Respiratory Flashcards
The upper airway ends at which cartilage?
cricoid cartilage
What structures comprise the lower airway?
trachea, bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, alveoli
What structure creates 2/3rds of the resistance to breathing?
nasal mucosa
What blood vessels provide arterial blood supply to the nasal mucosa?
opthalmic, facial, and maxillary
What nerve and branches supply the nasal mucosa?
trigeminal nerve, ophthalmic and maxillary branches
What is the result of decreased SNS stimulation to the nasal mucosa during general anesthesia?
engorgement of tissues leading to higher potential for bleeding
What happens to the soft palate during general anesthesia?
falls back against the nasal passages causing symptoms of sleep apnea
What are examples of diseases with underdeveloped tongue, maxilla, and or mandible?
Pierre-Robin, Apert, Treacher Collins
What disorders can obstruct the airway due to macroglossia? (2)
Beckwith Wideman, Down
Which vertebrae is consistent with the level of the nasopharynx?
C1
What nerve innervates the nasopharynx?
Maxillary division of the trigeminal nerve
What are the superior and inferior borders of the oropharynx?
soft palate superior, and epiglottis inferior
What vertebrae and cartilage mark the end of the hypopharynx?
C5/C6 at cricoid cartilage
What is the reflex arch of stimulation to the pharynx?
stimuli to wall of pharynx -> afferent: glossopharyngeal nerve -> medulla -> efferent: vagus nerve -> gag reflex
Where does the internal SLN provide sensory input to?
hypopharynx above the vocal cords
The external SLN provides motor innervation to what muscle?
cricothyroid
What nerve provides sensory innervation to the subglottic area and trachea?
RLN
What are symptoms of injury to the RLN?
hoarsness and stridor
The RLN provides motor innervation to what structures?
all muscle of the larynx except the cricothyroid
Does unilateral RLN damage cause respiratory distress?
no
Damage to bilateral RLN results in what?
stridor and respiratory distress
What are the three unpaired cartilages of the larynx?
cricoid, thyroid, and epiglottis
What are the three paired cartilages of the larynx?
arytenoid, corniculate, cuneiform
What are the four functions of the larynx?
protect from aspiration, phonation, airway patency, gag and cough reflex
Mature alveoli are not present until how many weeks gestation?
36
What anatomical structure extends from the cricoid cartilage to the carina?
trachea
What is the only complete cartilaginous ring in the trachea?
cricoid
What is the first anatomical structure of the respiratory system to lack cartilage distal to the trachea?
bronchioles
Describe the right main bronchus? angle and length
25 degree, 2.5 cm
Describe the left main bronchus? angle and length
45 degrees, 5cm
Where does sympathetic innervation to the tracheobronchial tree originate?
1-5th thoracic ganglia
What nerve supplies the diaphragm?
phrenic (C3-C5 roots)
Inadequate BMV is indicated by: (4)
no chest rise, deficient exhaled CO2, absent breath sounds, decreased SpO2
What are hallmark signs of upper airway obstruction? (4)
hoarse voice, difficulty swallowing secretions, stridor, and dyspnea
How do lower airway obstructions present?
high peak airway pressures, low Vt, impaired ventilation
What are two predictors of difficult mask ventilation?
OSA and snoring
What is a potential risk factor for difficult BMV?
obesity
What two things are required in order to provide apneic oxygenation?
nasal cannula and patent upper airway
Conditions that decrease lung compliance, and contribute to ineffective BVM include:
bronchospasm, pulmonary edema, ARDS, pneumonia
Is using a video laryngoscopy for intubation considered a direct or indirect means to visualize the vocal cords?
indirect
What are the 7 airway assessments?
mallampati, interincisor gap, thyromental distance, neck circumference, mandibular protrusion test, A-O joint mobility, look for obstruction,
What does a MMT assess?
tongue size relative to the oropharyngeal space.
What can you visualize with each Mallampati score?
1: tonsils pillars, faucet, uvula, soft palate.
2: faucet, uvula, soft palate
3: uvula, soft palate
4: hard palate
What neck circumference size is consistence with difficult airway?
