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2 Review Course > Respiratory > Flashcards

Respiratory Flashcards

1
Q

The upper airway ends at which cartilage?

A

cricoid cartilage

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2
Q

What structures comprise the lower airway?

A

trachea, bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, alveoli

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3
Q

What structure creates 2/3rds of the resistance to breathing?

A

nasal mucosa

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4
Q

What blood vessels provide arterial blood supply to the nasal mucosa?

A

opthalmic, facial, and maxillary

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5
Q

What nerve and branches supply the nasal mucosa?

A

trigeminal nerve, ophthalmic and maxillary branches

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6
Q

What is the result of decreased SNS stimulation to the nasal mucosa during general anesthesia?

A

engorgement of tissues leading to higher potential for bleeding

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7
Q

What happens to the soft palate during general anesthesia?

A

falls back against the nasal passages causing symptoms of sleep apnea

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8
Q

What are examples of diseases with underdeveloped tongue, maxilla, and or mandible?

A

Pierre-Robin, Apert, Treacher Collins

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9
Q

What disorders can obstruct the airway due to macroglossia? (2)

A

Beckwith Wideman, Down

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10
Q

Which vertebrae is consistent with the level of the nasopharynx?

A

C1

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11
Q

What nerve innervates the nasopharynx?

A

Maxillary division of the trigeminal nerve

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12
Q

What are the superior and inferior borders of the oropharynx?

A

soft palate superior, and epiglottis inferior

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13
Q

What vertebrae and cartilage mark the end of the hypopharynx?

A

C5/C6 at cricoid cartilage

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14
Q

What is the reflex arch of stimulation to the pharynx?

A

stimuli to wall of pharynx -> afferent: glossopharyngeal nerve -> medulla -> efferent: vagus nerve -> gag reflex

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15
Q

Where does the internal SLN provide sensory input to?

A

hypopharynx above the vocal cords

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16
Q

The external SLN provides motor innervation to what muscle?

A

cricothyroid

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17
Q

What nerve provides sensory innervation to the subglottic area and trachea?

A

RLN

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18
Q

What are symptoms of injury to the RLN?

A

hoarsness and stridor

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19
Q

The RLN provides motor innervation to what structures?

A

all muscle of the larynx except the cricothyroid

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20
Q

Does unilateral RLN damage cause respiratory distress?

A

no

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21
Q

Damage to bilateral RLN results in what?

A

stridor and respiratory distress

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22
Q

What are the three unpaired cartilages of the larynx?

A

cricoid, thyroid, and epiglottis

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23
Q

What are the three paired cartilages of the larynx?

A

arytenoid, corniculate, cuneiform

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24
Q

What are the four functions of the larynx?

A

protect from aspiration, phonation, airway patency, gag and cough reflex

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25
Q

Mature alveoli are not present until how many weeks gestation?

A

36

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26
Q

What anatomical structure extends from the cricoid cartilage to the carina?

A

trachea

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27
Q

What is the only complete cartilaginous ring in the trachea?

A

cricoid

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28
Q

What is the first anatomical structure of the respiratory system to lack cartilage distal to the trachea?

A

bronchioles

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29
Q

Describe the right main bronchus? angle and length

A

25 degree, 2.5 cm

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30
Q

Describe the left main bronchus? angle and length

A

45 degrees, 5cm

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31
Q

Where does sympathetic innervation to the tracheobronchial tree originate?

A

1-5th thoracic ganglia

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32
Q

What nerve supplies the diaphragm?

A

phrenic (C3-C5 roots)

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33
Q

Inadequate BMV is indicated by: (4)

A

no chest rise, deficient exhaled CO2, absent breath sounds, decreased SpO2

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34
Q

What are hallmark signs of upper airway obstruction? (4)

A

hoarse voice, difficulty swallowing secretions, stridor, and dyspnea

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35
Q

How do lower airway obstructions present?

A

high peak airway pressures, low Vt, impaired ventilation

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36
Q

What are two predictors of difficult mask ventilation?

A

OSA and snoring

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37
Q

What is a potential risk factor for difficult BMV?

A

obesity

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38
Q

What two things are required in order to provide apneic oxygenation?

A

nasal cannula and patent upper airway

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39
Q

Conditions that decrease lung compliance, and contribute to ineffective BVM include:

A

bronchospasm, pulmonary edema, ARDS, pneumonia

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40
Q

Is using a video laryngoscopy for intubation considered a direct or indirect means to visualize the vocal cords?

