Respiratory Flashcards
What defines the thorax cage anatomy?
- The thorax cage anatomy is defined by the sternum
- 12 pairs of ribs
- 12 pairs of thoracic vertebrae.
How is the thorax divided?
- the anterior thorax
- posterior thorax.
What are the true ribs?
Ribs 1-7 are known as ‘true ribs’ because they attach directly to the sternum by costal cartilage.
How do ribs 8, 9, and 10 attach?
Ribs 8, 9, and 10 attach to the costal cartilage of the ribs above.
What are ribs 11 and 12 known as?
Ribs 11 and 12 are known as ‘free floating’ ribs, and their tips can be palpated.
What is the posterior attachment of ribs?
includes
* the costotransverse joint
* the costovertebral joint.
What is the costotransverse joint?
The costotransverse joint is between the tubercle of the rib and the transverse costal facet of the corresponding vertebra.
What is the costovertebral joint?
The costovertebral joint is between the head of the rib, the superior costal facet of the corresponding vertebra, and the inferior costal facet of the vertebra above.
What is unique about Rib 1?
- Rib 1 is shorter and wider than the other ribs and **has only one facet **on its head for articulation with its corresponding vertebra.
- The superior surface of Rib 1 is marked by two grooves for the subclavian vessels.
How does Rib 2 compare to Rib 1?
Rib 2 is thinner and longer than Rib 1 and has two articular facets on the head.
The roughened area on Rib 2’s upper surface is where the serratus anterior muscle originates.
What is unique about Rib 10?
Rib 10 only has one facet for articulation with its numerically corresponding vertebra.
What is special about Ribs 11 and 12?
Ribs 11 and 12 have no neck and only contain one facet for articulation with their corresponding vertebra.
What is the suprasternal notch?
The suprasternal notch is a U-shaped depression just above the sternum between the clavicles.
What is the manubriosternal angle also known as?
The manubriosternal angle is also known as the ‘Angle of Louis’ or ‘Sternal Angle.’
What are the parts of the sternum?
- Manubrium
- Body of sternum
- Xiphoid process
Where is the manubriosternal angle located?
It is located at the articulation of the manubrium and sternum and is continuous with the second rib.
To identify this, palpate the 2nd rib, and slide down to second instercostal space -> angle of Luis is right here.
Why is the Angle of Louis important?
- marks the site of tracheal bifurcation into right and left main bronchi
- corresponds with the upper border of the atria of the heart.
- lies above the fourth thoracic vertebra on back
What forms the costal angle in the anterior thoracic cage?
when does this angle increase?
- The right and left costal margins form an angle where they meet at the xiphoid process.
- Usually less than 90 degrees;
- angle increases when rib cage is chronically overinflated as in emphysema.
What are the posterior thoracic landmarks?
The posterior thoracic landmarks include
* the vertebra prominens
* spinous processes
* inferior border of scapula
* twelfth rib
What is the vertebra prominens?
- The vertebra prominens is the seventh cervical vertebra.
- It is the largest and most inferior vertebra in the neck region
- flex your head to feel for the most prominent bony spur protruding at the base of the neck.
- no split at the tip
How do spinous processes align with ribs?
Spinous processes align with the same rib only down to T4; after T4 they angle downward and no longer correspond with the same rib.
Where is the inferior border of the scapula usually located?
The lower tip of the scapula is usually at the 7th or 8th rib.
How can you identify the twelfth rib?
Palpate midway between the spine and a person’s side to identify its free tip.
What are the reference lines for the anterior chest?
- the midsternal line
- the midclavicular line
What are the reference lines for the posterior chest?
The reference lines for the posterior chest are the vertebral (midspinal) line and the scapular line.
What are the lateral reference lines?
The lateral reference lines include the anterior axillary line, posterior axillary line, and midaxillary line.
What is the thoracic cavity?
enclosed by
* ribs
* sternum
* vertebral column
* top of the diaphragm
What important items are located in the thoracic cavity?
include:
* respiratory
* cardiovascular
* nervous
* immune
* digestive systems
What structures sit in the mediastinum?