> 43cm
What is visualized on a Cormack and Lehan grade 1?
full view of the glottic opening
What is visualized on a Cormack and Lehan grade 2?
only the posterior portion of the glottis opening
What is visualized on a Cormack and Lehan grade 3?
only the epiglottis
What is visualized on a Cormack and Lehan grade 4?
only the soft palate
What is visualized on a Cormack and Lehan grade 2a?
partial view of the vocal cords
What is visualized on a Cormack and Lehan grade 2b?
arytenoids, and epiglottis only
When assigning a POGO rating, what structures are used?
anterior commissure, interarytenoid notch
What airway assessment looks at the dispensability of the tongue?
TMD
What are the borders of the thyromental space?
lateral- neck
superior- mentum
inferior- hyoid
What are characteristics of a TMD >9cm that make DL difficult?
large hypopharyngeal tongue, caudal larynx, longer mandibulohyoid distance
History of what clues the anesthesia provider to a possible hypo pharyngeal tongue?
OSA and snoring
What is the 3-3-2 test?
3 finger breadths interincisor
3 finger breadths TMD
2 finger breadths from neck junction to thyroid notch
What is an “appropriate” inter incisor gap?
2-3 fingers, or 4cm
What is the full range of neck extension?
90-165 degrees
What angle of neck extension is predictive of difficult direct laryngoscopy?
23 degrees
What are the three mandibular protrusion test classifications?
1: bite the upper lip
2: upper and lower teeth align
3: lowers cant align with upper.
What conditions reduce A-O movement potentially causing difficulty with supraglottic airways?
ankylosing spondylosis and RA
What conditions make cricothyroitomy more difficult?
surgery, hematoma, obesity, radiation, tumor
What is the gold standard for ruling out cervical fractures?
CT scan
What are 3 positive predictors for difficult laryngoscopy in obese patients?
excessive pretracheal soft tissue, large neck, sleep apnea
What is elevation of the shoulders, head and neck called?
ramping
Preoxygenation can provide oxygen to the blood for up to how long?
8 minutes
What is the required minimum fresh gas flow during preoxygenation
5 L/min
If your preoxygnation time is cut short to only 1 minute. How should you instruct your patient to breathe in those 60 seconds?
8 vital capacity breaths
What type of pressure is used to enhance visualization of the vocal cords?
Backwards, Upwards, Rightwards Pressure
BURP
What is the common cause of an unanticipated difficult airway?
enlarged lymphoid tissue at the base of the tongue
What are the three instances that determine a difficult airway?
difficult mask, difficult laryngoscopy, difficult intubation or all three
What are the four endpoints to the ASA difficult airway algorithm?
intubation awake or asleep, adequate or inadequate facemark or LMA ventilation, intubation by special means, surgical or non-surgical emergency airway
In the event of a failed intubation what is the next step in the difficult airway algorithms?
facemask ventilation or LMA
If initial attempts at intubation fail but subsequent ventilation attempts are successful what is the next step?
awaken the patient
If intubation fails and facemask and LMA are unsuccessful what is the next step?
cricothyrotomy
When anesthetizing the airway in preparation for an awake intubation, which medication class allows topical local anesthetics to better penetrate the mucosa and enhance the effects of the LA?
antisialagogue
What is the most widely used LA for anesthetizing the airway?
lidocaine
What three cranial nerves need to be anesthetized to perform an awake oral or nasal intubation?
trigeminal, glossopharyngeal, and vagus
aspiration of blood during a glossopharyngeal block is likely from which vessel?
carotid
What is the landmark for the SLN block?
hyoid
Before loss of consciousness, how many kg of pressure should be applied for cricoid pressure?
2kg
After loss of consciousness, how many kg of pressure should be applied for cricoid pressure?
4kg
Cricoid pressure during vomiting can lead to what complication?
esophageal rupture
What is a airway device that sits above or surrounds the glottis?
supraglottic
what is an airway device called if it passes behind the larynx and enters the esophagus?
retroglottic or infraglottic
LMA cuff pressure should not exceed what pressure?
60cmH2O
Which supraglottic airway has a large oropharyngeal balloon and a smaller esophageal balloon, with a single pilot ballon to insufflate the cuffs?
king airway
What is the retroglottic airway device with two lumens with two separate pilot balloons?
combitube
What is the significant concern with supraglottic airways?
aspiration
A bougie should inserted to what depth?