A

indirect

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41
Q

What are the 7 airway assessments?

A

mallampati, interincisor gap, thyromental distance, neck circumference, mandibular protrusion test, A-O joint mobility, look for obstruction,

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42
Q

What does a MMT assess?

A

tongue size relative to the oropharyngeal space.

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43
Q

What can you visualize with each Mallampati score?

A

1: tonsils pillars, faucet, uvula, soft palate.
2: faucet, uvula, soft palate
3: uvula, soft palate
4: hard palate

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44
Q

What neck circumference size is consistence with difficult airway?

A

> 43cm

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45
Q

What is visualized on a Cormack and Lehan grade 1?

A

full view of the glottic opening

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46
Q

What is visualized on a Cormack and Lehan grade 2?

A

only the posterior portion of the glottis opening

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47
Q

What is visualized on a Cormack and Lehan grade 3?

A

only the epiglottis

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48
Q

What is visualized on a Cormack and Lehan grade 4?

A

only the soft palate

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49
Q

What is visualized on a Cormack and Lehan grade 2a?

A

partial view of the vocal cords

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50
Q

What is visualized on a Cormack and Lehan grade 2b?

A

arytenoids, and epiglottis only

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51
Q

When assigning a POGO rating, what structures are used?

A

anterior commissure, interarytenoid notch

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52
Q

What airway assessment looks at the dispensability of the tongue?

A

TMD

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53
Q

What are the borders of the thyromental space?

A

lateral- neck
superior- mentum
inferior- hyoid

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54
Q

What are characteristics of a TMD >9cm that make DL difficult?

A

large hypopharyngeal tongue, caudal larynx, longer mandibulohyoid distance

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55
Q

History of what clues the anesthesia provider to a possible hypo pharyngeal tongue?

A

OSA and snoring

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56
Q

What is the 3-3-2 test?

A

3 finger breadths interincisor
3 finger breadths TMD
2 finger breadths from neck junction to thyroid notch

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57
Q

What is an “appropriate” inter incisor gap?

A

2-3 fingers, or 4cm

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58
Q

What is the full range of neck extension?

A

90-165 degrees

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59
Q

What angle of neck extension is predictive of difficult direct laryngoscopy?

A

23 degrees

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60
Q

What are the three mandibular protrusion test classifications?

A

1: bite the upper lip
2: upper and lower teeth align
3: lowers cant align with upper.

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61
Q

What conditions reduce A-O movement potentially causing difficulty with supraglottic airways?

A

ankylosing spondylosis and RA

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62
Q

What conditions make cricothyroitomy more difficult?

A

surgery, hematoma, obesity, radiation, tumor

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63
Q

What is the gold standard for ruling out cervical fractures?

A

CT scan

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64
Q

What are 3 positive predictors for difficult laryngoscopy in obese patients?

A

excessive pretracheal soft tissue, large neck, sleep apnea

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65
Q

What is elevation of the shoulders, head and neck called?

A

ramping

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66
Q

Preoxygenation can provide oxygen to the blood for up to how long?

A

8 minutes

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67
Q

What is the required minimum fresh gas flow during preoxygenation

A

5 L/min

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68
Q

If your preoxygnation time is cut short to only 1 minute. How should you instruct your patient to breathe in those 60 seconds?

A

8 vital capacity breaths

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69
Q

What type of pressure is used to enhance visualization of the vocal cords?

A

Backwards, Upwards, Rightwards Pressure

BURP

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70
Q

What is the common cause of an unanticipated difficult airway?

A

enlarged lymphoid tissue at the base of the tongue

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71
Q

What are the three instances that determine a difficult airway?

A

difficult mask, difficult laryngoscopy, difficult intubation or all three

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72
Q

What are the four endpoints to the ASA difficult airway algorithm?

A

intubation awake or asleep, adequate or inadequate facemark or LMA ventilation, intubation by special means, surgical or non-surgical emergency airway

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73
Q

In the event of a failed intubation what is the next step in the difficult airway algorithms?

A

facemask ventilation or LMA

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74
Q

If initial attempts at intubation fail but subsequent ventilation attempts are successful what is the next step?

A

awaken the patient

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75
Q

If intubation fails and facemask and LMA are unsuccessful what is the next step?

A

cricothyrotomy

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76
Q

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?