The middle section of the thoracic cavity that contain
* esophagus
* trachea
* heart
* great vessels
What are the characteristics of the lungs?
- The right and left pleural cavities contain lungs, which are not symmetrical.
- right lung is shorter due to underlying liver,
- left lung is narrower because heart bulges to the left.
- Right = 3 lobes
- Left = 2 lobes
- segments separated by fissures
What are the lung borders?
The **apex **is the highest point of lung tissue, located 3 to 4 cm above the inner 1/3 of the clavicle.
The base is the lower border of the lung, resting on the diaphragm around the 6th rib at the midclavicular line.
What is notable about the anterior chest regarding lung lobes?
The anterior chest contains mostly the upper and middle lobes with very little lower lobe.
What is notable about the posterior chest regarding lung lobes?
The posterior chest is almost entirely composed of lower lobes.
What is the function of pleurae?
Slippery pleurae form an envelope between the lungs and chest wall, with the visceral pleura lining the outside of the lungs.
What is the pleural cavity?
The pleural cavity normally has a vacuum or negative pressure, which holds the lungs tightly against the chest wall and is filled with a few milliliters of lubricating fluid.
What is the trachea’s location and length?
The trachea lies anterior to the esophagus and is 10 to 11 cm long in adults.
How do the right and left main bronchi differ?
The right main bronchus is shorter, wider, and more vertical than the left main bronchus.
What is the role of trachea and bronchi?
Transport gases from the environment to the lung parenchyma
What is considered dead space?
- space that is filled with air but not available for gas exchange.
- 150 ml in adult
What is role of bronchial tree?
protests alveoli from small particulate matter in inhaled air.
what secretes mucus?
Goblet cells. they line the bronchial tree
What is the acinus?
The acinus is the functional unit of the respiratory system, consisting of
* bronchioles
* alveolar ducts
* alveolar sacs
* alveoli.
What developmental changes occur in infants and children?
- Development occurs in utero, with birth demanding instant performance.
- Increased vulnerability of the respiratory system is associated with environmental tobacco smoke exposure.
ETS includes:
SIDS, negative behavioral and cognitive functioning, increased rates of adolescent smoking
What impact does pregnancy have on the respiratory system?
- Pregnancy impacts the respiratory system due to the enlarging uterus and physiologic dyspnea.
- uterus elevates diaphragm 4 cm in pregnancy
- 32 weeks surfactant is present in adequate amounts
- extra estrogen relaxes chest cage ligaments.
What changes occur in the aging adult’s respiratory system?
- There is decreased vital capacity and increased residual volume based on structural changes,
- histologic changes that lead to decreased gas exchange.
What is the significance of lung cancer?
Lung cancer is the second most commonly diagnosed cancer, with smoking leading to a mutational burden.
What is the global impact of tuberculosis?
Tuberculosis affects more than 1/3 of the world’s population and is considered a social and migratory disease.
What is the prevalence of asthma?
- Asthma is the most common chronic disease in childhood,
- highest burden seen in those living at or below the federal poverty level.
- ethnic and environmental factors play significant role
What subjective data is important in respiratory assessments?
Important subjective data includes
* cough
* shortness of breath
* chest pain with breathing
* history of respiratory infections
* smoking history
* environmental exposure
What should be assessed regarding chest pain with breathing?
- ask pt point to exact location
- Assess for the onset and timing of pain - constant vs intermittent
- pain characteristics in terms of quality and intensity
- associated clinical symptoms
- treatment interventions used to decrease pain
What is the second most commonly diagnosed cancer?
- Lung cancer
- primarily due to smoking leading to mutational burden.
What disease has affected more than 1/3 of the world’s population?
Tuberculosis is a social and migratory disease that has affected more than 1/3 of the world’s population.
What is the most common chronic disease in childhood?
Asthma
Who experiences the highest burden of asthma?
The highest burden of asthma is seen in those living at or below the federal poverty level.
What factors play a significant role in asthma prevalence?
Ethnic and environmental factors play a significant role in asthma prevalence.
What subjective data should be collected regarding respiratory issues?
