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Pharm Final review > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Where is the anatomical location of the larynx in the adult?

A

located anterior to 3rd-6th cervical vertebrae

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2
Q

Where is the anatomical location of the larynx?

A

At birth: level at C3-4

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3
Q

What is the normal A-O extension (Atlanto Occipital)?

A

normally 35 degrees

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4
Q

Mallampati classification?

A

Pt sitting, neck extended, mouth opened fully, tongue protruded, no phonation.

MP Class. 1: full view of uvula and tonsillar pillars, soft palate

MP Class. 2: partial view of uvula or uvular base, partial view of tonsils, soft palate

MP Class. 3: soft palate only

MP Class. 4: hard palate only

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5
Q

What is the PUSH acronym?

A

Referes to mallampati assessment

Pillars and everything
Uvula
Soft palate
Hard palate

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6
Q

Irritation of which nerve stimulates laryngospasm?

A

Internal branch Superior Laryngeal nerve (CNX) – mucus membrane above the VC’s, glottis – stimulation is laryngospasm

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7
Q

Does the recurrent laryngeal nerve innervate above or below the vocal chords?

A

The trachea BELOW VC’s

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8
Q

What are the nerves of LarynxSuperior Laryngeal Nerve?

A

Vagus Nerve (X) Branch
SLN divides into two nerves:

*Internal SLN provides sensation to supraglottic & ventricle compartment, STIMULATION CAUSES LARYNGOSPASM

*External SLN provides motor innervation of cricothyroid muscle

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9
Q

The Nerves of LarynxRecurrent Laryngeal Nerve

A

Vagus Nerve Branch (CN X):

Left RLN passes @ Aortic Arch
Provides Sensory innervation to infraglottis
Motor innervation to all larynx except cricothyroid muscle
Stimulation causes abduction of VC
Damage to RLN cause VC adduction

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10
Q

What is the tightest part of the airway in children?

A

The cricoid ring – can use uncuffed tube when intubating kids

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11
Q

Facts about the trachea

A

Flexible cylindrical tube supported by 20-25 C-shaped cartilages

18-20mm diameter

12.5-18cm length

Extends from C6 to T5

At carina (level T5-7) divides into 2 bronchi @ 25cm from teeth

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12
Q

Where does gas exchange begin to occur?

A

The respiratory bronchioles

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13
Q

Where is smooth muscle the thickest?

A

Smooth muscle is thickest in the bronchioles

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14
Q

What nerve transmits motor stimulation to the diaphragm?

A

The phrenic nerve (C 3,4,5) transmits motor stimulation to the diaphragm

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15
Q

What nerves send motor innervation to the external intercostal muscles?

A

Intercostal nerves (T 1-11)

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16
Q

Is the act of inhaling positive pressure or negative pressure ventilation?

A

Negative pressure

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17
Q

Does the diaphragm move up or down with inspiration?

A

DOWN with inspiration and UP with expiration

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18
Q

Is pleural pressure always negative?

A

YES

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19
Q

What is perhaps the most important spirometry value?

A

FRC - it is what is left when the patient goes apneic

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20
Q

What are some things that decrease FRC?

A

steep trendelenberg, laparoscopic case, obesity

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21
Q

What is normal tidal volume?

A

6-8 ml/kg. Normal amount of air moved with each breath

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22
Q

What is minute ventilation?

A

Tidal volume x respiratory volume

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23
Q

What is normal alveolar ventilation?

A

(tidal volume - dead space) x respiratory rate

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24
Q

Inspiratory reserve volume?

A

the volume of gas that can be forcefully inhaled after a tidal breath (about 3L)

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25
Q

Expiratory reserve volume

A

Amount of air that can be forcefully exhaled after tidal breathing (1,100ml)

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26
Q

Residual volume

A

Volume of gas that remains in the lungs after a complete exhale (1200ml)

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27
Q

Total lung capacity

A

IRV + TV + ERV + RV (5800ml)

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28
Q

Vital capacity

A

IRV + TV + ERV (4500ml)

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29
Q

Inspiratory capacity

A

IRV + TV (3500ml)

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30
Q

Functional residual capacity (FRC)

A

ERV + RV (2300ml)

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31
Q

Is tidal volume based on actual body weight or ideal?

A

Ideal. Basing it on actual body weight would result in very large tidal volumes for obese patients

32
Q

Can spirometry measure residual volume?