A

antisialagogue

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77
Q

What is the most widely used LA for anesthetizing the airway?

A

lidocaine

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78
Q

What three cranial nerves need to be anesthetized to perform an awake oral or nasal intubation?

A

trigeminal, glossopharyngeal, and vagus

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79
Q

aspiration of blood during a glossopharyngeal block is likely from which vessel?

A

carotid

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80
Q

What is the landmark for the SLN block?

A

hyoid

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81
Q

Before loss of consciousness, how many kg of pressure should be applied for cricoid pressure?

A

2kg

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82
Q

After loss of consciousness, how many kg of pressure should be applied for cricoid pressure?

A

4kg

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83
Q

Cricoid pressure during vomiting can lead to what complication?

A

esophageal rupture

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84
Q

What is a airway device that sits above or surrounds the glottis?

A

supraglottic

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85
Q

what is an airway device called if it passes behind the larynx and enters the esophagus?

A

retroglottic or infraglottic

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86
Q

LMA cuff pressure should not exceed what pressure?

A

60cmH2O

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87
Q

Which supraglottic airway has a large oropharyngeal balloon and a smaller esophageal balloon, with a single pilot ballon to insufflate the cuffs?

A

king airway

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88
Q

What is the retroglottic airway device with two lumens with two separate pilot balloons?

A

combitube

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89
Q

What is the significant concern with supraglottic airways?

A

aspiration

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90
Q

A bougie should inserted to what depth?

A

25cm

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91
Q

How can we prevent fogging of a FOB?

A

soak in warm saline

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92
Q

What are indications for FOB?

A

difficult airway, cervical spine immobility, upper airway abnormalities, failed intubation but able to ventilate

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93
Q

Which oral airways help in placement of a FOB?

A

williams, ovassapian, berman

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94
Q

What is a more advantageous use of the suction port other than for suctioning?

A

supplemental O2, 2-4L

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95
Q

during TTV, what are causes of hyperinflation and incomplete exhalation of CO2?

A

obstructions to passive exhalation, large tidal volumes

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96
Q

What are indications for a surgical cric?

A

failed airway, traumatic facial injuries, upper airway obstruction, airway for neck or facial surgery when traditional intubation is not possible

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97
Q

What is the absolute contraindication for surgical cric?

A

children younger than 12

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98
Q

what are relative contraindications for a cric?

A

tumors, infections, abscess, hematoma, bleeding diathesis, hx of coagulopathy

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99
Q

How is the patients head positioned for a surgical cric?

A

neutral

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100
Q

Where is a tracheostomy placed?

A

4-6th tracheal ring, below the isthmus of the thyroid gland

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101
Q

Which patients are most likely to not tolerate extubation?

A

those with marginal cardiopulmonary reserve

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102
Q

Complications of extubation are most common during which Guedel stage of anesthesia?

A

stage 2

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103
Q

What are signs of readiness for extubation?
VC:
Inspiratory force:
Vt:

A

VC: > 15mL/kg
Inspiratory force: -20 cmH2O
Vt: 4-5mL/lg

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104
Q

What are appropriate measures to extubate a difficult airway?

A

over a flexible FOB, place a supraglottic airway, airway exchange catheter, leave the ETT in

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105
Q

What are three complications after tracheal extubation?

A

laryngospasm, residual NBM, and laryngotracheobronchitis

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106
Q

The afferent réponse to laryngospasm occurs via which nerves?

A

external SLN, and RLN

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107
Q

During laryngospasm, what occurs during “glottis shutter closure”?

A

vocal cord adduction causing partial airway obstruction

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108
Q

During laryngospasm, what occurs during “ball valve closure”?

A

extrinsic laryngeal muscles close the false vocal cords causing complete airway obstruction

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109
Q

What is the Larson maneuver used to treat? How do you do it?

A

laryngospasm. vigorous jaw thrust

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110
Q

Where does laryngotracheobronchitis occur?

A

inflammation and edema below the level of the vocal cords

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111
Q

What is a sign of laryngotracheobronchitis?

A

inspiratory and expiratory stridor

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112
Q

What are the three treatments for croup?

A

humidified O2, racemic epi, dexamethasone

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113
Q

What are 4 complications of airway management?

A

airway trauma, aspiration, esophageal intubation, endobronchial intubation

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114
Q

Of the anesthesia related malpractice claims, what is the most common one?