Subjective data includes cough, shortness of breath, chest pain with breathing, history of respiratory infections, smoking history, environmental exposure, and frequency of rescue inhaler use.
What should be assessed regarding chest pain with breathing?
Assess the onset, timing, pain characteristics, associated symptoms, and treatment interventions used to decrease pain.
What past history should be inquired about for respiratory infections?
- past history of breathing trouble or lung diseases such as brontitis, emphysema, asthma, PNA
- unusually frequent or severe colds
- family history of allergies, tuberculosis, or asthma.
What aspects of smoking history should be evaluated?
Evaluate the onset, duration, and pattern of smoking, secondhand exposure, smoking cessation, and counseling using the
**five A’s: **Ask, Advise, Assess, Assist, and Arrange.
What are five A’s?
- Ask
- Advise
- Assess
- Assist
- Arrange
What environmental exposures should be assessed?
- occupational factors,
- protection from exposure,
- monitoring and follow-up to exposure
- awareness of symptoms signaling breathing problems
What additional history should be collected for infants and children?
- Collect history of frequent or severe colds,
- family history of allergies,
- cough or congestion,
- noisy breathing or wheezing,
- emergency care measures for choking,
- and presence of smokers in the home or car.
What additional history should be collected for aging adults?
- Inquire about shortness of breath or fatigue with daily activities, usual physical activity,
- adult with hx of COPD, lung cancer, TB: use Lung Function Questionnaire.
- ask for energy levels, chest pain with breathing, and chest pain after coughing or falling.
What are techniques of examination?
- inspection
- palpation
- percussion
- auscultation
on posterior and lateral thorax.
What is involved in the objective data preparation and equipment?
Equipment includes a stethoscope, small ruler, marking pen, and alcohol wipe.
What should be inspected in the posterior chest?
Inspect the thoracic cage for shape and configuration, skeletal deformities, AP to transverse diameter ratio, breathing position, skin color and condition, lesions, and symmetric expansion.
What is ratio of AP to transverse diameter?
0.70 - 0.75
What is assessed during palpation of the posterior chest?
Symmetric expansion and tactile (or vocal) fremitus are assessed using hands.
How is tactile fremitus assessed?
By using hands to assess for palpable vibrations while the patient repeats phrases like ‘99’ or ‘blue moon’.
What is the technique for percussion of lung fields?
Determine the predominant note over lung fields starting at the apices and percuss a band of normally resonant tissue across the tops of both shoulders.
What sound predominates in healthy lung tissue?
Resonance, which is a low-pitched, clear, hollow sound.
What is evaluated during auscultation of the chest?
The presence and quality of normal breath sounds both anterior and posterior.
How long should you listen to lung sound?
- Use diaphragm of stethoscope, listen to at least 1 full respiration in each location.
- perform bilateral to compare
What are the three types of breath sounds normally heard in adults?
- Bronchial
- bronchovesicular
- vesicular
What are adventitious sounds?
Added sounds that are not normally heard in the lungs.
What are common terms used for adventitious sounds?
Crackles (or rales) and wheeze (or rhonchi).
What are atelectatic crackles?
A type of adventitious sound that is not pathologic, characterized by short, popping, crackling sounds. that sound like fine crackles but do not last beyond a few breaths.
What is stridor?
An inspiratory crowing sound, loudest in the neck.
What are the types of discontinuous adventitious sounds?
- Fine crackles
- coarse crackles
- atelectatic crackles
- pleural friction rub
What are the types of continuous adventitious sounds?
- Wheeze—sibilant
- wheeze—sonorous rhonchi
- stridor
What is the quality of normal voice sounds or vocal resonance as noted in tactile fremitus?
- Soft, muffled, and indistinct.
- you can hear sound through stethoscope but cannot distinguish exactly what is being said.
Pathology that increases lung density causes what to transmission of voice sounds?
Pathology that increases lung density enhances transmission of voice sounds.
if you suspect lung pathology on basis of earlier data, what would you do?
perform supplemental maneuvers: bronchophony, egophony, and whispered pectoriloquy
What should be noted during inspection of the anterior chest?
