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Resp PDF Flashcards

1
Q

Which nerve innervates motor function of vocal cords?

A

RLN

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2
Q

What innervates the motor function of the cricothyroid?

A

External branch of the SLN

**SLN is all sensory except the cricothyroid

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3
Q

Which muscle opens the glottis?

A

Thyroepiglottic

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4
Q

Which two muscles close the glottis?

A

Aryepiglottic

Oblique arytenoid

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5
Q

Which nerve does the RLN branch off of?

A

Vagus (CN 10)

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6
Q

What is the most common cause of voice change following thyroid surgery?

A

injury to the SLN external branch

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7
Q

How is a nerve blocked performed on SLN?

A

2mL - Below the border of the greater cornu of the hyoid bone

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8
Q

During an SLN block you aspirate air, what does this mean?

A

Needle is too deep

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9
Q

How is a transtracheal block performed?

A

Needle is advanced caudal as it penetrates cricothyroid

**after aspiration but before injection have the patient take a deep breath

Inject 5mL, patient will cough and saturate the vocal cords

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10
Q

Which nerve causes a laryngospasm?

A

Internal branch of SLN

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11
Q

Signs of laryngospasm?

A

Rocking horse
Lower rib flailing
Inspiratory stridor
Suprasternal and supraclavicular retraction during inspiration

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12
Q

What is mullers maneuver?

A

Inhalation against a closed glottis

**negative pressure pulmonary edema

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13
Q

What increases as the airway bifurcates?

A

-Number of airways
-Cross sectional area
-Muscular layer

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14
Q

More likely to right mainstem or left?

A

More likely to right mainstem do to the 25 degree angle

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15
Q

Where does the respiratory zone begin ?

A

Respiratory bronchioles

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16
Q

Where does the conducting zone begin and end?

A

Begins in the trachea and ends in the terminal bronchioles

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17
Q

Does transpulmonary pressure always stay positive or negative?

A

Always positive to keep airways open

**Slightly negative on forced expiration

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18
Q

Is intrapleural pressure always positive or negative?

A

Always negative

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19
Q

Which two muscles are apart of passive inhalation?

A

Diaphragm + external intercostals

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19
Q

What is example of Boyles law?

A

Breathing

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20
Q

What determines the rate of CO2 elimination?

A

Alveolar ventilation, NOT minute ventilation

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21
Q

How is Alveolar ventilation calculated?

A

TV-dead space * RR

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22
Q

Average dead space on an adult?

A

2mL per kilogram

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23
Q

What is alveolar dead space proportional to? Inversely proportional?

A

Proportional = CO2 production

Inversely = PaCO2

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24
Q

How does hypotension affect dead space?

A

increases it by reducing pulmonary blood flow

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25
Q

How does atropine affect dead space?

A

Increases it because it is a bronchodilator

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26
Q

How does positive pressure ventilation affect dead space?

A

Increases dead space by increasing ventilation

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27
Q

How does a LMA and ETT affect dead space?

A

Decreases it

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28
Q

How does old age affect dead space?

A

Increases

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29
Q

Which law describes alveolar surface tension?

A

Law of Laplace

Pressure
Radius
Wall tension

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30
Q

How does surfactant affect surface tension?

A

Surfactant decreases surface tension

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31
Q

What is the most common cause of hypoxemia in PACU?

A

V/Q mismatch - specifically atelectasis

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32
Q

What is the alveolar gas equations?

A

PAO2=
FiO2 x (760-47) - (PaCO2/0.8)

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33
Q

How does reduced FiO2 affect A-A gradient? Does O2 fix this?

A

Stays normal - O2 helps

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34
Q

How does reduced hypoventilation affect A-A gradient? Does O2 fix this?

A

Stays normal - O2 helps

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35
Q

How does diffusion limitation affect A-A gradient? Does O2 fix this?

A

Increases it - O2 helps

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36
Q

How does V/Q mismatch affect A-A gradient? Does O2 fix this?