A

dental injury

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115
Q

The development of pneumonia after aspiration is dependent on what three things?

A

type of aspirate, volume of aspirate, pt’s comorbid conditions

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116
Q

The administration of non particulate antacids should be given how long before induction of anesthesia to reduce gastric pH?

A

10-20 minutes

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117
Q

A histamine blocking agent should be administer at what time interval before induction to reduce stomach acid production and raise the pH?

A

45-60 minutes. famotidine, cemitidine, ranitidine

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118
Q

What medication is given 10-20 minutes before induction to speed gastric emptying?

A

metoclopramide

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119
Q

What are two sensitive methods for confirming ETT placement?

A

EtCO2, FOB

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120
Q

What are 4 signs of endobronchial intubation?

A

increased peak pressures, asymmetric chest expansion, unilateral breath sounds, hypoxemia

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121
Q

How is a partial obstructed ETT treated?

A

suction or FOB

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122
Q

How is a completely obstructed ETT managed?

A

pass a stylet or AEC down the ETT

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123
Q

What is obstruction of the posterior nasal airway called?

A

choanal atresia

124
Q

Which concha is most commonly injured during nasal intubation?

A

inferior concha

125
Q

What type of cells in the respiratory mucosa produces mucus?

A

goblet cells

126
Q

What arteries supply the nasal fossa?

A

ophthalmic, internal maxillary, sphenopalatine

127
Q

What are the three important functions of the nose?

A

filtration, humidification, and heating inspired air

128
Q

Nasal filtration is extremely effective for particles above ___ mcm and less than ___ nm.

A

10 mcm
1 nm
efficiency is inverse to particle size 10 nm to 1 mcm

129
Q

Where do ingested foreign bodies typically get lodged?

A

where the pharynx becomes continuous with the esophagus. C6

130
Q

What structure acts as a first line defense against bacterial invasion of the nasal and buccal passages?

A

Waldeyer tonsilar ring

131
Q

Which cervical vertebrae are consistent with the location of the larynx

A

C3-C6

132
Q

which laryngeal cartilage is consistent with the beginning of the trachea and esophagus?

A

cricoid

133
Q

What are the two structures visualized at the base of the vocal cords during laryngoscopy?

A

corniculate and cuneiform cartilages. Not arytenoids!

134
Q

What is the narrowest part of the larynx in adults and children?

A

adult: vocal cords
children: cricoid cartilage

135
Q

where is the supraglottic area of the larynx?

A

above the false vocal cords to the tip of the epiglottis

136
Q

Where is the second compartment of the larynx located?

A

between the false and true vocal cords

137
Q

Where is the infraglottic region of the vocal cords?

A

below the true vocal cords and above the beginning of the trachea

138
Q

What is the space between the true vocal cords?

A

rima glottidis

139
Q

Where do the true vocal cords attach?

A

anterior: thyroid cartilage
posterior: arytenoids

140
Q

Which muscle lengthens and shortens the vocal cords?

A

lengthens: cricothyroid
shortens: thyroarytenoid

141
Q

Where does the internal SLN provide sensation?

A

inferior epiglottis to the vocal cords

142
Q

Which nerve innervates the inerarytenoid muscles which are important for phonation?

A

internal SLN

143
Q

How does damage to the RLN manifest?

A

unilateral or bilateral vocal cord paralysis, hoarseness, or dyspnea

144
Q

What is the distance from the incisors to the carina?

A

26cm

145
Q

What vertebrae are consistent with the carina?

A

T4-T5

146
Q

How does neck flexion and extension move the carina.

A

Flexion: upward movement
extension: downward

147
Q

As the airways divide and multiply what happens to the area and airflow velocity?

A

cross section area increases, airflow velocity decreases

148
Q

In what part of the lungs does gas exchange first occur?

A

respiratory bronchioles

149
Q

The lung volume at which small airways begin to close?

A

closing volume

150
Q

What structures allow collateral gas flow between alveoli and provide a mechanism of relief from gas stagnation from airway closure?

A

pores of Kohn

151
Q

What makes up the respiratory zone?

A

respiratory bronchi, alveolar ducts, alveolar sacs, alveoli

152
Q

What is the transition zone of the lungs?

A

respiratory bronchi, alveolar ducts

153
Q

What type of cells play a role in the development of adenocarcinoma and other chronic lung disease?