- Shape and configuration of chest wall,
- patient’s facial expression,
- level of consciousness,
- skin color and condition, and
- quality of respirations (effort, symmetry, involved accessory muscles)
What is assessed during palpation of the anterior chest?
- Symmetric chest expansion,
- tactile (vocal) fremitus,
- tenderness or lumps, and
- skin mobility, turgor, temperature, and moisture.
What are the types of abnormal tactile fremitus?
- Increased tactile fremitus
- decreased tactile fremitus
- rhonchial fremitus
- pleural friction fremitus
What is the first step in percussion of the anterior chest?
- Begin percussing apices in supraclavicular areas.
- then perform bil comparision
- do not percuss directly over female breast tissue
What are border of cardiac dullness normally found on anterior chest?
- Do not confuse these with suspected lung pathology.
- In right hemithorax, upper border of liver dullness is located in fifth intercostal space in right midclavicular line.
- On left, tympany is evident over gastric space.
What is forced expiratory time?
number of seconds it takes to exhale from total lung capacity to residual volume.
useful in pulmonary function test
What is the normal chest circumference for a newborn?
30 to 36 cm.
When does children’s thorax reach adult ratio of 1:2?
by age 6
What is the Apgar scoring system used for?
It measures the successful transition to extrauterine life.
What is the normal respiratory rate for a newborn?
30 to 40 breaths per minute, but may spike up to 60 breaths per minute.
infant breath through_____ until ______
nose
3 months
normal infant resp rate?
30-40 breaths per minute
may spike up to 60 breaths per minute.
with irregular pattern
What is periodic breathing in infants?
Brief periods of apnea less than 10 or 15 seconds are common.
How should you palpate for symmetric chest expansion in infants?
Encircle the infant’s thorax with both hands.
What breath sounds are normally heard in infants and young children?
Bronchovesicular breath sounds.
What changes occur in the thoracic cage of a pregnant woman?
The thoracic cage may appear wider with deeper respirations and an increase in tidal volume by 40%.
What changes in aging adults?
- Increase AP diameter
- Kyphosis
- outward curvature of thoracic spine
- decreased chest expansion
- tire easily
What are some abnormal respiration patterns?
- Sigh
- tachypnea
- hyperventilation
- bradypnea
- hypoventilation
- Cheyne-Stokes respiration
- Biot’s respiration
- chronic obstructive breathing
What are some diagnostic clues to chronic dyspnea?
- Pulmonary issues, (Alveolar, interstitial, obstruction of airflow, restrictive, or vascular )
- cardiac issues ( Dysrhythmia, heart failure, restrictive or constrictive pericardial disease, or valvular)
- gastrointestinal issues (aspiration)
- neuromuscular issues (resp muscle weakness)
- psychological issues (anxiety)
What are common respiratory conditions?
Atelectasis,
lobar pneumonia,
bronchitis,
emphysema, asthma,
pleural effusion,
tuberculosis,
pulmonary embolism,
ARDS,
lung cancer.
Who are likely to have Postop pulm complications?
COPD. x2 risk
What is a risk factor for postoperative pulmonary complications in COPD?
Preoperative sepsis, emergency operations, age, smoking, other comorbid diseases, preoperative weight loss, obesity, upper respiratory infection, type of surgery, length of surgery, elevated creatinine.
What is the diagnostic criteria for chronic bronchitis in COPD?
Productive cough for more than 3 months, for 2 successive years, not attributed to another cause
What causes increased bronchial secretions in chronic bronchitis?
Mucous gland hyperactivity and chronic airway inflammation
What is emphysema?
Permanent enlargement of airspaces with destruction of alveolar walls
productive cough for greater than 3 months
2 successive years
not attributed to another cause
What structural changes occur in emphysema?
Loss of alveolar attachments and reduced elastic recoil of alveoli
What FEV₁ value corresponds to GOLD 1 (mild) COPD?
FEV₁ ≥ 80%
What FEV₁ range corresponds to GOLD 2 (moderate) COPD?
50% < FEV₁ < 80% of predicted (Moderate)
What FEV₁ range corresponds to GOLD 3 COPD?
