Pulmonary Restrictive Flashcards

Question

Risk factors for development of laryngospasm? Anesthesia, patient and surgical r/f?

Answer 1

Anesthesia * INSUFFICIENT DEPTH OF ANESTHESIA * ACCUMULATIO OF SECRETIONS/BLOOD IN AIRWAY * Drugs: desflurane, isoflurane & sugammadex * Airway: LMA (induction) and ETT (extubating) * Inexperienced providers- *may be related to insuff. depth on intubation and not fully awake on extubation* Patient * Children * ASA Class 3 or 4- *may be related to anesthetics we use for these cases. Lower doses of anesthetics= lighter anesthesia= more risk for laryngospasm* * GERD * SMOKING (2nd hand in children) * URI- *especially last 3/4 weeks* Surgical * Airway surgery * Appendectomy * Genitourinary * Thyroid surgery * Esophageal surgery

Answer 2

* Chest movement with limited airflow at mouth and nose * Limited anesthesia bag movement * Silence or stridor on inspiration * Absence of ETCO2 * Body movements – engorged neck veins * Tracheal tugging * Paradoxical breathing * Desaturation

Answer 3

* Anaphylaxis * Angioedema * Foreign body in airway * Vocal cord paralysis * Breath holding * Loss of upper airway tone * Residual muscle relaxants or opioids * Bronchospasm

Answer 4

* Anticholinergic drugs * Probably be limited to patients with c**opious secretions or ketamine administration** * Propofol induction *vs thiopental (sulfa group can cause bronchospasm)* * Lidocaine * IV – equivocal studies- *some show good, some bad* * Topical - some benefits; danger – blood/secretions can accumulate in an insensate area - *may not be able to cough/clear and increase risk laryngospasm* * Magnesium * Smooth muscle relaxation; few/underpowered studies * **Adequate depth of anesthesia** * Especially with inhalational induction * Wait a few minutes after loss of lid reflex to start IV * Cough on extubation to force secretions out

Answer 5

* Remove stimulus * Suctioning is controversial (clenched jaws or induce further spasm) * Call for help * Jaw thrust and 100% oxygen- *larson maneuver* * CPAP with tight fitting mask- *give slow, easy, gentle ventilations* * Deepen the anesthetic * Lidocaine 1-1.5 mg/kg * Propofol 0.5 mg/kg * Muscle relaxation * Succinylcholine * IV: Succinylcholine 20 mg – onset 30 – 60 seconds- *realize may need to give amnestic too!!* * IM: Succinylcholine 4 mg/kg – 4 minutes * In pediatrics – may also want to give atropine to prevent bradycardia * Rocuronium 1 mg/kg- *can stick around for awhile, make sure to give amnestic!* * Intubation- *if all of the above fail to break laryngospasm*

Answer 6

* Definition – unwanted muscular response of the larynx * Epidemiology – difficult to ascertain * Mechanism – afferent and efferent limbs * Risk factors – anesthesia, patient & surgery * Presentation – silence/stridor, limited bag movement, NO etco2 * Treatment – remove, ask for help, jaw thrust, 100% O2, deepen the anesthetic, paralyze & re intubation

Answer 7

* edema- Leakage of intravascular fluid into the interstitium of the lungs and alveoli Cause * Increased capillary pressure * Hydrostatic or cardiogenic * Increased capillary permeability * Aspiration * Sepsis

Answer 8

* Manifestation of upper airway obstruction and generation of large negative intrathoracic pressure * Young, healthy, athletic patients at high risk- *can generate higher negative intrathoracic pressure* * Typically follows laryngospasm, biting ETT, or foreign body aspiration Pathology * Upper airway obstruction * Trying to inhale against an obstruction * **Develops high levels of NEGATIVE intrathoracic pressure** * Venous return to the heart increases * CO decreases * Pressure in pulmonary vascular bed increases * Alveolar membrane junction disrupted * Fluid from interstitial space flows into alveoli * Pulmonary edema develops

Answer 9

* Inspiratory stridor * Wheezing * Use of accessory muscles * PANIC… * Hypoxia * **Pink frothy sputum**

Answer 10

* Anaphylaxis * Acute lung injury * Residual paralysis * Fluid maldistribution * TURP syndrome * Neurogenic * Increases SNS activity * MI * Heart failure

Answer 11

* Relieve obstruction * May require emergent re-intubation * Correct hypoxia * Facemask to BiPap * Chest x-ray- ground glass opacities * Labs * CMP & ABG * Pharmacologic * Diuretics * B2 Agonists * Placement * PACU keep vs stepdown/ICU- *Depending on clinical picture*