A

Increases it- O2 helps

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37
Q

How does shunt affect A-A gradient? Does O2 fix this?

A

Increases it - O2 does NOT help

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38
Q

How does aging affect the A-a gradient?

A

Increases

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39
Q

How do vasodilators affect the A-a gradient?

A

Increases

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40
Q

How does R to L shunt affect A-a gradient?

A

Increases

Ex: atelectasis, pneumonia, bronchial intubation, cardiac defect

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41
Q

What is a normal vital capacity?

A

35 ml/kg

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42
Q

How can FRC be indirectly measured?

A

nitrogen washout, helium wash in, body plethysmography

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43
Q

What conditions increases FRC?

A

-Advanced age
-Obstructive lung disease (air trapping)
-Peep

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44
Q

Which conditions increase closing volume?

A

Close-P

COPD
LV failure
Obesity
Smoking
Extreme age
Pregnancy

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45
Q

What is the oxygen carrying content equation?

A

(1.34xHgbxSaO2) + (PaO2x0.003)

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46
Q

What is the DO2 equation?

A

CaO2 x CO x 10

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47
Q

What is a normal VO2?

A

3.5mL/kg/min
250mL/min

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48
Q

What shifts the oxyhemoglobin curve to the Left?

A

Decreased everything

+ Increased PH (alkalosis)

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49
Q

What shifts the oxyhemoglobin curve to the Right?

A

Increased everything

+ Decreased PH (acidosis)

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50
Q

What is the Bohr effect?

A

IncreasedCO2 and hydrogen ions cause a change in the Hgb molecule and release O2

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51
Q

What are the three key processes involved in aerobic glucose metabolism?

A
  1. Glycolysis
  2. Krebs cycle
  3. Electron transport
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52
Q

What does glycolysis turn glucose into?

A

The goal is 1 glucose = 2 pyruvic acid

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53
Q

What does pyruvic acid turn into?

A

2 pyruvic acid = Acetyl CoA

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54
Q

How many ATP is produced during the Krebs cycle?

A

2 ATP

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55
Q

How many ATP are produced during glycolysis?

A

2 ATP

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56
Q

How many ATP are produced during oxidative phosphorylation?

A

34 ATP

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57
Q

What is produced when no oxygen is available?

A

Lactic acid

++Causes anion gap metabolic acidosis

*lactate is cleared by the liver

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58
Q

How is the majority of CO2 transported?

A

70% Bicarb

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59
Q

What is the breakdown of CO2 transport? (Form and %)

A

-70% Bicarb
-23% Bound to Hgb
-7% dissolved in plasma

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60
Q

What enzyme is required for required to convert CO2 to bicarb?

A

Carbonic anhydrase

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61
Q

When compared to O2, how many more times soluble is CO2?

A

20x

Henrys Law

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62
Q

What is the Haldane effect?

A

Causes hgb to release CO2

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63
Q

What does hypercapnia cause?

A

-Increased ICP
-Hypoxemia
-Increased p50
-Cardiac+smooth muscle depression
-SNS stimulation
-Increased alveolar depression
-Increased K + Ca
-Decreased LOC

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64
Q

What does increased CO2 cause the lungs to do?

A

Vasoconstrict - Pulmonary HTN

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65
Q

What happens when CO2 passes 80mmHG?

A

Respiratory depressant

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66
Q

What does a left shift on the ventilatory response curve indicate?

A

Respiratory alkalosis

Metabolic acidosis

67
Q

What does a right shift on the ventilatory response curve indicate?

A

Metabolic alkalosis
Respiratory acidosis
Caused by carotid, anesthetics, opioids

68
Q

What is considered the pacemaker of breathing?

A

Dorsal respiratory group

69
Q

Where is the dorsal and ventral respiratory group located?

A

Medulla

70
Q

Where are the pneumotaxic and apneustic centers located?

A

Pons

71
Q

What causes expiration?