A

Spirometry cannot measure Residual Volume (RV) thus Functional Residual Capacity (FRC) and Total Lung Capacity (TLC) cannot be determined using spirometry alone.

33
Q

Since RV, FRC, TLC cannot be determined by spirometry, what can determine these?

A

FRC and TLC can be determined by 1) Helium dilution, 2) Nitrogen washout, or 3) body plethysmography

34
Q

Flow volume loops

A

Intrathoracic - blocks exhalation
Extrathoracic - blocks inhalation

35
Q

What does surfactant do?

A

Lowers surface tension of alveoli & lung
Increases compliance of lung
Reduces work of breathing

Promotes stability of alveoli
300 million tiny alveoli have tendency to collapse
Surfactant reduces forces causing atelectasis
Assists lung parenchyma ‘interdependant’ support

Prevents transudation of fluid into alveoli
Reduces surface hydrostatic pressure effects
Prevents surface tension forces from drawing fluid into alveoli from capillary

36
Q

Poiseuille’s Law

A

R = (8 * L * h) / (p * r4)
R is resistance to flow in a tube
L is length of tube
h is viscosity of the fluid
p = 3.14
r is radius of tube (to 4th power)
**reducing r by 16% will double the R
**reducing r by 50% will increase R 16-fold

37
Q

Is the pulmonary system low pressure?

A

Very low pressure, very distensible, acts as a volume capacitor and helps maintain preload/C.O

38
Q

Pulmonary recruitment and distention

A

Recruitment: opening of previously closed vessels
Distention: increase in caliber of vessels

These are responsible for the decrease in pulmonary vascular resistance that occurs as vascular pressures are raised

Increased PRESSURE or flow IN THE PULMONARY SYSTEM DECREASES resistance from recruitment and distention…….recruitment most important

39
Q

The Pulmonary Capillaries

A

Functional capillary volume
Capillary volume increases by opening closed segments (recruitment)
70 ml (1 ml/kg body weight) normal volume at rest
200 ml at maximal anatomical volume

40
Q

Zone 1

A

Not ideal. No blood flow and no gas exchange

PA > Pa > Pv

V/Q > 1

41
Q

Zone 2

A

Intermittent exchange

Pa > PA > Pv

V/Q = 1

42
Q

Zone 3

A

Ideal

Pa > Pv > PA

Ventilation AND perfusion are highest at the base

V/Q < 1

43
Q

Factors Affecting Vasomotor Tone - vasoconstrictors

A

Reduced PAO2
Increased PCO2
Thromboxane A2
α-adrenergic catecholamines
Histamine
Angiotensin
Prostaglandins
Neuropeptides
Leukotrienes
Serotonin
Endothelin
Norepinephrine

44
Q

Factors Affecting Vasomotor Tone - vasodilators

A

Increased PAO2
Prostacyclin
Nitric oxide
β-adrenergic catecholamines
Acetylcholine
Bradykinin
Dopamine
Isoproterenol

45
Q

What is hypoxic pulmonary vasoconstriction?

A

Alveolar hypoxia produces hypoxic pulmonary vasoconstriction (HPV)

Localized response of pulmonary arterioles

Caused by hypoxia and enhanced by hypercapnia & acidosis

Contraction of smooth muscle in small arterioles in hypoxic region

Opposite reaction than systemic circulation to hypoxia

HPV is an important mechanism of balancing V/Q ratio

Shift of flow to better ventilated pulmonary regions

Results from decreased formation & release of
Nitric Oxide by pulmonary endothelium in hypoxic region

46
Q

What is oxygen consumption at rest?

A

250 ml/min

47
Q

Co2 production at rest?

A

200

48
Q

What is normal alveolar Po2 and co2?

A

Po2: 100 mmHg
Co2: 40 mmHg

49
Q

Expired air

A

Combination of dead space & alveolar air

Dead space air is first portion which consists of humidified air

Second portion is mixture of both

Alveolar air is expired at end of exhalation

50
Q

Fick’s Law

A

The bigger the area the bigger the gas exchange

51
Q

Physiologic Shunt - V/Q is below normal

A

Mucous plug is an example

Shunt = perfusion but no ventilation

Blood is being shunted from pulmonary artery to pulmonary vein without participating in gas exchange

Inadequate ventilation with a fraction of deoxygenated blood passing through capillaries and not becoming oxygenated