Answer 12

* Pathology – trying to inhale against a closed glottis * S/Symptoms – Stridor, wheezing & pink frothy sputum * Treatment – Remove obstruction, correct hypoxia, diuretics & placement * *Minor can go home after monitoring in PACU* * *Severe may need ICU*

Answer 13

* Life threatening respiratory disease process characterized by * Hypoxemia * Reduced lung compliance * Increased hospitalization, ICU days & morbidity * Mortality – 45% Pathology * Varies based on causative pathology * Inflammatory process that (*this doesn't vary...)* * Damages endothelial cells * Inhibits surfactant production * Impairs coagulation * Inhibits normal alveolar immune response * Increased vascular permeability * DAMAGED ALVEOLAR – CAPILLARY MEMBRANE

Answer 14

* Damage to alveoli and inflmmatory responst from macrophages produces mediators(TNF, IL1, IL6, brings in more neutrophils)--. decrease capillary membrane permeability * damaged hyaline membrane develops and releases protease that breakdown membrane * damage to pulmonary capillary membrane

Answer 15

Direct * Pneumonia * Aspiration * Inhalational injury * Pulmonary contusion * Drowning Indirect * Major trauma * Pancreatitis * Severe Burns * Drug overdose * TRALI

Answer 16

* Based on: * timing- within 1 week known insult * chest imaging- bilateral opacities not explained by effusions/lung collapse/nodules * origin of edema- not explained by cardiac failure or fluid overload * oxygenation * mild- PaO2/FiO2 200-300 with PEEP \>5- * mod- PaO2/FiO2 100-200 with peep \>5 * severe- PaO2/FiO2 \<100 with peep \>5

Answer 17

* Peak pressure= resistive pressure * shows maximal pressure in proximal airways * equated to action of blowing up a balloon * If peak pressure and plateau pressure are \>5 mmHg, then elevated peak pressure * high peak pressure= airway issue * bronchospasm * retained secretion * mucus plug * blocked ETT tip/sitting agianst wall * Plateau pressure= elastic/compliance of lungs/how stiff lungs are * surrogate for end alveolar presure (end expiratory alveolar pressure) * equated to when you stop blowing the balloon, the pressure equalizes b/w balloon and your airway * high plateau signifies: * PNA * Pneumothorax * pulmonary edema * ARDS

Answer 18

* Mechanical forces generated by positive pressure ventilation can contribute lung injury * Especially at the interface between normal lung units and damaged lung units * Limit stretch, strain, and biotrauma

Answer 19

* FiO2 * Lowest to maintain SaO2 between 88 -95% * Hyperoxia – oxidative damage & alveolar collapse * PEEP * Maintains open airways * Prevent recurrent opening and closing of airways * Increase intrathoracic pressure * Mode * Does not appear to change outcomes, but PCV most common * TV * Low tidal volumes 6-8 ml/kg ideal body weight * Low plateau pressure * \< 16 cm H20 goal * \< 30 cm H20 decreased mortality * Decrease shear stress

Answer 20

* PaCO2 * Permissive hypercapnia * Unless head trauma or severe right heart failure * Recruitment Maneuvers * Prevention of atelectasis * 40 cmH20 for 40 seconds * Stepwise fashion – increase by 5 cm H20 to 40 * Controversial * Some studies – routine * May be associated with hemodynamic instability * Data is inconclusive- *if hard time oxygenating, recruitment maneuvers may be beneficial*

Answer 21

* yellow- needs more data * HFO= high frequency oxygenation

Answer 22

* Little evidence to choose one type over another * Inhaled * May be protective against ischemic/reperfusion injury * Anti-inflammatory * Con – inhibits hypoxic pulmonary vasoconstriction * TIVA * Propofol – possibly anti-inflammatory

Answer 23

* Fluids * Judicious * Blood * Hemoglobin trigger of 7 g/dl is described * Independent risk of ARDS

Answer 24

* Defined as: entry of liquid or solid material into the trachea and lungs * Typically occurs when patients without sufficient laryngeal protective reflexes **passively** (*at night)* or **actively** regurgitate gastric contents * Occurring 1:2000 – 3000 surgeries requiring anesthesia * About 50% of patients who aspirate develop a lung injury such as pneumonitis and aspiration pneumonia