A

Ventral respiratory

72
Q

What diffuses through the BBB?

CO2?
HCO3?
H?

A

Just CO2

73
Q

Once CO2 diffuses through the BBB what happens?

A

Reacts with carbonic anhydrase and turns into H+ and HCO-

74
Q

What is the most important stimulus for the central chemoreceptor?

A

Hydrogen ion concentration

75
Q

What is the chief responsibility of the peripheral chemoreceptors ? Where are they located?

A

Monitor PaO2

Carotid Body and Aortic arch

*carotid body plays a larger role

76
Q

What are the secondary functions of the peripheral chemoreceptors?

A

-Monitor PaCO2, H+, perfusion pressure

77
Q

What is the afferent pathway of the Hypoxic ventilatory response?

A

Hering’s nerve then along the glossopharyngeal nerve (CN IX)

78
Q

Which procedure severs the afferent limb of the hypoxic ventilatory response ?

A

Carotid endartectomy

79
Q

What happens if bilateral carotid endartectomys are performed at the same time or close together?

A

May completely wipe out the hypoxic ventilatory response

80
Q

What conditions do not impair the hypoxic ventilatory response?

A

-Anemia
-Carbon monoxide poisoning

81
Q

What is the Hering Breuer INFLATION reflex? What nerve?

A

When the lungs inflate 1.5L above the FRC, it stops further inspiration

Vagus nerve

82
Q

What is the Hering Breuer DEFLATION reflex? What nerve?

A

When lung volume is too low, stimulate a breath

83
Q

What are J receptors?

A

Causes tachypnea through C fiber response?

84
Q

What conditions stimulate J receptors?

A

PE, Pulmonary congestion from CHF

85
Q

What is the paradoxical reflex of head?

A

Causes newborn babies to take a breath

86
Q

What stimulates the HPV? What does not?

A

A reduction in alveolar oxygen tension - NOT arterial PO2

87
Q

What is the HPV mechanism?

A

Increases PVR , shunts blood away from poorly ventilated areas

88
Q

What impairs the HPV?

A

Mac > 1.5
Vasodilators and Constrictors

89
Q

What does not impair HPV?

A

IV anesthetics

90
Q

How does Beta2 stimulation cause bronchodilation?

A

Gs protein is stimulated

Activates adenylate cyclase

Adenylate cyclase activates cAMP

cAMP reduces Ca

91
Q

How is the Beta2 pathway turned off?

A

Phosphodiesterase 3 deactivates cAMP by converting it to AMP

92
Q

How does Nitric oxide effect the smooth muscle ?

A

Potent smooth muscle relaxant

Stimulates cGMP which relaxes and causes bronchodilation

93
Q

How does the PNS affect bronchioles?

A

Bronchoconstriction

M3 is coupled by Gq

Gq activates Phospholipase C

Phospholipase C activates IP3

IP3 stimulates Ca

94
Q

what other mediators cause bronchoconstriction?

A

Mast cells, other proinflammatory cells

95
Q

What is FEV1? Normal?

A

Volume of air that can be exhaled in 1 second

Declines with Age

Normal - >80%

96
Q

What is Forced vital Capacity? Normal?

A

Volume that can be exhaled after a deep inhalation breath?

Males - 4.8L
Females - 3.7L

97
Q

What is the ration of FEV1 to FVC?

A

80%

98
Q

What is the Forced expiratory flow at 25-75% Vital Capacity?

A

Measures flow in the middle of expiration

100 +/- 25% predicted value

99
Q

What is the best test to assess medium size airways?

A

Forced expiratory flow at 25-75%

100
Q

What is Maximum Voluntary Ventilation?

A

Maximum amount of air inhaled and exhaled over 1 minute

Test of endurance

Males - 150L
Females- 100L

101
Q

What is diffusing capacity?

A

Tests ability to exchange CO2

17-25

102
Q

What test assesses nutritional value?

