isoflurane can lower PAP
  • Avoid N2O as it increases PVR
  • Intravenous agents generally have little effect on PVR.
  • Ketamine should be avoided due to its potential to increase PVR.
  • Crucial to avoid any manipulations that could increase PAP during anesthesia stages.
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7
Q

Intra-operative Principles for Cor Pulmonale:

A
  • Maintain good oxygenation.
  • Avoid acidosis.
  • Avoid exogenous and endogenous vasoconstrictors.
  • Avoid stimuli that increase sympathetic tone.
  • Avoid hypothermia.
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8
Q

Pulmonary Embolism (PE) is caused by:

A
  • A dislodged thrombus entering the pulmonary vascular bed.
  • Significant thrombus obstruction leads to forward ischemia and rearward cardiac overload.
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9
Q

Pulmonary Embolism (PE) Etiology:

A
  • Primarily caused by Deep Vein Thrombosis (DVT).
  • Venous thrombi formation promoted by

Virchow’s triad:

  • Stasis of blood flow.
  • Venous injury.
  • Hypercoagulable state.
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10
Q

Thromboembolic Risk Factors:

A
  1. Hereditary Thrombophilias
  2. Acquired Surgical Predisposition
  3. Acquired Medical predisposition
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11
Q

Thromboembolic Risk Factors

Hereditary Thrombophilias:

A
  1. Protein C deficiency
  2. Protein S deficiency
  3. Antithrombin II deficiency
  4. Factor V leiden mutation
  5. Prothrombin 20210 G A variation
  6. Hyperhomocysteinemia
  7. Dysfibrinogenemia
  8. Familial plasminogen deficiency
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12
Q

Thromboembolic Risk Factors

Acquired Surgical Predispositions

A
  • Major thoracic, abdominal, or neuro procedures
  • General anesthsia > 30 min
  • Hip arthroplasty
  • Knee arthroplasty
  • Knee arthroscopy
  • Hip fracture
  • Major trauma
  • Open prostatectomy
  • Spinal cord injury
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13
Q

Thromboembolic Risk Factors

Acquired Medical Predispositions

A
  • Previous venenous Thromboembolism
  • Advance age > 60 yr
  • Malignancy
  • CHF
  • CVA
  • Nephrotic syndrome
  • Estrogen therapy
  • Pregnancy
  • Postpartum period
  • Obesity
  • Prolonged immobilization
  • Antiphospholipid antibody syndrome
  • Lupus anticoagulant
  • Inflammatory bowel disease
  • Paroxysmal nocturnal hemoglobinuria
  • Behcet syndrome
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14
Q

Pulmonary Embolism (PE) Pathophysiology:

A
  • Occlusion of the pulmonary artery decreases ventilation distal to the obstruction.
  • Result: Bronchoconstriction due to alveolar PCO2 (PACO2) effect on local small airways.
  • Reduced airflow to the unperfused lung minimizes wasted ventilation.
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15
Q

Pulmonary Embolism (PE) Clinical Features:

A
  • Clinical presentation heavily influenced by embolus size.
  • Signs and symptoms of PE are varied and nonspecific, overlapping with many disorders.
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16
Q

Differential Dx of Acute Intraoperative PE

A
  1. Anaphylactic reaction
  2. Aortic dissection
  3. Aortic stenosis
  4. Brain stem stroke
  5. Bronchospasm
  6. Heart failure
  7. Hypertrophic cardiomyopathy
  8. Myocardial infarction
  9. Pulmonary hypertension
  10. Tension pneumothorax
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17
Q

Most common symptoms of Pulmonary Embolism:

A
  • Unexplained dyspnea
  • Chest pain (either pleuritic or atypical)
  • Anxiety
  • Cough
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18
Q

Most common signs of Pulmonary Embolism:

A
  1. Tachypnea
  2. Tachycardia
  3. Low-grade fever
  4. Left parasternal lift
  5. JVD
  6. Tricuspid regurgitant murmur
  7. Accentuated P2
  8. Hemoptysis
  9. Leg edema, erythema, tenderness
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19
Q

Diagnostic tests for suspected Pulmonary Embolism

A
  • Chest CT (most accurate)
  • D-dimer (rule out)
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20
Q

ECG signs assocaited with PE

A
  • Tachycardia
  • Negative T wave in V1-V5
  • Negative T wave in II, III, aVF
  • Right axis deviation > 90 degrees
  • Pulmonary P wave
  • R > S or Q in VR
  • RV ischemia
  • Complete or incomplete RBBB
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21
Q