Answer 25

* The degree of lung damage is modified by: * Degree of acidity * Volume of aspirate * Presence/absence of particulate matter in aspirate fluid * **As little as 50 ml’s of gastric content can be considered severe** * **_Remember 25_** * **_Volume \< 25 ml’s_** * **_pH \> 2.5_**

Answer 26

Pulmonary Syndromes * Dry cough/bronchospasm * Mild pneumonitis * Pneumonia * ARDS * Cardiopulmonary collapse * Death Phases * Phase 1: Immediate damage from low pH/ high pH * Phase 2: Inflammatory response * Infection * Infiltration

Answer 27

* Chemical irritaion causes loss of cilia * dead and dmaged epithelial cells * mucous lining lost * allows capillary membrane to open and interstitial fluid to flow in * body needs to repair damage, brings neutrophil, macrophages which break down capillary membrane further and release proteases. more fluid flows into alveoli * proteases damage the capillary-membrane lining * cyclic process that takes time to resolve

Answer 28

* Risk Factors: Medications * Drugs that either induce loss of consciousness or alter LES tone * Propofol/thiopental/etomidate/ketamine * Volatile anesthetics * Opioids * Thiopental * Atropine/glycopyrrolate

Answer 29

**Any condition that increases gastric pressure (overcome LES) or lessen LES tone and allow acid regurg.** * GERD * Gastrointestinal obstruction * Altered level of consciousness * Patients taking opioids/sedatives * Need for emergency surgery/trauma * Hiatal hernia * Lack of coordination of swallowing * Obesity * Diabetes * Pregnancy- *pushes up gastric contents, higher intragastric pressure and causes backflow up LES* * Unrecognized difficult airway- *pushing lots of air into stomach while ventilating*

Answer 30

* Improper decision making * Not using preventative measures * Lack of experience * Inadequate patient preparation- *trauma* * Cricoid pressure * Neural reflex that is not well understood- *may be triggering swallowing reflex from UES causing LES to relax and risk increased aspiration*

Answer 31

* Preoperative fasting * ASA guidelines * Nasogastric tube ? * No evidence to support routine use; HOWEVER – IF PRESENT – USE! * Medications * H2 blockers, PPI, prokinetics, non-particulate antacids, & anticholinergics * h2 blockers- *decrease volume, increase pH, takes time to work* * PPI- *increase pH and decrease volume, take time* * bicitra- *used for immediate relief, good for emergencies, may make pt vomit d/t taste* * reglan- *decrease pyrloric sphincter and move things though stomach/intestine* * Positioning * Head down – recommended, *allows aspirant to go out of the mouth* * 15 – 45 degrees –with mouth at level of larynx * RSI * Cricoid pressure – benign practice & should be used * Released if creating difficulties in securing the airway * 50% incorrectly applied * What’s a Newton?

Answer 32

* Clear liquids= 2 h * breast milk= 4 h * infant formular 4-6 h * non human milk 6 h * light meal 6 h * heavy meal (fat and meat) 8 h

Answer 33

* Recognition * Identification of gastric content in oropharynx – 70% * Silent – micro * Signs & Symptoms * Hypoxia * Increased peak airway pressures * Adventitious lung sounds * Laryngospasm/bronchospasm * Differential * Anaphylaxis * PE * ETT obstruction * *light anesthesia??*

Answer 34

* Place head down and turn to the side * Suction the airway * Secure the airway * *recognize that contents can leak around the cuff* * **Suction the airway prior to initiating positive pressure ventilation- don't start ventilating once tube placed, suciton first!!!** * Administer bronchodilators as needed * Peep * Neutrophil inhibitors – lidocaine or sivelestat (neutrophil elastase inhibitor) * Bronchoscopy * Flexible- *just looks around in the lung* * Rigid- *if particulate matter have to convert to rigid to pull it out*

Answer 35

* Proceed with case?? * dpeends on urgency of surgery and patient status (maintain saturation, having bronchospasms, etc) * Chest x-ray * When is best time to get?-- takes time to develop damage. get up front and then 2-3 hours later * Antibiotics/steroids * NOT routinely used * PACU/ICU * Oxygenation status * Majority does not require treatment * Circulatory collapse * ACLS * ECMO

Answer 36

* Aspiration – entry of liquid or solid material to trachea/lungs * Complex pattern – Mild to ARDS to circulatory collapse * Risk factors – Medications, patient, provider * Prevention – Risks assessment, fasting, medications, RSI & positioning * Management – Clear secretions, secure airway, suction, steroids and antibiotics are not routinely used, what about case, and where do they need to go?