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APEX > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Which muscles tense and relax the vocal cords?

A

Cricoartyenoid - tenses the vocal cords, elongates them (SLN - external)
Thyroarytenoid - relaxes the vocal cords, shortens them
Vocalis - relaxes the vocal cords, shortens them

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2
Q

Which muscles abduct and adduct the vocal cords?

A

Lateral cricoarytenoid - aDDuction of glottic opening
Thyroarytenoid - aDDuction of glottic opening
Posterior cricoarytenoid - aBDuction of glottic opening

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3
Q

Describe the sensory innervation of the upper airway

A

Trigeminal Nerve (CN 5) has three branches
V1 = opthalamic (anterior ethmoidal nerve n.) sensory innervation to the nares and anterior 1/3 septum
V2 = mandibular (sphenopalatine n.) sensory innervation to the turbinates and septum
V3 = maxillary (lingual n.) sensory innervation to anterior 2/3 of the tongue, motor innervation to muscles of mastication.

Glossopharyngeal (CN 9)
-Sensory to the oropharynx, tonsils, soft palate, vallecula, anterior side of epiglottis, posterior 1/3 tongue

SLN - internal branch innervates the posterior side of the epiglottis to the level of the vocal cords

RLN - below vocal cords sensation to the trachea

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4
Q

RLN injury

A

unilateral = hoarseness (the ipsilateral vocal cord will assume a paramedian approach)
bilateral = emergent glottic closure of airway (if it is chronic, there is no respiratory distress)

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5
Q

Name 3 airway blocks and identify key landmarks for each one

A

GPN (bilateral) - palatoglossal arch at the anterior tonsillar pillar
SLN (bilateral) - greater cornu of hyoid bone
RLN - CTM

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6
Q

Where does the adult larynx extend from?

A

C3 - C6
Has 9 cartilages (3 paired, 3 unpaired)

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7
Q

What is the treatment for laryngospasm

A
  1. oxygen
  2. remove stimulus
  3. deepen anesthetic
  4. cpap 15 cm H2O
  5. chin lift, jaw thrust
  6. larson’s maneuver
  7. succ (4 mg/kg IM for adults & kids, 5 mg/kg for infants IM)
    IV = 0.1 - 1 mg/kg
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8
Q

what law describes the respiratory muscle function

A

boyle’s law

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9
Q

describe the muscles of inspiration

A

-diaphragm contracts & pulls lungs down
-external intercostals expand a/p diameter
-accessory muscles = scalene and SCM

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10
Q

exhalation muscles

A

-typically passive
-forced = abdominus rectus, internal intercostals, EOM, IOM

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11
Q

minute ventilation vs alveolar ventilation

A

MVe = RR x TV (nml = 5 - 8 L)
Alveolar ventilation = (TV - Vd) X rr

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12
Q

what is compliance

A

change in volume/change in pressure

this is why alveoli in the base are more compliant compared to the apex

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13
Q

what does the V/Q ratio reflect

A

the ventilation to perfusion ratio (mve/CO) = 0.8

> 0.8 = dead space
< 0.8 = shunt

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14
Q

define the west zones of the lung

A

Zone 1 = dead space = V/Q= INFINITY
- PA > Pa > Pv

Zone 2 = watershed = v/q = 1
-Pa > PA > Pv

Zone 3 = shunt - V/Q = 0
-Pa > Pv > PA

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15
Q

Recite the alveolar gas equation

A

= FiO2 x (Pb - PH2O) - (PaCO2/RQ)

in a healthy patient breathing room air = 105.98

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16
Q

What is the A-a gradient, and what factors affect it?

A

Normal = 5 - 15 mmHg

Increased by high FiO2, aging, vasodilators, shunt, diffusion limitation

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17
Q

List the 5 causes of hypoxemia. Which ones do supplemental oxygen reverse?

A

-hypoxic hypoxia - o2 fixes (nml a-a gradient)
-hypoventilation - o2 fixes (nml a-a gradient)
-v/q mismatch - o2 fixes
-diffusion limitation - o2 fixes
-shutn - o2 does not fix

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18
Q

give reference values for the 5 lung volumess

A

TV = 500 mL
IRV = 3,000 mL
RV = 1,200 mL
ERV = 1,100 mL

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19
Q

What factors influence FRC?

A

FRC = RV + ERV (35 mL/kg)
-conditions that reduce outward lung expansion and/or reduce lung compliance
-when FRC is reduced, intrapulmonary shunt (Zone III) increases.

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20
Q

what test can measure FRC

A

nitrogen washout
helium wash in
body plethysmography

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21
Q

what is closing volume and what increases it?

A

the volume about FRC where small airways begin to close.