Medical Management for Acute PE

A
  1. Begin UFH IV
  2. aPTT goal 80 sec
  3. Volume resucitation 500-1000 mL
  4. Give vasopressors and Inotropes
  5. Determine risk of thrombolytic therapy
  6. Consider IVC filter, embolectomy, sx embolectomy if therapy is too risky
  7. Avoid combination of Thrombolytics and IVC filter insertion
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22
Q

Prevention of Venous Thromboembolism by condition

A
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23
Q

Pulmonary Embolism (PE) Anesthetic Management:

A
  • Focus on preventing further embolism and supporting respiratory and cardiovascular function.
  • Aims to maintain vital organ function and minimize anesthetic-induced myocardial depression.
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24
Q

PE Anesthesia induction and maintenance must avoid:

A
  • Worsening arterial hypoxemia
  • Systemic hypotension
  • Pulmonary hypertension
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25
Q

Part II

Pulmonary Embolism (PE) Anesthetic Management:

A
  • Anesthesia should use drugs that avoid significant myocardial depression.
  • AVOID Nitrous oxide potential to increase PVR
  • A nNMBs drug that does not release histamine is preferred for its safer profile.

Avoid: Mivacurium & Atracurium

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26
Q

Initial indicators of Pulmonary Embolism (PE) During Anesthesia:

A
  • Decrease PETCO2
  • Tachycardia
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27
Q

Detection of Pulmonary Embolism (PE) During Anesthesia:

A
  • Decrease PETCO2 (initial)
  • Tachycardia (initial)
  • Decrease SaO2
  • Abnormal ABGs
  • Arterial hypoxemia
  • Increased PAP and CVP
  • Bronchospasm can occur
  • ECG may show right axis deviation
  • Incomplete or complete RBBB
  • Peaked T waves
28
Q

What are the classic nonspecific signs of a Massive Pulmonary Embolism?

A
  • Abrupt, unexplained hypotension
  • Tachycardia
29
Q

Pulmonary Embolism (PE) Anesthesia Management Intraop:

A
  • Prevent CV complications
  • Ensure airway by ETT
  • Stop anesthetics agents
  • Start 100% FiO2
  • Support circulation IV fluids/blood
  • Norepinephrine (vasopressor of choice)
  • Epi, Dopamine, Dobutamine + Norepi
30
Q

Part II

Pulmonary Embolism (PE) Anesthesia Management Intraop:

A
  • Treat ventricular dysrhythmias with IV lidocaine or amiodarone.
  • Optimize oxygenation with PEEP
  • Consider thrombolysis or pulmonary embolectomy
  • Prepare for severe hemodynamic challenges
  • Continue resuscitative efforts
  • In extreme cases, cardiopulmonary bypass may be required until obstruction is relieved
31
Q

Cor Pulmonale Primary Tx Focus:

A
  • Improve gas exchange
  • Especially in COPD patients
32
Q

Normal pulmonary circulation is:

A
  • Passive
  • Low resistance
  • Highly distensible
33
Q

Pulmonary Hypertension is caractherized by:

A
  • Increase Vascular tone
  • Growth and proliferation of pulmonary vascular smooth muscle
34
Q

Overload of the Right Ventricle can lead to:

A
  • Cor Pulmonale
  • Inhibition of coronary perfusion
35
Q

PH initial reversible vasoconstriction may progress to:

A
  • Muscle Hypertrophy
  • Irreversible degeneration
36
Q

Pulmonary Hypertension clinical features:

A
  • Dyspnea (first common)
  • Excercise intolerance (first common)
  • Angina
37
Q

Pulmonary Hypertension Diagnosis:

A
  • ECG changes
  • CXR
  • Cardiac Cath
  • Open-lung biopsy
  • ETCO2
38
Q

ECG changes seen with PH:

A
  • Right atrial hypertrophy
  • Right ventricular hypertrophy
39
Q

Chest x-ray on PH will show:

A

Enlarged pulmonary artery

40
Q

Pulmonary Angiography is most informative in assessment of:

A
  • PAH
  • Cardiac reserve
  • Pulmonary vasodilators therapy (effects)
41
Q

Non-invasive evaluation for PH include:

A

Dopple echocardiography

Tricuspid valve regurgitation

42
Q

ETCO2 is significantly reduced in patients with:

A

PAH

43
Q

PAH Pharmacological treatment:

A
  • Vasodilator agents(reversible vasoconstriction)
  • Alpha and Beta Adrenergic (least benefit)
  • Prostacyclin (Best benefit)
44
Q

Medications class commonly used with PAH:

A
  1. Soluble Guanylate Cyclase
  2. Endothelin Receptor Antagonist
  3. Phosphodiasterase-5 Inhibitors
  4. Prostacyclins
45
Q

PAH Anesthetic Management:

A
  • Prevent increases in PAH
  • Avoid major hemodynamic changes
46
Q

PAH PreOp Eval includes:

A
  • ECG
  • Echocardiogram
  • CXR
  • ABGs
47
Q

In PAH this condition should be optimize Preop:

A

COPD

48
Q

Chronic therapy for PAH should not be ________ for fears of its hypotensive effect

A

Discontinue

49
Q

PAH intraop hypotension treatment:

A
  • Vasopressors
  • Treat aggressively
50
Q

Anesthesia techniques used with PAH:

A
  • General (more complications)
  • Regional
51
Q

PAH General anesthesia induction use:

A
  • Etomidate
  • Avoid KETAMINE (increase PVR)
  • Avoid Desflurane
  • Avoid hypoxemia
  • Avoid hypercarbia
  • Avoid acidosis
  • Avoid pain
  • Avoid hypothermia (increases PVR)
  • Use A-line monitoring
52
Q

What is Cor Pulmonale?

A

Right heart failure 2/2 pulmonary pathology

53
Q

Cor Pulmonale leading cause:

A

COPD

54
Q

Cor Pulmonale arises from variety disorders including:

A
  • PAH
  • PAH with left heart disease
  • PAH with lung disease/hypoxemia
  • PAH due to chronic thrombotic /embolic disease
  • Miscellaneous
55
Q

COPD is associated with:

A
  • Functional loss of pulmonary capillaries
  • Subsequent arterial hypoxemia
56
Q

Pulmonary vasoconstriction is the leading cause of:

A

Chronic Cor Pulmonale

57
Q

Conditions associated with Hypoxic Pulmonary Vasoconstriction:

A
  1. COPD
  2. Bronchioectasis
  3. Chronic mountain sickness
  4. Cystic fibrosis
  5. Idiopathic alveolar hypoventilation
  6. Obesity-related hypoventilation syndrome
  7. Neuromuscular disease
  8. Kyphoscoliosis
  9. Pleuropulmonary fibrosis
  10. Upper airway obstruction
58
Q

Conditions that produce obstruction or oblitration of the pulmonary vasculature:

A
  1. Pulmonary embolism
  2. Pulmonary fibrosis
  3. Pulmonary lymphangitic carcinomatosis
  4. Idiopathic PAH
  5. Progressive sytemic sclerosis
  6. Sarcoidosis
  7. Intravenous drug abuse
  8. Pulmonary vasculitis
  9. Pulmonary venoocclusive disease
59
Q

Pulmonary hypertsion is always an underlying pathology of

A

Cor pulmonale

60
Q

Sustain pulmonary hypertension produces:

A
  • Hypertrophy of smooth muscle in the tunica media
  • Remodeling of vascular smooth muscle
61
Q

Remodeling of smooth muscle leads to:

A

Increase in PVR

62
Q

Symptoms of Cor pulmonale:

A
  1. Retrosternal pain
  2. Cough and dyspnea on exertion
  3. Weakness
  4. Fatigue
  5. Early exhaustion
  6. Hemoptysis
  7. Occasional hoarseness (LRLN compression)
  8. Syncope
63
Q

Physical sings of Cor Pulmonale:

A
  • Elevation of JV pressure
  • Cardiac heave or thrust along the left sternal border
  • S3 gallop
  • S4 sound
  • Wide split S2
  • Pulmonic and Tricuspid insufficiency murmur
64
Q

Cor Pulmonale late signs:

A
  • Hepatomegaly
  • Ascites
  • LE edema
65
Q

Cor Pulmonale Diagnosis:

A
  • Chest radiography
  • Echocardiography
  • MRI
66
Q

Three major drug classes for PAH treatment:

A
  1. Prostanoids
  2. Endothelin receptor antagonist
  3. Phosphodiesterase inhibitors
67
Q

Cor Pulmonale Preop Eval:

A
  • Control acute or chronic pulmonary infections
  • Improve clearance secretions
  • Hydration
  • Reversal of bronchospasm
  • Correct any electrolyte imbalance

Advance Anesthesia II (7 decks)

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