Shunted blood is not oxygenated

Physiologic shunt is total amount of shunted blood per minute

The greater physiologic shunt the greater the amount of blood that fails to be oxygenated in lungs

52
Q

Physiologic Dead Space - V/Q greater than normal

A

Pulmonary embolus

Dead space = ventilation but no perfusion

Ventilation to alveoli is good but blood flow is low

More available oxygen in alveoli than can be transported away by flowing blood

Physiologic dead space includes:
- Wasted ventilation
- Anatomical dead space

When physiologic dead space is great much of work of breathing is wasted effort because ventilated air does not reach blood

53
Q

Saturation (Hb) and PaO2

A

Saturation PO2
100 100+
95 75
90 60
75 40 (mixed venous)
60 30
50 27 (Hb 50 point)

Very rough rule – PaO2: 40,50,60 for Sat.: 70,80,90

54
Q

Hemoglobin dissociation curve

A

Right shift - less affinity and releases o2

Left shift - more affinity and holds onto 02

55
Q

What shift the hemoglobin curve to the right?

A

Increase co2, increase temperature, increase H+, increase 2,3 DPG, decrease in PH

Right shift = Hb has less affinity for O2, releases O2, saturation will be less for a given PO2

56
Q

What shift the hemoglobin curve to the left?

A

Decrease co2, decrease temperature, decrease H+, decrease 2,3 DPG, increase pH

Left shift = Hb has higher affinity for O2, binds O2, saturation will be higher for a given PO2

57
Q

O2 Content in blood (CaO2)

A

The sum of O2 carried on Hb and dissolved in plasma

CaO2 = (SO2 * [Hb] * 1.31) + (PO2 * 0.003)

Example: Pt with sat. of 97%, Hb 15, and PO2 200: CaO2 = (0.97 * 15 * 1.31) + (200 * 0.003) CaO2 = (19) + (0.6) ml/dL

DO2 (oxygen delivery) = CaO2 * CO (cardiac output)

58
Q

How is most co2 transported?

A

As bicarb

59
Q

What group is responsible for breathing at rest?

A

The Dorsal Respiratory Group

The DRG controls inspiration & respiratory rhythm

The DRG extends most of length of medulla with most of DRG neurons contained in Nucleus of the tractus solitarius

Vagal (X) & Glossopharyngeal (IX) nerves deliver sensory information to DRG

Receives peripheral sensory signals for aid in control of respiration

DRG receives signals from three sources:
Peripheral chemoreceptors
Baroreceptors
Lung receptors

60
Q

Chemo-sensitive Area of Brainstem

A

Highly sensitive area on the ventral medulla surface = central chemoreceptors
Responsive to changes in blood Pco2 or H ion concentration
Stimulates other portions of the respiratory center

61
Q

Effects of Blood Carbon Dioxide

A

Respiratory center activity is increased very strongly by elevations in blood carbon dioxide levels

CO2 has potent direct effect, via [H], on the chemosensitive area

CO2 is highly permeable to blood-brain barrier so blood & brain concentrations are equal

CO2 reacts with H2O to form carbonic acid which dissociates into hydrogen & bicarbonate ions in interstitial fluid of medulla or CSF

The released hydrogen ions in brain stimulate respiratory center activity

*High co2 in the blood means high co2 in the brain…triggers chemosensitive area of brainstem which triggers ventilation

62
Q

Peripheral Chemoreceptors

A

Backup stimulation to breath…stimulated by low o2 (hypoxia).. Will see this more with copd’ers because they chronically have high co2 so they ignore it

Chemoreceptors located mostly in carotid & aorta

Special high flow arterial blood supply exposure, stimulated by hypoxemia

Carotid bodies:
-Bifurcations in common carotid
-Afferent nerve fibers pass via CN IX to act on DRG

Aortic bodies:
-Aortic arch
-CN X to DRG

63
Q

More on chemoreceptors

A

Stimulation of chemo-receptors is caused by decreased arterial oxygen content

Impulse rate is sensitive to drops in PaO2 from a range of 60 mmHg to 30 mmHg (hypoxia)

This range is when hemoglobin-oxygen saturation decreases rapidly

64
Q

High risk PFT results

A

FEV1 < 2L

FEV1/FVC < 0.5

VC < 15cc/Kg in adult & < 10cc/Kg in child

VC < 40 to 50% than predicted

65
Q

Intubation criteria:

A

Mechanics: RR>35, VC <15cc/Kg in adult or <10cc/Kg in child, MIF more neg. than -20cmH2O
Oxygenation: PaO2 < 70mmHg on FiO2 of 40%, A-a gradient > 350mmHg on 100% O2
Ventilation: PaCO2 > 55 (except in chronic hypercarbia), Vd/Vt > 0.6 (remember normal dead space is 30%)
Clinical: airway burn, chemical burn, epiglottitis, mental status change, rapidly deteriorating pulmonary status, fatigue, angioedema

66
Q

Extubation criteria:

A

VSS, awake & alert, resp. rate < 30
ABG on FiO2 of 40%  PaO2 >70 and PaCO2 <55
MIF is more negative than -20cm H2O
Vital capacity (VC) > 15cc/Kg

67
Q

ABG normal values

A

pH: 7.35 – 7.45
PCO2: 35 – 45 mmHg
PO2: 75 – 105 mmHg
Bicarbonate: 20 – 26 mmoles/L
Base excess: -3 to +3 mmoles/L

68
Q

Co2 rule

A

Rule: an increase of PCO2 by 10 mmHg causes a decrease in pH by 0.08, likewise, a decrease of PCO2 by 10 mmHg will increase pH by 0.08
So an acute increase in CO2 to 60 should cause a drop in pH to 7.24

69
Q

A-a gradient

A

A-a gradient – a measure of efficiency of lung
PAO2 = (PB-PH2O)(FiO2) – (PaCO2/0.8)
PAO2 = (760-47)(0.21) – (40/0.8) = 100
PAO2 = (760-47)(0.5) – (40/0.8) = 306
PAO2 = (760-47)(1) – (40/0.8) = 663

Normal A-a = approximately (Age / 3)

A-a gradient is widened during anesthesia and with intrinsic lung Dz: PTX, PE, shunt, V/Q mismatch, diffusion problems

A-a gradient is normal with hypoventilation or low FiO2

Tx is supplemental O2, adjust ventilation, tx atelectasis, add PEEP, tx underlying cause

70
Q

Bicarb rule

A

Rule: a decrease in bicarb. by 10 mmoles decreases the pH by 0.15, likewise, an increase in bicarb. By 10 mmoles increases pH by 0.15
A bicarb. of 13 would result in a pH of 7.25
Total body bicarb. deficit = (base deficit * wt in Kg * 0.4), in mEq/L, usually replace ½ of deficit

71
Q

What is used to calculate base excess

A

Base excess is calculated directly using PaCO2, pH, and bicarbonate values

72
Q

Pulse oximetry

A

Mandatory intraoperative monitor

Oximetry depends upon the observation that oxygenated and deoxygenated hemoglobin differ in their absorption of red and infrared light

Measures a difference between background absorption in diastole and peak absorption during systole, plethysmography displays as a waveform the differences in absorption during arterial pulsation in systole

Involves transillumination of tissue with two frequencies of light (two light-emitting diodes & one light detecting photodiode)
940nm = infrared light, oxyhemoglobin absorbs more of this light, corresponds to 100% saturation
660nm = red light, deoxyhemoglobin absorbs more of this light, corresponds to 50% saturation

73
Q

Pulse ox and Carboxyhemoglobin (COHb) (carbon monoxide)

A

from CO poisoning is viewed as oxyhemoglobin by pulse ox. and shows a SpO2 of 100%, this is an overestimation of the true oxygenation, co-oximeter used to distinguish between the two

74
Q

Pulse ox and Methemoglobin (MetHb)

A

Fe in Hb is oxidized to +3 form and cannot transport O2, cyanosis seen when 15% of Hb is in methemoglobin form, caused by nitrates, nitrites, sulfonamides, benzocaine (hurricane spray), nitroglycerine (NTG), nitroprusside (SNP), absorbs equally at both wavelengths, 1:1, shows a SpO2 of 85%, Tx’d with low dose methylene blue or ascorbic acid (vit C)

75
Q

Do Fetal hemoglobin and bilirubin affect pulse oximetry?

A

No

76
Q

What is the gold standard for tracheal intubation?

A

+ EtCO2 is gold standard for tracheal intubation***

77
Q

Does capnography rapidly detect endobronchial intubation?

A

*Rapidly and reliably indicates esophageal intubation but does not reliably detect endobronchial intubation

Pharm Final review (24 decks)

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