25cm
How can we prevent fogging of a FOB?
soak in warm saline
What are indications for FOB?
difficult airway, cervical spine immobility, upper airway abnormalities, failed intubation but able to ventilate
Which oral airways help in placement of a FOB?
williams, ovassapian, berman
What is a more advantageous use of the suction port other than for suctioning?
supplemental O2, 2-4L
during TTV, what are causes of hyperinflation and incomplete exhalation of CO2?
obstructions to passive exhalation, large tidal volumes
What are indications for a surgical cric?
failed airway, traumatic facial injuries, upper airway obstruction, airway for neck or facial surgery when traditional intubation is not possible
What is the absolute contraindication for surgical cric?
children younger than 12
what are relative contraindications for a cric?
tumors, infections, abscess, hematoma, bleeding diathesis, hx of coagulopathy
How is the patients head positioned for a surgical cric?
neutral
Where is a tracheostomy placed?
4-6th tracheal ring, below the isthmus of the thyroid gland
Which patients are most likely to not tolerate extubation?
those with marginal cardiopulmonary reserve
Complications of extubation are most common during which Guedel stage of anesthesia?
stage 2
What are signs of readiness for extubation?
VC:
Inspiratory force:
Vt:
VC: > 15mL/kg
Inspiratory force: -20 cmH2O
Vt: 4-5mL/lg
What are appropriate measures to extubate a difficult airway?
over a flexible FOB, place a supraglottic airway, airway exchange catheter, leave the ETT in
What are three complications after tracheal extubation?
laryngospasm, residual NBM, and laryngotracheobronchitis
The afferent réponse to laryngospasm occurs via which nerves?
external SLN, and RLN
During laryngospasm, what occurs during “glottis shutter closure”?
vocal cord adduction causing partial airway obstruction
During laryngospasm, what occurs during “ball valve closure”?
extrinsic laryngeal muscles close the false vocal cords causing complete airway obstruction
What is the Larson maneuver used to treat? How do you do it?
laryngospasm. vigorous jaw thrust
Where does laryngotracheobronchitis occur?
inflammation and edema below the level of the vocal cords
What is a sign of laryngotracheobronchitis?
inspiratory and expiratory stridor
What are the three treatments for croup?
humidified O2, racemic epi, dexamethasone
What are 4 complications of airway management?
airway trauma, aspiration, esophageal intubation, endobronchial intubation
Of the anesthesia related malpractice claims, what is the most common one?
dental injury
The development of pneumonia after aspiration is dependent on what three things?
type of aspirate, volume of aspirate, pt’s comorbid conditions
The administration of non particulate antacids should be given how long before induction of anesthesia to reduce gastric pH?
10-20 minutes
A histamine blocking agent should be administer at what time interval before induction to reduce stomach acid production and raise the pH?
45-60 minutes. famotidine, cemitidine, ranitidine
What medication is given 10-20 minutes before induction to speed gastric emptying?
metoclopramide
What are two sensitive methods for confirming ETT placement?
EtCO2, FOB
What are 4 signs of endobronchial intubation?
increased peak pressures, asymmetric chest expansion, unilateral breath sounds, hypoxemia
How is a partial obstructed ETT treated?
suction or FOB
How is a completely obstructed ETT managed?
pass a stylet or AEC down the ETT
What is obstruction of the posterior nasal airway called?
choanal atresia
Which concha is most commonly injured during nasal intubation?
inferior concha
What type of cells in the respiratory mucosa produces mucus?
goblet cells
What arteries supply the nasal fossa?
ophthalmic, internal maxillary, sphenopalatine
What are the three important functions of the nose?
filtration, humidification, and heating inspired air
Nasal filtration is extremely effective for particles above ___ mcm and less than ___ nm.
10 mcm
1 nm
efficiency is inverse to particle size 10 nm to 1 mcm
Where do ingested foreign bodies typically get lodged?
where the pharynx becomes continuous with the esophagus. C6
What structure acts as a first line defense against bacterial invasion of the nasal and buccal passages?