30% < FEV₁ < 50% of predicted (Severe)
What FEV₁ value corresponds to GOLD 4 COPD?
FEV₁ < 30% of predicted (Very Severe)
Which short-acting anticholinergic is used in COPD?
Ipratropium
Which long-acting anticholinergics are used in COPD?
Tiotropium, Aclidinium, Umeclidinium, Glycopyrronium
Which short-acting beta agonists are used in COPD?
Albuterol, Pirbuterol
Which long-acting beta agonists are used in COPD?
Salmeterol, Formoterol, Vilanterol, Olodaterol, Indacaterol
Which inhaled corticosteroids are commonly used in COPD?
Beclomethasone, Fluticasone, Budesonide, Ciclesonide
Which xanthines are used for COPD treatment?
Theophylline, Aminophylline, Doxofylline
What is the PDE4 inhibitor used in COPD management?
Roflumilast
What medications are included in triple therapy for COPD?
LAMA/LABA/ICS:
Umeclidinium/Vilanterol/Fluticasone Furoate
Glycopyrronium/Formoterol/Beclomethasone
What are the key components of the preoperative assessment in COPD?
- Assess severity
- evaluate perioperative pulmonary risks
- optimize medical management before surgery
- plan perioperative care
When would you do pulmonary function testing preoperatively in COPD?
When there are changes in condition or the patient is undergoing intrathoracic surgery
When might ABGs be useful in the preoperative COPD assessment?
- If they may change perioperative management or in cases of suspected hypoxemia, hypercapnia, or likely need for post-op ventilator support
When should a chest X-ray be considered preoperatively in COPD?
- Not routinely
- consider if there are changes from baseline
- comorbid cardiac/respiratory conditions
- major intrathoracic/intraabdominal surgeries
**
What specific perioperative concern should you look for on chest X-ray in COPD patients?
Bullae—large air pockets that form inside the lung
What are common postoperative pulmonary complications in COPD patients?
- Atelectasis
- respiratory infections with exacerbation of underlying disease
- hypoxemia requiring invasive or noninvasive mechanical ventilation
What is asthma?
A chronic inflammatory disease affecting the airways
What are key features of asthma?
Bronchial hyperresponsiveness and airflow obstruction
What are the pathologic changes seen in asthma?
- Chronic airway inflammation
- increased bronchial smooth muscle mass
- mucus hypersecretion
- luminal narrowing
When does asthma typically present?
Before age 20
What are common symptoms of asthma?
- Bronchoconstriction
- intermittent cough
- wheezing
- chest tightness
- shortness of breath
How is asthma diagnosed?
By spirometry
What test may be needed if spirometry is inconclusive?
Bronchoprovocation testing
What are common differential diagnoses for asthma?
- Other obstructive pulmonary diseases
- cystic fibrosis
- heart failure
- tracheal stenosis
What is the treatment for Step 1 asthma?
SABA PRN
What is the preferred treatment for Step 2 asthma?
Low-dose ICS (alternative: Cromolyn, LTRA, Nedocromil, Theophylline)
What is the preferred treatment for Step 3 asthma?
Low-dose ICS + LABA or medium-dose ICS (alternative: low-dose ICS plus LTRA, Theophylline, or Zileuton)
What is the preferred treatment for Step 4 asthma?
Medium-dose ICS + LABA (alternative: medium-dose ICS plus LTRA, Theophylline, or Zileuton)
What is the preferred treatment for Step 5 asthma?
High-dose ICS + LABA and consider Omalizumab if allergies are present
What is the preferred treatment for Step 6 asthma?
High-dose ICS + LABA + oral corticosteroids and consider Omalizumab if allergies are present
What are the major perioperative and postoperative concerns with asthma?
Bronchospasm and status asthmaticus
What should be included in the preoperative optimization for an asthma patient?
Detailed history: specific triggers, history of hospitalization, mechanical ventilation, and current therapies
What are signs that asthma is not controlled?
- Symptoms >2 days/week,
- nighttime awakening,
- limited activity,
- frequent SABA use (2 days/week),
- FEV₁ or PEFR <80%,
- ≥2 steroid-requiring exacerbations in the past year
What are key physical exam findings in asthma?