A

Clara cells

154
Q

What is accumulation of air in the pleural space?

A

pneumothorax

155
Q

What type of pneumothorax develops as inspired air accumulates in the pleural space?

A

tension pneumo

156
Q

Which law explains how during inspiration, the increase in volume creates a reduction in pressure which causes air to move into the lungs?

A

Boyle’s

157
Q

Which nerve roots innervate the diaphragm?

A

C3,C4,C5

158
Q

Spinal cord injuries above what vertebral level lead to dependence on mechanical ventilation?

A

C5

159
Q

For air to move into alveoli, alveolar pressure must be ___ than atmospheric pressure.

A

less

160
Q

How do you define lung compliance

A

volume / pressure

161
Q

What factors cause changes in static lung compliance?

A

fibrosis, obesity, vascular engorgement, edema, ARDS, surgeon leaning on the chest

162
Q

What disease increases static lung compliance?

A

emphysema

163
Q

What law of physics applies to inflation of alveoli?

A

Laplace

164
Q

Aside from surfactant, what plays the most important role in preventing alveolar collapse?

A

connective tissue and elastic forces

165
Q

What is the prevalent cause of ARDS in premature infants?

A

lack of surfactant

166
Q

Pleural pressure is always

A

negative

167
Q

What Reynolds number describes laminar and turbulent flow?

A

laminar < 2000
Turbulent > 4000
Transitional 2000-4000

168
Q

Where is airflow turbulence the greatest?

A

large airways

169
Q

Where does the greatest resistance to airflow occur?

A

medium sized bronchi

170
Q

In order to promote laminar flow in obstructive lung disease, which intervention will lower airflow velocity and airflow density?

A

heliox

171
Q

How do we calculate alveolar ventilation?

A

(Vt - dead space) x RR

172
Q

What conditions increase closing volume? (6)

A

supine, pregnancy, obesity, age, COPD, CHF

173
Q

What is alveolar dead space?

A

alveoli that are ventilated but not perfused

174
Q

What is physiologic dead space?

A

anatomic and alveolar dead space

175
Q

What does the Bohr equation tell you? What is the formula?

A

calculates dead space ventilation.

(PaCO2 - PECO2) / PaCO2

176
Q

In the upright lung which alveoli are more compliant?

A

those in the base

177
Q

What is the alveolar gas equation?

A

PAO2 = FiO2 x (760-47) - (PACO2/0.8)

178
Q

In what type of cells does gas exchange occur?

A

squamous epithelium

179
Q

What increases PVR?

A

NE, serotonin, histamine, hypoxia, hypercapnia

180
Q

What drugs can be given to acutely decrease PVR?

A

NO, sidenafil

181
Q

Is negative pressure pulmonary edema treated with steroids and diuretics?

A

No. remove the causative agent, normalize ventilation, reduce lung congestion and fluid

182
Q

What values (high/low) of PaO2 and CO2 occur in dependent regions of the lung?

A

low PaO2

high CO2

183
Q

What values (high/low) of PaO2 and CO2 occur in nondependent regions of the lung?

A

high PaO2

low PCO2

184
Q

Does high ventilatory settings and PEEP cause a shunt or dead space?

A

deadspace

185
Q

What causes a left shift on the oxyhemoglobin dissociation curve?

A

decreased temperature, 2,3- DPG, CO2, alkalosis

186
Q

What causes a right shift on the oxyhemoglobin dissociation curve?

A

increased temp, 2,3-DPG, CO2, and acidosis

187
Q

What is the normal P50 value?

A

26-27

188
Q

How is methemoglobinemia treated?

A

O2, methylene blue 1-2mg/kg over 5 min

189
Q

What is the formula for O2 carrying capacity?

A

CaO2 = (Hgb x 1.34 x SpO2) + (PaO2 x 0.003)

190
Q

What are the normal values for CaO2 and CvO2?

A

CaO2: 20
CvO2: 15

191
Q

What is the difference between the Haldane and Bohr effect?

A

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)

192
Q

How is respiratory acidosis treated?

Metabolic acidosis?

A

respiratory: increase alveolar ventilation
metabolic: NaHCO3

193
Q

Where is the respiratory center located?

A

medulla in the reticular formation

194
Q

What is the pacemaker of normal breathing?

A

dorsal respiratory center

195
Q

What respiratory center takes over during active breathing?