Waldeyer tonsilar ring
Which cervical vertebrae are consistent with the location of the larynx
C3-C6
which laryngeal cartilage is consistent with the beginning of the trachea and esophagus?
cricoid
What are the two structures visualized at the base of the vocal cords during laryngoscopy?
corniculate and cuneiform cartilages. Not arytenoids!
What is the narrowest part of the larynx in adults and children?
adult: vocal cords
children: cricoid cartilage
where is the supraglottic area of the larynx?
above the false vocal cords to the tip of the epiglottis
Where is the second compartment of the larynx located?
between the false and true vocal cords
Where is the infraglottic region of the vocal cords?
below the true vocal cords and above the beginning of the trachea
What is the space between the true vocal cords?
rima glottidis
Where do the true vocal cords attach?
anterior: thyroid cartilage
posterior: arytenoids
Which muscle lengthens and shortens the vocal cords?
lengthens: cricothyroid
shortens: thyroarytenoid
Where does the internal SLN provide sensation?
inferior epiglottis to the vocal cords
Which nerve innervates the inerarytenoid muscles which are important for phonation?
internal SLN
How does damage to the RLN manifest?
unilateral or bilateral vocal cord paralysis, hoarseness, or dyspnea
What is the distance from the incisors to the carina?
26cm
What vertebrae are consistent with the carina?
T4-T5
How does neck flexion and extension move the carina.
Flexion: upward movement
extension: downward
As the airways divide and multiply what happens to the area and airflow velocity?
cross section area increases, airflow velocity decreases
In what part of the lungs does gas exchange first occur?
respiratory bronchioles
The lung volume at which small airways begin to close?
closing volume
What structures allow collateral gas flow between alveoli and provide a mechanism of relief from gas stagnation from airway closure?
pores of Kohn
What makes up the respiratory zone?
respiratory bronchi, alveolar ducts, alveolar sacs, alveoli
What is the transition zone of the lungs?
respiratory bronchi, alveolar ducts
What type of cells play a role in the development of adenocarcinoma and other chronic lung disease?
Clara cells
What is accumulation of air in the pleural space?
pneumothorax
What type of pneumothorax develops as inspired air accumulates in the pleural space?
tension pneumo
Which law explains how during inspiration, the increase in volume creates a reduction in pressure which causes air to move into the lungs?
Boyle’s
Which nerve roots innervate the diaphragm?
C3,C4,C5
Spinal cord injuries above what vertebral level lead to dependence on mechanical ventilation?
C5
For air to move into alveoli, alveolar pressure must be ___ than atmospheric pressure.
less
How do you define lung compliance
volume / pressure
What factors cause changes in static lung compliance?
fibrosis, obesity, vascular engorgement, edema, ARDS, surgeon leaning on the chest
What disease increases static lung compliance?
emphysema
What law of physics applies to inflation of alveoli?
Laplace
Aside from surfactant, what plays the most important role in preventing alveolar collapse?
connective tissue and elastic forces
What is the prevalent cause of ARDS in premature infants?
lack of surfactant
Pleural pressure is always
negative
What Reynolds number describes laminar and turbulent flow?
laminar < 2000
Turbulent > 4000
Transitional 2000-4000
Where is airflow turbulence the greatest?
large airways
Where does the greatest resistance to airflow occur?
medium sized bronchi
In order to promote laminar flow in obstructive lung disease, which intervention will lower airflow velocity and airflow density?
heliox
How do we calculate alveolar ventilation?
(Vt - dead space) x RR
What conditions increase closing volume? (6)
supine, pregnancy, obesity, age, COPD, CHF
What is alveolar dead space?
alveoli that are ventilated but not perfused
What is physiologic dead space?
anatomic and alveolar dead space
What does the Bohr equation tell you? What is the formula?
calculates dead space ventilation.
(PaCO2 - PECO2) / PaCO2
In the upright lung which alveoli are more compliant?
those in the base
What is the alveolar gas equation?
PAO2 = FiO2 x (760-47) - (PACO2/0.8)
In what type of cells does gas exchange occur?
squamous epithelium
What increases PVR?
NE, serotonin, histamine, hypoxia, hypercapnia
What drugs can be given to acutely decrease PVR?
NO, sidenafil
Is negative pressure pulmonary edema treated with steroids and diuretics?