-COPD
-LVF
-Obesity
-SUrgery
-Extremes of age
-Pregnancy

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22
Q

State the equation and normal value for oxygen-carrying capacity and delivery

A

CaO2 = 1.34 x Hgb x SaO2 + (.003 x PaCO2)

normal = 20 mL O2 /dL

DO2 = CaO2 x 10 x CO
normal = 1,000 mL O2/m

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23
Q

Left shift of oxyhgb curve

A

decreased CO2, 2,3,DPG, temperature
increased fetal hgb, HgbCO, HgbMet

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24
Q

How is carbon dioxide transported in the blood

A

70% - bicarbonate
23% - bound to hgb
7% - dissolved into blood

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25
Q

Describe the Bohr Effect

A

In the presence of excess CO2, the hemoglobin releases oxygen more readily.

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26
Q

Describe the Haldane Effect

A

deoxygenated blood can carry more CO2 than oxygenated blood. B/C increased oxygen causes the erythrocyte to release CO2

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27
Q

List 3 causes of hypercarbia

A
  1. increased CO2 production (severe shivering, sz, burns, overfeeding)
  2. decreased CO2 elimination (increased dead space, opioid OD)
  3. rebreathing
28
Q

Describe the four areas in the respiratory center

A

-DRG (medulla … specifically in the NTS)
It is the pacemaker for inspiration. Primarily for active inspiration.
-VRG (medulla … specifically in the NTS and nucleus retro ambiguous)
Has inspiration and expiration function. Primarily active during expiration. Quiet during normal breathing. Active when Ve increase. CAUSES EXPIRATION

-Pneumotaxic center (upper pons) inhibits DRG
Triggers the end of inspiration. Strong stimulus = rapid, shallow breathing. Weak stimulus = slow, deep breathing
-Apneustic center (lower pons) stimulates DRG
antagonizes the pneumotaxic center which causes inspiration. This action is inhibited by the pulmonary stretch receptors (J receptors)

29
Q

Contrast the location and function of the central and peripheral chemoreceptors

A

Central chemoreceptor = located in the medulla. Responds to the hydrogen ion concentration in the CSF.

Peripheral chemoreceptors = located in carotid bodies (Nerves of Hering –> GPN CN 9) and also located in aortic arch (vagus n). Respond to hypoxia, hypercarbia, and increased hydrogen ions.

30
Q

Which reflex prevents overinflation of the lungs

A

Hering-Breuer Inflation Reflex

Stimulus = 1.5 L
Afferent via CN 10
Efferent via phrenic n (C3 - C5)

31
Q

What is HPV?

A

Minimizes shunt by reducing blood flow through poorly ventilated alveoli. Think atelectasis or OLV.

A low alveolar PO2 (NOT ARTERIAL) is the trigger that activates HPV
The effect beings immediately and reaches its full effect in 15 minutes

32
Q

What things impair HPV? What is the consequence of this?

A

Halogenated anesthetics > 1 - 1.5 MAC
PDE inhibitors
Dobutamine
Vasodilators

33
Q

What does the diffusing capacity for carbon monoxide (DLCO) tell us?

A

Normal = 17 - 25 mL/CO/m/mmHg
Using Fick’s law of diffusion, DLCO tells us (surface area i.e., decreased by emphysema) and thickness

34
Q

Describe the short term benefits of smoking cessation

A

P50 normalizes within 12 hours (CaO2 improves)
t 1/2 of carbon monoxide 4 - 6 hours
SNS stimulating effects dissipate after 20 - 30 minutes

35
Q

Describe the intermediate benefits of smoking cessation

A

within 6 weeks
-decreased sputum production
-improved mucociliary clearance
-hepatic enzyme induction normalizes in 6wks
-improved immune function

36
Q

compare and contrast pulmonary function tests in obstructive vs restrictive

A

FEV1 & FVC <70% in restrictive dx
FEV1/FVC < 70% in obstructive dx (FEF25-75 & FEV1 also decreased)

37
Q

Extrathoracic vs intrathoracic obstruction

A

-extrathoracic is normal flow on expiration
-intrathoracic is normal flow on inspiration

38
Q

what is alpha 1 antitrypsin deficiency?

A

alveolar elastase is a normally occurring enzyme that breaks down pulmonary connective tissue and it is kept in check by alpha-1 antitrypsin

when there’s a deficiency in A1A, pan lobular emphysema results. the only treatment is a liver transplant.

39
Q

give examples of intrinsic lung disease (acute & chronic)

A

acute = aspiration, opioid OD, pulmonary edema, upper airway obstruction, NPPE
chronic = sarcoidosis, amiodarone induced pulmonary fibrosis

40
Q

Give examples of extrinsic lung disease (acute & Chronic)

A

acute = pneumothorax, flail chest
chronic = neuromuscular disease, kyphosciolosis

41
Q

Define pulmonary hypertension and discuss the goals of anesthetic management

A

PAH defined > 25 mmHg

Goals: decrease PVR, treat hypotension aggressively.

42
Q

Discuss the pathophysiology of CO poisoning

A

CO reduces oxygen carrying capacity of blood. Left shift. Latches onto Hgb 200x. Oxidative phosphorylation is impaired.