A

ventral respiratory center

196
Q

Where are the apneustic and pneumotaxic centers located?

A

pons

197
Q

What is the inspiratory “cuff of switch”?

A

pneumotaxic center

198
Q

What is the Hering-Breuer inflation reflex?

A

inhibits large tidal breaths 1.5x above FRC, or 3x Vt

199
Q

What is the Hering-Breuer deflation reflex?

A

increased ventilation elicited when the lungs are deflated

200
Q

What is the paradoxical reflex of the head?

A

stimulates the newborn to take their first breath

201
Q

What nerve provides afferent pathways for all of the airways irritant receptors?

A

vagus

202
Q

Does PE or pulmonary vascular congestion cause rapid, shallow breathing?

A

PE

203
Q

What is responsible for the COPD patients drive to breathe?

A

hypoxia. Limit FiO2

204
Q

What are pauses of at least 10 seconds between breaths with cessation of respiratory effect?

A

central sleep apnea

205
Q

What is the triad of obesity hypoventilation syndrome?

A

obesity, daytime hypoventilation, sleep-disorder breathing

206
Q

What is the STOP-bang questionnaire used to assess?

A

OSA

207
Q

Which patients have a decreased FEV1 and FEV1/FVC ratio?

A

increased airway resistance

208
Q

Which spirometry test is the most sensitive indicator of small airway disease?

A

FEF25-75%

209
Q

What respiratory disease flow volume loop is characterized by a reduced peak flow rate and a sloping of the expiratory limb?

A

obstructive

210
Q

What respiratory disease flow volume loop is characterized by normal or heightened peak expiratory flows, but a very narrow loop?

A

restrictive disease

211
Q

What is chronic bronchitis?

A

chronic or recurrent excess mucus secretion occurring on most days for at least 3 months of the year for at least 2 consecutive years

212
Q

Define emphysema.

A

abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

213
Q

What is the difference in centrilobular and panlobular emphysema?

A

centrilobular: affects upper lobes
panlobular: widespread alveolar destruction

214
Q

What is the primary genetic related cause of COPD?

A

a-1 antitrypsin deficiency

215
Q

What causes airway narrowing in COPD?

In asthma?

A

COPD: thickening of airway walls
Asthma: increase in smooth muscle tone

216
Q

What are the hallmark symptoms of COPD?

A

Chronic productive cough and progressive exercise limitation.

217
Q

What spirometry measurement is the hallmark of COPD?

A

Reduced FEV1

218
Q

A low FEV1 and normal FEV1/FVC ratio is indicative of what respiratory disease?

A

Restrictive disease

219
Q

Does obstructive disease cause a increase or decrease in RV and FRC?

A

Increase both

220
Q

Cor pulmonale is common in what obstructive lung disease?

A

Chronic bronchitis

221
Q

What x-ray findings are consistent with emphysema?

A

Hyperlucency and hyperinflation

222
Q

What medication is contraindicated in patients with emphysema? Why?

A

N2O, it expands bullae, potentially leading to rupture.

223
Q

What are the most frequent post-op pulmonary complications of a patient with COPD?

A

Atelectasis followed by pneumonia and hypoxia.

224
Q

Differentiate extrinsic and intrinsic asthma.

A

Extrinsic: more common in kids, exacerbated by allergens
Intrinsic: more common in adults, no attack provoking stimuli

225
Q

Allergic asthma is triggered by what type of Ig mediated immune reponse.

A

IgE

226
Q

What are the most common mediators of the pro inflammatory cascade?

A

Eosinophils, mast cells, neutrophils, and macrophages

227
Q

Exercise induced asthma is very responsive to what class of medications?

A

Beta-2 adrenergic receptor agonist

228
Q

What are the three causes of airflow limitation in asthma?

A

Bronchoconstriction, airway hyper responsiveness, airway edema

229
Q

What is status asthmaticus?

A

Severe airway obstruction refractory to bronchodilators

230
Q

How does asthma affect RV, FRC, and TLC?

A

All increase

231
Q

What is the hallmark of an incipient exacerbation of asthma?

A

Reduction in the peak expiratory flow rate

232
Q

What ABG result do asthma patients have?

A

Respiratory alkalosis

233
Q

What do chest x-rays of asthma patients typically reveal?

A

Hyperinflation with flattening of the diaphragm

234
Q

Are anticholinergics or corticosteroids more useful in patients with asthma?