No. remove the causative agent, normalize ventilation, reduce lung congestion and fluid
What values (high/low) of PaO2 and CO2 occur in dependent regions of the lung?
low PaO2
high CO2
What values (high/low) of PaO2 and CO2 occur in nondependent regions of the lung?
high PaO2
low PCO2
Does high ventilatory settings and PEEP cause a shunt or dead space?
deadspace
What causes a left shift on the oxyhemoglobin dissociation curve?
decreased temperature, 2,3- DPG, CO2, alkalosis
What causes a right shift on the oxyhemoglobin dissociation curve?
increased temp, 2,3-DPG, CO2, and acidosis
What is the normal P50 value?
26-27
How is methemoglobinemia treated?
O2, methylene blue 1-2mg/kg over 5 min
What is the formula for O2 carrying capacity?
CaO2 = (Hgb x 1.34 x SpO2) + (PaO2 x 0.003)
What are the normal values for CaO2 and CvO2?
CaO2: 20
CvO2: 15
What is the difference between the Haldane and Bohr effect?
Bohr effect causes release of O2 (presence of CO2 causes release of O2)
Haldane causes release of CO2 (presence of O2 causes release of CO2)
How is respiratory acidosis treated?
Metabolic acidosis?
respiratory: increase alveolar ventilation
metabolic: NaHCO3
Where is the respiratory center located?
medulla in the reticular formation
What is the pacemaker of normal breathing?
dorsal respiratory center
What respiratory center takes over during active breathing?
ventral respiratory center
Where are the apneustic and pneumotaxic centers located?
pons
What is the inspiratory “cuff of switch”?
pneumotaxic center
What is the Hering-Breuer inflation reflex?
inhibits large tidal breaths 1.5x above FRC, or 3x Vt
What is the Hering-Breuer deflation reflex?
increased ventilation elicited when the lungs are deflated
What is the paradoxical reflex of the head?
stimulates the newborn to take their first breath
What nerve provides afferent pathways for all of the airways irritant receptors?
vagus
Does PE or pulmonary vascular congestion cause rapid, shallow breathing?
PE
What is responsible for the COPD patients drive to breathe?
hypoxia. Limit FiO2
What are pauses of at least 10 seconds between breaths with cessation of respiratory effect?
central sleep apnea
What is the triad of obesity hypoventilation syndrome?
obesity, daytime hypoventilation, sleep-disorder breathing
What is the STOP-bang questionnaire used to assess?
OSA
Which patients have a decreased FEV1 and FEV1/FVC ratio?
increased airway resistance
Which spirometry test is the most sensitive indicator of small airway disease?
FEF25-75%
What respiratory disease flow volume loop is characterized by a reduced peak flow rate and a sloping of the expiratory limb?
obstructive
What respiratory disease flow volume loop is characterized by normal or heightened peak expiratory flows, but a very narrow loop?
restrictive disease
What is chronic bronchitis?
chronic or recurrent excess mucus secretion occurring on most days for at least 3 months of the year for at least 2 consecutive years
Define emphysema.
abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
What is the difference in centrilobular and panlobular emphysema?
centrilobular: affects upper lobes
panlobular: widespread alveolar destruction
What is the primary genetic related cause of COPD?
a-1 antitrypsin deficiency
What causes airway narrowing in COPD?
In asthma?
COPD: thickening of airway walls
Asthma: increase in smooth muscle tone
What are the hallmark symptoms of COPD?
Chronic productive cough and progressive exercise limitation.
What spirometry measurement is the hallmark of COPD?
Reduced FEV1
A low FEV1 and normal FEV1/FVC ratio is indicative of what respiratory disease?
Restrictive disease
Does obstructive disease cause a increase or decrease in RV and FRC?
Increase both
Cor pulmonale is common in what obstructive lung disease?
Chronic bronchitis
What x-ray findings are consistent with emphysema?
Hyperlucency and hyperinflation
What medication is contraindicated in patients with emphysema? Why?
N2O, it expands bullae, potentially leading to rupture.
What are the most frequent post-op pulmonary complications of a patient with COPD?
Atelectasis followed by pneumonia and hypoxia.
Differentiate extrinsic and intrinsic asthma.