-need co-oximeter b/c pulse oximeter falsely elevates
-cherry red appearance
-desiccated soda lime (des > iso&raquo_space; sevo) can cause this.

43
Q

Treatment of carbon monoxide poisoning

A
  1. oxygen
  2. hyperbaric oxygen if > 25%
  3. oxygen should remain on patient for 6 hours or until CO < 5%

*t 1/2 of CO = 4 - 6 hours on RA and 69 - 90 minutes with 100% FiO2

44
Q

Absolute indications for OLV

A
  1. To avoid contamination (infection, hemorrhage)
  2. Control of ventilation (bronchopleural fistula, surgical opening of a major airway, large unilateral lung cyst/bulla, life-threatening hypoxemia)
  3. Unilaateral bronchopulmonary lavage (pulmonary alveolar proteinosis)
45
Q

Relative indications for OLV

A

Surgical exposure (high priority) - TAA, pneumonectomy, thorascopy, upper lobectomy, mediastinal exposure
-Low priority: middle/lower lobectomy, esophageal resection, thoracic spinal surgery

Others: pulmonary edema s/p CABG, robotic mitral valve surgery, severe hypoxemia d/t lung dx

46
Q

discuss how anesthesia in the lateral decubitus position affects v/q relationship

A

-nondependent lung: moves from flatter region (less compliance) to an area of better compliance (slope). Ventilation is optimal in this lung

-dependent lung: moves from the slope to the flatter area of the curve (less compliant). perfusion is best in this lung.

47
Q

list 5 indications for a bronchial blocker

A
  1. child < 8 years old
  2. nasotracheal intubation
  3. tracheostomy
  4. have a single lumen ETT
  5. require intubation post surgery
48
Q

how can the lumen of the bronchial blocker be used during OLV?

A

suction air out or provide oxygenation

cannot suction blood, mucus, etc

49
Q

what is mediastinoscopy and why is it performed?

A

obtain biopsy of paratracheaal lymph nodes aat the level of the carina. this helps the surgeon stage the tumor prior to lung resection

50
Q

potential complications of mediastinoscopy?

A
  1. HEMORRHAGE
  2. PNEUMOTHORAX

others: thoracic aorta hemorrhage, innominate artery compression, vena cava hemorrhage, trachea airway obstruction, chylothorax, phrenic and RLN damage

51
Q

where do you place the pulse oximeter and NIBP cuff during mediasstinoscopy?

A

pulses ox - right hand
NIBP- left arm

52
Q

What is the interincisor gap used for? What is normal?

A

Mouth opening. A smaller inter-incisor gap creates a more acute angle between oral and glottic openings.

Normal = 2 - 3 FB (4 cm)

53
Q

What is TMD?

A

The distance between the mentum and hyoid bone. Tells you how much room you have to displace the tongue.

-Normal = > 6 cm (3 FB) but < 9 cm

54
Q

What is the Mandibular Protrusion Test?

A

Upper Lip Bite Test
Class I = nml
2 = UI aligned with LI
3 = unable to align UI and LI (DAW) risk

55
Q

What conditions impair AO mobility?

A

-Klippel Feil
-Trisomy 21
-Goldenhaur
-DM
-Rheumatoid Arthritis
-Ankylosing Spondylitis

56
Q

How do you treat angioedema anaphylaxis?

A

epi
antihistamines
steroids

57
Q

How do you treat angioedema (ACEi or hereditary?

A

-FFP
-C1 esterase concentrate
-Ecallantide (prevents conversion to bradykinin)
-Icatibant (blocks bradykinin)

58
Q

What is Ludwig’s angina?

A

Bacterial infection (cellulitis) of the floor of the mouth. Secure airway via awake FOI or awake nasal intubation

59
Q

List the types of OPAs.

A
  1. Guedel
  2. Berman
  3. Williams (FOI)
  4. Ovassapian (FOI)
60
Q

When is an NPA contraindicated?

A

-Coagulopathy
-Fracture of cribriform plate (LeFort II, III), basilar fracture (racoon eyes, periorbital edema, rhinorrhea)
-nasal fracture
-previous transphenoidal hypophysectomy or caldwell-luc procedure

61
Q

Recommended cuff pressures for LMA vs ETT

A

LMA = 60 cmH20
LMA PPV = 20 cm H2O (Proseal does 30, Unique does 20)

ETT= 25 cm H2O

62
Q

Largest ETT that can be passed through each LMA

A

1 = 3.5
1.5 = 4
2 = 4.5
2.5 = 5
3 = 6
4 = 6
5 = 7

63
Q

List 6 indications for Bullard

A

-small MO (> 7 mm)
-c-spine impaired
-short, thick neck
-Treacher Collins
-Pierre Robin

64
Q

2 indications for RI

A

-unstable C-spine
-Upper airway bleeding

65
Q

what can you do with an airway exxchange catheter

A

-use for DAW extubation b/c it can be left in place for 72 hours
-measure ETCO2
-insufflate O2
-jet ventilation

APEX (18 decks)

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