A

If albumin is <3.5g/dl

103
Q

Does short term cessation of smoking reduce risk of pulmonary complications?

A

NO

104
Q

**What is the best way to recruit alveolar?

A

**Increase PIP to 40Cm for 8 seconds

105
Q

What is the issue with obstructive lung disease?

A

Getting air out

106
Q

What is the issue with restrictive lung disease?

A

Getting air in

107
Q

What two PFTs are normal in restrictive disease?

A

FEV1/FVC ratio
FEF 25-75%

*** all other tests are DECREASED

108
Q

Which two PFTs are significantly decreased with obstructive disease??

A

FEF 25-75
FEV1/FVC ration

*(opposite of restrictive)

109
Q

What does the pressure volume look like with a variable extra thoracic obstruction?

A

Normal EXhalation

110
Q

What does the pressure volume look like with a variable intra thoracic obstruction?

A

normal INhalation

111
Q

What is the most common ABG finding with asthma?

A

Respiratory alkalosis without hypocarbia

112
Q

What does an elevated PaCO2 suggest with asthma?

A

***air trapping, muscle fatigue

Impending respiratory failure**

113
Q

Which drugs should be avoided in asthma?

A

-Histamine releasing drugs (Morphine, meperidine,sux, atracurium)
-Toradol
-H2 antagonists

114
Q

Which drug should NOT be used with a bronchospasm?

A

Montelukast ****

115
Q

Which deficiency is linked to COPD?

A

Alpha-1 Antitrypsin

116
Q

In chronic bronchitis, what happens to RBCs?

A

They are overproduced to compensate for the V/Q mismatch

117
Q

What should the I:E ratio be in restrictive lung disease?

A

1:1 - prolong inspiration

118
Q

What is Mendelson’s syndrome?

A

Chemical aspiration pneumonitis

Gastric pH <2.5
Gastric volume >25mL

*common in OB

119
Q

What shouldn’t be apart of aspiration pneumonia treatment?

A

Steroids don’t help

Antibiotics only if a fever or Increased WBC after 48 hours

120
Q

How does a PPI affect VAP?

A

increases chance

121
Q

What are hallmark signs of a tension pneumo?

A

Increased airway pressures
Hypoxemia
Hypotension
Tachycardia
Increased CVP

122
Q

Treatment of tension pneumo?

A

14g angiocath into the 2nd intercostal space at the midclavicular line

OR

4th intercostal at the axillary line

123
Q

What is a key step with a tension pneumo?

A

***TURN OFF NITROUS

124
Q

Key characteristic of a flail chest?

A

Paradoxical chest movement

125
Q

What happens to the chest wall during inspiration with a flail chest?

A

Chest wall moves inward during inspiration

126
Q

What happens to the chest wall during expiration with a flail chest?

A

Chest wall moves outward during exhalation

127
Q

Hallmark sign of a venous air embolism?

A

Air on TEE

Mill wheel murmur

Decreased EtCO2
Increased PA pressure

128
Q

Treatment for venous air embolism?

A

100% FiO2
Flood field with NS
Discontinue insufflation
Place in Left lateral decubitus
Aspirate air
Hemodynamic support

129
Q

Carboxyhemoglobin sign and symptoms?

A

Cherry red appearance
SNS activation
NEED co-oximeter

130
Q

Treatment of Carboxyhemoglobin?

A

100% FiO2
Hyperbaric

131
Q

*****What are the best predictors for patients undergoing pulmonary surgery?

A

FEV1 < 40%
DLCO <40% predicted
VO2 Max < 15ml/kg

132
Q

What are the sizes for DLT in men and women? Insertion depth?

A

Men 39-41 = 29cm
Women 37-39 = 27cm

133
Q

Once the DLT is confirmed to be in the correct position, what step is next when troubleshooting?

A
  1. Apply 10 CPAP to the non- dependent lung
134
Q

After applying CPAP to the dependent lung, what step is next when troubleshooting?