Extrinsic: more common in kids, exacerbated by allergens
Intrinsic: more common in adults, no attack provoking stimuli
Allergic asthma is triggered by what type of Ig mediated immune reponse.
IgE
What are the most common mediators of the pro inflammatory cascade?
Eosinophils, mast cells, neutrophils, and macrophages
Exercise induced asthma is very responsive to what class of medications?
Beta-2 adrenergic receptor agonist
What are the three causes of airflow limitation in asthma?
Bronchoconstriction, airway hyper responsiveness, airway edema
What is status asthmaticus?
Severe airway obstruction refractory to bronchodilators
How does asthma affect RV, FRC, and TLC?
All increase
What is the hallmark of an incipient exacerbation of asthma?
Reduction in the peak expiratory flow rate
What ABG result do asthma patients have?
Respiratory alkalosis
What do chest x-rays of asthma patients typically reveal?
Hyperinflation with flattening of the diaphragm
Are anticholinergics or corticosteroids more useful in patients with asthma?
Corticosteroids
What medications used to prevent gastric aspiration are contraindicated in patients with asthma?
H-2 receptor blockers; cimetidine, and ranitidine
What is the induction agent of choice for asthmatic patients?
Ketamine
What is the agent of choice for inhalation induction of kids with asthma?
Sevo
What 3 medications should be avoided in patients with asthma?
Atracurium, mivacurium, and morphine
What is the beta blocker of choice for asthmatic patients?
Esmolol
What is the treatment of bronchospasm?
Deepen, 100% FiO2, short acting B-2 agonist, epi, corticosteroids
What two medications can help reduce airway sensitivity during emergence and extubation?
Fentanyl and lidocaine
What medication should be used to reverse patients with asthma?
Sugammadex
What PAP and PAOP pressure are diagnostic of pulmonary HTN?
PAP at least 25
PAOP no more than 15
What induction agent should be avoided in patients with pulmonary HTN?
Ketamine
What increases PVR and thus should be avoided in pulmonary HTN?
Hypoxemia, hypothermia, acidosis, hypercarbia, pain
What are some signs of cor pulmonale?
Hepatomegaly, ascites, lower extremity edema
Where do 90% of pulmonary embolisms originate?
iliofemoral vessels
What is Virchows triad?
venous status, vessel injury, hypercoagulable
What type of embolus is N2O contraindicated in?
venous air embolus
What type of embolus is N2O contraindicated in?
venous air embolus
What type of embolus is N2O contraindicated in?
venous air embolus
What are the first signs of PE in a ventilated patient?
decreased EtCO2, and tachycardia
What is the intraoperative management of a new PE?
intubate if not already
100% FiO2 and PEEP
IV fluids or Blood
NE as a vasopressor
In restrictive disease, how is spirometry affected: FEV1 FVC TLC FEV1/FVC ratio
FEV1 decreased
FVC decreased
TLC decreased
FEV1/FVC ratio normal or increased
What are acute intrinsic disorders?
pulmonary edema, aspiration pneumonia, ARDS
Examples of chronic intrinsic lung disorders include:
pulmonary fibrosis, radiation injury, amiodarone infusion, O2 toxicity, autoimmune disease, sarcoidosis
What are the chronic extrinsic lung disorders?
flail chest, pneumothorax, pleural effusions, ascites, obesity, pregnancy, skeletal and neuromuscular disorders
When hydrostatic pressure in the pulmonary capillaries increases what type of pulmonary edema occurs?
cardiogenic
What is the most common cause of non-cardiogenic pulmonary edema?
sepsis leading to ARDS
What is the earliest sign of pulmonary edema?
rapid, shallow breathing
What time frame do most aspirations take place?
intubation or w/i 5 minutes of extubation
What gastric volume and pH are indicators for risk of gastric aspiration?
pH <2.5
volume 25 mL or 0.4mL/kg
What treatments are of no use if your patient aspirates stomach contents because the damage is already done?
tracheal suctioning and bronchoscopy
What is the hallmark and first sign of aspiration pneumonitis?
arterial hypoxia
Sodium citrate and bacitra should be given in what time frame to reduce gastric pH?
15 minutes before surgery. 15-60min
What are the H2 receptor blockers used to prevent gastric aspiration? When should they be given?
cimetidine, famotidine, ranitidine. 45-60min prior to sx.