- Signs of bronchoconstriction,
- respiratory infection,
- abnormal pulse ox or RR,
- retractions,
- prolonged expiration,
- wheezes, and diminished/absent breath sounds
When is pulmonary function testing indicated in asthma?
If there is a clinical change or if the patient is undergoing lung resection
When is a chest X-ray indicated in asthma patients?
usually not indicated unless there are concerns of pulmonary infection or heart failure
When should elective surgery be postponed in asthma patients?
If there is active wheezing, poorly controlled asthma, or recent respiratory infection (delay 6 weeks)
What are important preop instructions for asthma patients undergoing surgery?
Continue asthma medications and encourage smoking cessation
What type of genetic disorder is cystic fibrosis?
Autosomal disorder
Where is the CFTR protein found, and what does it affect?
On epithelial cells of most exocrine glands
What does the CFTR mutation cause?
Abnormal/thickened secretions and abnormalities in other systems
What type of lung disorder is cystic fibrosis classified as?
- Obstructive lung disorder
- chronic and progressive
What are the pulmonary function test findings in cystic fibrosis?
- Decreased FEV₁,
- decreased FEV₁/FVC ratio, and
- increased residual volume
What lung sounds are associated with cystic fibrosis?
Wheezing and sounds consistent with upper airway secretions
What are some common upper airway manifestations of cystic fibrosis?
Sinusitis and nasal polyposis
What are common pulmonary complications in cystic fibrosis?
Viscous mucus, recurrent infections, blebs, pneumothorax, chronic hypoxemia, pulmonary HTN, hemoptysis
What pancreatic issues are associated with cystic fibrosis?
Exocrine pancreatic insufficiency, malabsorption, CF-related diabetes, pancreatitis
What hepatobiliary conditions are common in cystic fibrosis?
Biliary disease, cirrhosis, portal hypertension
What gastrointestinal issues are seen in cystic fibrosis?
GERD, distal intestinal obstruction, constipation
What are musculoskeletal complications in cystic fibrosis?
Low bone density, fractures, hypertrophic osteoarthropathy
What is the anesthetic care plan for patients with cystic fibrosis?
- Avoid general anesthesia if possible
- restrict fluids
- optimize pain control
- maintain chest physiology
- use incentive spirometry
What should be assessed during preop evaluation in cystic fibrosis?
Progression of disease: cough, sputum, wheezing, decreased exercise tolerance
What comorbidities are commonly associated with cystic fibrosis?
Diabetes, liver disease, and GERD
What are other important preoperative considerations for cystic fibrosis?
- Multidisciplinary approach
- continue CF medications
- plan for glucose control
- plan for sputum clearance techniques
How is restrictive lung disease diagnosed?
Pulmonary function test (PFT)
What are the hallmark PFT findings in restrictive lung disease?
- Decreased TLC,
- decreased FEV₁ and FVC,
- normal or increased FEV₁/FVC ratio
What are the main categories of causes of restrictive lung disease?
- Intrinsic (e.g. ILD)
- extrinsic (e.g. pleural effusion, obesity)
- neuromuscular disorders (e.g. MG, GBS, muscular dystrophies)
What defines interstitial lung disease?
- It’s a type of restrictive lung disease involving inflammation
- fibrosis of lung parenchyma
- decreased lung distensibility with increased recoil
What are common clinical symptoms of ILD?
Progressive dyspnea on exertion and non-productive cough
What history is important when considering ILD?
Occupational exposure
**What are common physical exam findings in ILD?
Fine crackles on auscultation and digital clubbing
Why is diagnosing ILD challenging?
Requires clinical assessment, radiographs, CT, and often surgical lung biopsy
Why might ILD patients present for surgery?
To obtain a surgical lung biopsy for diagnosis
What are key preoperative considerations in ILD?
Optimize medical management, assess for exacerbations, consult pulmonology, screen for pulmonary hypertension
Which body systems can ILDs affect beyond the lungs?
Cardiac, renal, hepatic (e.g. sarcoidosis, lupus, rheumatoid arthritis)
What are key components of the pre-op assessment for ILD patients?