A

Corticosteroids

235
Q

What medications used to prevent gastric aspiration are contraindicated in patients with asthma?

A

H-2 receptor blockers; cimetidine, and ranitidine

236
Q

What is the induction agent of choice for asthmatic patients?

A

Ketamine

237
Q

What is the agent of choice for inhalation induction of kids with asthma?

A

Sevo

238
Q

What 3 medications should be avoided in patients with asthma?

A

Atracurium, mivacurium, and morphine

239
Q

What is the beta blocker of choice for asthmatic patients?

A

Esmolol

240
Q

What is the treatment of bronchospasm?

A

Deepen, 100% FiO2, short acting B-2 agonist, epi, corticosteroids

241
Q

What two medications can help reduce airway sensitivity during emergence and extubation?

A

Fentanyl and lidocaine

242
Q

What medication should be used to reverse patients with asthma?

A

Sugammadex

243
Q

What PAP and PAOP pressure are diagnostic of pulmonary HTN?

A

PAP at least 25

PAOP no more than 15

244
Q

What induction agent should be avoided in patients with pulmonary HTN?

A

Ketamine

245
Q

What increases PVR and thus should be avoided in pulmonary HTN?

A

Hypoxemia, hypothermia, acidosis, hypercarbia, pain

246
Q

What are some signs of cor pulmonale?

A

Hepatomegaly, ascites, lower extremity edema

247
Q

Where do 90% of pulmonary embolisms originate?

A

iliofemoral vessels

248
Q

What is Virchows triad?

A

venous status, vessel injury, hypercoagulable

249
Q

What type of embolus is N2O contraindicated in?

A

venous air embolus

249
Q

What type of embolus is N2O contraindicated in?

A

venous air embolus

249
Q

What type of embolus is N2O contraindicated in?

A

venous air embolus

250
Q

What are the first signs of PE in a ventilated patient?

A

decreased EtCO2, and tachycardia

251
Q

What is the intraoperative management of a new PE?

A

intubate if not already
100% FiO2 and PEEP
IV fluids or Blood
NE as a vasopressor

252
Q 
In restrictive disease, how is spirometry affected:
FEV1
FVC
TLC
FEV1/FVC ratio
A

FEV1 decreased
FVC decreased
TLC decreased
FEV1/FVC ratio normal or increased

253
Q

What are acute intrinsic disorders?

A

pulmonary edema, aspiration pneumonia, ARDS

254
Q

Examples of chronic intrinsic lung disorders include:

A

pulmonary fibrosis, radiation injury, amiodarone infusion, O2 toxicity, autoimmune disease, sarcoidosis

255
Q

What are the chronic extrinsic lung disorders?

A

flail chest, pneumothorax, pleural effusions, ascites, obesity, pregnancy, skeletal and neuromuscular disorders

256
Q

When hydrostatic pressure in the pulmonary capillaries increases what type of pulmonary edema occurs?

A

cardiogenic

257
Q

What is the most common cause of non-cardiogenic pulmonary edema?

A

sepsis leading to ARDS

258
Q

What is the earliest sign of pulmonary edema?

A

rapid, shallow breathing

259
Q

What time frame do most aspirations take place?

A

intubation or w/i 5 minutes of extubation

260
Q

What gastric volume and pH are indicators for risk of gastric aspiration?

A

pH <2.5

volume 25 mL or 0.4mL/kg

261
Q

What treatments are of no use if your patient aspirates stomach contents because the damage is already done?

A

tracheal suctioning and bronchoscopy

262
Q

What is the hallmark and first sign of aspiration pneumonitis?

A

arterial hypoxia

263
Q

Sodium citrate and bacitra should be given in what time frame to reduce gastric pH?

A

15 minutes before surgery. 15-60min

264
Q

What are the H2 receptor blockers used to prevent gastric aspiration? When should they be given?

A

cimetidine, famotidine, ranitidine. 45-60min prior to sx.

265
Q

When are proton pump inhibitors best given to prevent gastric aspiration?

A

the night before and preoperatively

266
Q

what is a hallmark finding in ARDS?

A

noncardiogenic pulmonary edema

267
Q

What is the time period to diagnose TRALI?

A

within 6 hours of transfusion

268
Q

Administration of what blood product is most likely to cause TRALI?

A

platelets

269
Q

Differentiate symptoms of TRALI and TACO.