A
  1. Apply 5-10 of PEEP to the dependent lung
135
Q

What conditions increase PVR?

A

-Hypoxia
-Hypercarbia
-High PEEP
-High airway pressures

136
Q

What is an absolute contraindication for a mediastinoscopy?

A

Previous mediastinoscopy

137
Q

Mallampati Score

A
138
Q

What three axis are aligned during the sniffing position ?

A

Oral
Pharyngeal
Laryngeal

139
Q

What is a normal incisor gap?

A

4cm

2-3 finger breaths

140
Q

What is a normal thyromental distance? What does this tell you?

A

6-9cm

How much submandibular space there is to displace the tongue

141
Q

Classes of the mandibular protrusion test

A

Class 1: But above lip
Class 2: can touch teeth or upper lip
Class 3: Cannot touch teeth

142
Q

What conditions impair the antlanto occipital joint mobility?

A

Joint disease
RA
Ankylosing spondylitis
Truma
Fixation
Kippel-Fei
Down syndrome

143
Q

What are the NPO guidelines?

A

2 hours - Clears
4 hours - Breast milk
6 hours - Food

144
Q

What are two causes of angioedema?

A

Ace inhibitors
Hereditary

145
Q

What is Ludwigs Angina? How to intubate?

A

Bacterial infection on floor of mouth

-Awake nasal intubation or trach

146
Q

What is contraindicated when patients have an infection above the trachea?

A

Retrograde intubation

147
Q

What three syndromes have C Spine anomalies?

A

Goldenhar
Klippel-Feil
Down syndrome

148
Q

Which two oral airways have a hole for intubation?

A

Williams and Ovassapian

149
Q

How to measure oral and nasal airways?

A

Oral - Corner of mouth to angle of mandible

Nasal- Nare to the angle of the mandible

150
Q

When should a nasal airway never be used?

A

Coagulopathy
Pregnancy
Raccoon Eyes
Periorbital edema
Basilar skull fracture
Lefort 2 or 3 fracture

151
Q

What is the max airway pressure with an LMA? Max cuff pressure?

A

20cm H20

Cuff- 60

152
Q

LMA sizes

A
153
Q

When is a ProSeal and Supreme indicated?

A

-Has a lumen to suction BUT must past an OG to suction

154
Q

Which LMA allows for a higher pressure of 30 cm H2O?

A

Proseal and Supreme

155
Q

What are the sizes for a combitube? Max amount of pressure?

A

<4 feet no option

4-6 feet - size 37

> 6 feet - size 41

Do not exceed 60cm H2O

156
Q

Which cuff is inflated first on the Combitube? What does this accomplish?

A

The proximal cuff first

-Occludes the hypopharynx

50 -100 mL of air

157
Q

Which cuff is inflated second on the Combitube? What does this accomplish?

A

Distal balloon - Occludes the esophagus

10mL of air

158
Q

If the tip of the Combitube is in the esophagus, which lumen should be used to ventilate?

A

Blue or proximal lumen

159
Q

If the tip of the Combitube is in the trachea, which lumen should be used to ventilate?

A

Clear or distal

160
Q

Contraindications with the combitube?

A

-Intact Gag
-Prolonged use over 3 hours
-Esophageal disease
-Incorrect sizing

161
Q

When using a trachlight, what should the tip be bent to? What about in children?

A

90 degrees in adults

60-80 degrees in children

162
Q

What should the PSI be for jet ventilation?

A

50 PSI

163
Q

Risks of jet ventilation?

A

Hypercapnia
Barotrauma
Pneumothorax
Subcutaneous emphysema

164
Q

Contradictions to jet ventilation?

A

Upper airway obstruction
Laryngeal injury

165
Q

ABSOULTE contraindications to a cricothyroidotomy ?

A

Children < 6 (some say 10)

166
Q

Contradictions to a tracheostomy?

A

None

MIDTERM (6 decks)

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