- Optimize medical management
- check for exacerbations
- consult pulmonology
- evaluate for pulmonary hypertension
- assess involvement of cardiac,
- renal, hepatic systems (e.g. sarcoidosis, lupus, RA)
What causes obstructive sleep apnea (OSA)?
- Repetitive upper airway collapse, with apnea episodes lasting ≥10 seconds
- most prevalent sleep disorder
Why is pre-op screening for OSA important?
Allows initiation of treatment and enables proper post-op monitoring
What is the gold standard for diagnosing OSA?
Overnight polysomnography (PSG)
What does PSG measure to diagnose OSA?
Apnea-hypopnea index (AHI) – number of abnormal respiratory events per hour
What are the criteria for an event to be counted in AHI?
Must last ≥10 seconds and reduce O2 saturation by 3–4%
What is the AHI range for mild OSA?
5–14 events/hour
What is the AHI range for moderate OSA?
15–30 events/hour
What is the AHI for severe OSA?
Greater than 30 events/hour
What screening tools are used for OSA?
- STOP-Bang
- P-SAP
- Berlin Questionnaire
- ASA Checklist
What does the STOP portion of STOP-Bang stand for?
Snoring, Tiredness, Observed apnea, high blood Pressure
What does the BANG portion of STOP-Bang stand for?
BMI >35, Age >50, Neck circumference, Gender (male)
How is risk level classified with STOP-Bang?
Low: 0–2 “Yes”
Intermediate: 3–4 “Yes”
High: 5–8 “Yes” or combinations of STOP + other risk factors
Should surgery be canceled if OSA is identified?
No, not unless other comorbidities are present.
How should unidentified OSA be treated preoperatively?
Treat like OSA until proven otherwise.
What should we do when pt has OSA?
Be suspicious of other systemic disorders.
What should be assessed regarding PAP therapy preop?
pt’s adherence to and continued use of PAP.
Are EKG or chest X-ray required preop for OSA?
No.
What are the ambulatory surgery criteria for known OSA patients?
- Optimized comorbidities
- use of PAP post-op
- facility capable of monitoring and overnight stay
What is the key post-op management for suspected or non-compliant OSA patients?
Pain control with minimal opioids.
What anesthesia strategies should be considered for OSA patients?
- Regional anesthesia,
- limit opioids,
- use short-acting drugs,
- monitor post-op, and
- inform the patient.
What is the leading cause of preventable morbidity and mortality?
Smoking.
What are long-term physiological impacts of smoking?
Reduced tissue perfusion, impaired immune and collagen function, reduced lung capacity, increased mucus, impaired cilia, ↑ sympathetic activity.
What are perioperative complications associated with tobacco use?
Increased CO levels, ↓ oxygen, delayed healing (wounds & bones), CV events, strokes, ICU admissions, prolonged ventilation, pneumonia, and death.
What are the key components of the preoperative assessment of COPD?
Assess severity, evaluate perioperative pulmonary risks, optimize medical management, plan perioperative care.
When should pulmonary function tests be considered for COPD patients?
With changes in condition or for intrathoracic surgery.
When are ABGs helpful in COPD patients?
If they will change perioperative management; helpful in suspected hypoxemia, hypercapnia, or if post-op ventilator management is likely.
Is a chest X-ray routinely needed for COPD?
No, unless there are changes from baseline, comorbid issues, or major surgeries; look for bullae.
What are common postoperative pulmonary complications in COPD?
Atelectasis, respiratory infections, exacerbation of underlying disease, and hypoxemia requiring mechanical ventilation.
What defines asthma?
Chronic inflammatory airway disease with bronchial hyperresponsiveness and airflow obstruction.
What are common asthma symptoms?
Intermittent cough, wheezing, chest tightness, shortness of breath, often before age 20.
What are the diagnostic tools for asthma?
Spirometry; bronchoprovocation testing may also be used.
What are key differentials for asthma?
Other obstructive lung diseases, cystic fibrosis, heart failure, tracheal stenosis.
What is the stepwise asthma treatment approach?