A

TRALI: fever, chills, dyspnea
TACO: tachycardia, dyspnea, pulmonary edema

270
Q

What is the key differentiating factor of TRALI and TACO? Which does it occur in?

A

circulatory overload. exists in TACO but not TRALI

271
Q

What are the most frequent symptoms of drug induced pulmonary injury?

A

interstitial pneumonitis and fibrosis

272
Q

What cytotoxic drug is most often implicated in causing drug induced lung injury?

A

Bleomycin

273
Q

What are pulmonary manifestations of sarcoidosis?

A

fibrosis. decreased compliance, diffusion capacity, reduced lung volumes

274
Q

What lung disease affect the lymph nodes of the lungs?

A

sarcoidosis

275
Q

What are the hallmark chest movements of a flail chest?

A

fail moves in with inspiration and out with expiration

276
Q

What type of pneumothorax is described as “air in the pleural cavity exchanges with atmospheric air through defect in the chest wall”

A

communicating pneumothorax

277
Q

What is a tension pneumothorax?

A

air progressively accumulates under pressure in the pleural cavity.

278
Q

What are hallmark symptoms of a tension pneumothorax?

A

HoTN, hypoxemia, tachycardia, increased CVP

279
Q

What is the treatment for tension pneumothorax?

A

decompression with a 14G angiocath needle in the 2nd or 3rd interspace anteriorly, or 4th-5th interspace laterally

280
Q

When is thoracotomy for a hemothorax indicated?

A

initial bleeding rate is greater than 20mL/kg/h

281
Q

What type of pneumothorax is a contraindication to N2O administration?

A

closed

282
Q

What is the most common cause of postoperative respiratory dysfunction?

A

atelectasis

283
Q

What is the most common cardiovascular abnormality in patients with scoliosis?

A

mitral valve prolapse

284
Q

What lab value is an important indicator of pulmonary complications?

A

hypoalbuminemia, < 3.6

285
Q

What tests the lungs ability to allow transport of gas across the alveolar-capillary membrane?

A

diffusion capacity

286
Q

What is a favorable VO2 max value?

A

greater than 20

287
Q

Patients with how many “pack year” history of smoking have increased risk of pulmonary complications following surgery?

A

20

288
Q

What are absolute indications for one lung ventilation?

A

isolate a lung to avoided contamination (infection, hemorrhage), control ventilation, unilateral lavage

289
Q

A 26F double lumen tube is equivalent to what size standard ETT?

A

7.5

290
Q

Double lumen tubes have a higher incidence of what complications compared to a bronchial blockers?

A

hoarseness and vocal cord lesions

291
Q

What is the depth of double lumen tube insertion for males and females?

A

27 females

29 males

292
Q

What type of cuff does a double lumen tube have?

____ pressure, ____ volume

A

high pressure, low volume

293
Q

How can you test the integrity of the bronchial cuff during lung isolation for infection?

A

ventilate the tracheal lumen and insert a tube from the bronchial port to a cup of water. Bubbles indicate an incomplete isolation

294
Q

What type of ETT specifically accommodates a bronchial blocker?

A

Univent - has a side channel

295
Q

What device is needed to guide placement of a bronchial blocker?

A

bronchoscope

296
Q

What type of bronchial blockers has a steerable tip to guide placement?

A

Cohen

297
Q

What are 4 disadvantages of a bronchial blocker?

A

require more time for placement, malpositioned more, lung deflation less effective, do not allow suctioning

298
Q

What type of drugs oppose the effects of hypoxic pulmonary vasoconstriction?

A

vasopressors- dopa, epi, neo

299
Q

What ventilation settings should be used for one lung ventilation?

A

Vt 6-8mL/kg, PEEP, peak pressure less than 25

300
Q

During one lung ventilation, PaCO2 should be kept below what value?

A

60-70`

301
Q

What are some interventions to improve oxygenation in one lung ventilation?

A

CPAP to nonventilated lung (can use Mapleson C circuit), low flow O2, more PEEP to ventilated lung

302
Q

When slowly reinflating the operative lung, peak pressures should be maintained no higher than what value?

A

30-40 cm H2O

303
Q

What are means to improve perfusion to the dependent lung to increase PaO2?

A

inhaled epoprostenol “flolan” or N2O.

304
Q

Where should an arterial line and NIBP be placed for a patient undergoing mediastinoscopy?

A

A-line right, BP left

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