When are proton pump inhibitors best given to prevent gastric aspiration?
the night before and preoperatively
what is a hallmark finding in ARDS?
noncardiogenic pulmonary edema
What is the time period to diagnose TRALI?
within 6 hours of transfusion
Administration of what blood product is most likely to cause TRALI?
platelets
Differentiate symptoms of TRALI and TACO.
TRALI: fever, chills, dyspnea
TACO: tachycardia, dyspnea, pulmonary edema
What is the key differentiating factor of TRALI and TACO? Which does it occur in?
circulatory overload. exists in TACO but not TRALI
What are the most frequent symptoms of drug induced pulmonary injury?
interstitial pneumonitis and fibrosis
What cytotoxic drug is most often implicated in causing drug induced lung injury?
Bleomycin
What are pulmonary manifestations of sarcoidosis?
fibrosis. decreased compliance, diffusion capacity, reduced lung volumes
What lung disease affect the lymph nodes of the lungs?
sarcoidosis
What are the hallmark chest movements of a flail chest?
fail moves in with inspiration and out with expiration
What type of pneumothorax is described as “air in the pleural cavity exchanges with atmospheric air through defect in the chest wall”
communicating pneumothorax
What is a tension pneumothorax?
air progressively accumulates under pressure in the pleural cavity.
What are hallmark symptoms of a tension pneumothorax?
HoTN, hypoxemia, tachycardia, increased CVP
What is the treatment for tension pneumothorax?
decompression with a 14G angiocath needle in the 2nd or 3rd interspace anteriorly, or 4th-5th interspace laterally
When is thoracotomy for a hemothorax indicated?
initial bleeding rate is greater than 20mL/kg/h
What type of pneumothorax is a contraindication to N2O administration?
closed
What is the most common cause of postoperative respiratory dysfunction?
atelectasis
What is the most common cardiovascular abnormality in patients with scoliosis?
mitral valve prolapse
What lab value is an important indicator of pulmonary complications?
hypoalbuminemia, < 3.6
What tests the lungs ability to allow transport of gas across the alveolar-capillary membrane?
diffusion capacity
What is a favorable VO2 max value?
greater than 20
Patients with how many “pack year” history of smoking have increased risk of pulmonary complications following surgery?
20
What are absolute indications for one lung ventilation?
isolate a lung to avoided contamination (infection, hemorrhage), control ventilation, unilateral lavage
A 26F double lumen tube is equivalent to what size standard ETT?
7.5
Double lumen tubes have a higher incidence of what complications compared to a bronchial blockers?
hoarseness and vocal cord lesions
What is the depth of double lumen tube insertion for males and females?
27 females
29 males
What type of cuff does a double lumen tube have?
____ pressure, ____ volume
high pressure, low volume
How can you test the integrity of the bronchial cuff during lung isolation for infection?
ventilate the tracheal lumen and insert a tube from the bronchial port to a cup of water. Bubbles indicate an incomplete isolation
What type of ETT specifically accommodates a bronchial blocker?
Univent - has a side channel
What device is needed to guide placement of a bronchial blocker?
bronchoscope
What type of bronchial blockers has a steerable tip to guide placement?
Cohen
What are 4 disadvantages of a bronchial blocker?
require more time for placement, malpositioned more, lung deflation less effective, do not allow suctioning
What type of drugs oppose the effects of hypoxic pulmonary vasoconstriction?
vasopressors- dopa, epi, neo
What ventilation settings should be used for one lung ventilation?
Vt 6-8mL/kg, PEEP, peak pressure less than 25
During one lung ventilation, PaCO2 should be kept below what value?
60-70`
What are some interventions to improve oxygenation in one lung ventilation?
CPAP to nonventilated lung (can use Mapleson C circuit), low flow O2, more PEEP to ventilated lung
When slowly reinflating the operative lung, peak pressures should be maintained no higher than what value?
30-40 cm H2O
What are means to improve perfusion to the dependent lung to increase PaO2?
inhaled epoprostenol “flolan” or N2O.
Where should an arterial line and NIBP be placed for a patient undergoing mediastinoscopy?
A-line right, BP left