Starts with SABA PRN and escalates through ICS, LABA, and possibly Omalizumab and oral corticosteroids by Step 6.
What are the big peri/postop concerns with asthma?
Bronchospasm and status asthmaticus.
What are signs asthma is not controlled?
Symptoms >2 days/week, nighttime awakenings, activity limitation, SABA use >2 days/week, FEV1/PEF <80%, ≥2 exacerbations/year requiring steroids.
What are key asthma physical exam findings?
Bronchoconstriction signs, infection, low pulse ox, increased RR, retractions, wheezes, prolonged expiration, diminished breath sounds.
When are pulmonary function tests and chest X-ray useful in asthma?
PFTs if condition changes or for lung resection; CXR if infection or heart failure is suspected.
When should elective surgery be postponed in asthma?
Active wheezing, poorly controlled asthma, or recent respiratory infection (within 6 weeks).
What causes cystic fibrosis?
Autosomal mutation in CFTR gene affecting exocrine glands, leading to thick secretions and multisystem issues.
What are key PFT findings in CF?
↓FEV1, ↓FEV1/FVC ratio, ↑residual volume.
What are typical lung sounds in CF?
Wheezing, upper airway secretions.
What does CF pre-op assessment include?
Disease progression (cough, sputum, wheeze, ↓exercise tolerance) and comorbidities like diabetes, liver disease, GERD.
What’s important for intraop anesthesia in CF?
Avoid general anesthesia if possible, restrict fluids, optimize pain control, promote chest physiology, use incentive spirometry.
What are other preop considerations in CF?
Multidisciplinary approach, continue CF meds, glucose control plan, sputum clearance techniques.
What defines restrictive lung diseases?
↓TLC, ↓FEV1/FVC, normal or ↑FEV1/FVC ratio; caused by ILD, pleural diseases, neuromuscular disorders.
What are signs of interstitial lung diseases (ILDs)?
Progressive exertional dyspnea, dry cough, history of occupational exposure, fine crackles, finger clubbing.
What is the pre-op approach for ILD patients?
Optimize management, assess for exacerbations, consult pulmonology, assess for pulmonary hypertension and systemic involvement.
What is obstructive sleep apnea (OSA)?
Repetitive airway collapse ≥10 seconds per event; most common sleep disorder, underdiagnosed.
How is OSA diagnosed and assessed preoperatively?
Polysomnography (AHI-based); screen using STOP-Bang, P-SAP, Berlin, ASA checklist.
What are the AHI thresholds for OSA severity?
Mild: 5–14, Moderate: 15–30, Severe: >30.
What are preop practices for OSA?
Treat as OSA until proven otherwise, continue PAP use, assess adherence, no routine EKG/CXR needed.
Can OSA patients undergo ambulatory surgery?
Yes, if diagnosed, optimized, can use PAP post-op, and facility is equipped; otherwise, minimize opioids.
What’s the anesthesia care plan for OSA?
Consider regional anesthesia, limit opioids, use short-acting meds, ensure post-op monitoring.
What are the effects of smoking on surgical risk?
↓perfusion, ↓immune function, poor healing, ↓lung capacity, ↑mucus, ↑SNS activity.
What are complications from chronic smoking?
↑CO levels, ↓O2, delayed healing, ICU admission, pneumonia, cardiovascular events, and death.
What is the benefit of smoking cessation before surgery?
3–4 weeks = ↓infection; 4 weeks = ↓respiratory issues; even post-op = improved bone healing and fusion
What improves smoking cessation success?
Brief counseling, free NRT, quitline/brochure; behavioral motivation improves outcomes.
How has smoking cessation guidance changed?
“Ask, Advise, Refer” → “Ask, Advise, Connect” for automatic enrollment and higher success.
What does the ACA require regarding tobacco use?
Insurance must cover screening and cessation interventions.
What are post-op respiratory complications?
- Atelectasis,
- infection,
- exacerbation of lung disease,
- hypoxemia,
- need for mechanical ventilation.
What are other causes of post-op pulmonary issues?
Microaspiration, excess fluids/blood, inflammation, immunosuppression.
