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*2Topics Anesthesia Oral Boards > Respiratory, Airway, and Ventilator Management > Flashcards

Respiratory, Airway, and Ventilator Management Flashcards

1
Q

DDx of Hypoxemia (Pathophysiological Mechanisms)

A
  1. Decreased Inspired Oxygen
    • Mechanical failure of anesthesia apparatus
    • Disconnection from O2 supply
    • Empty/depleted O2 cylinder
    • Gas pressure failure, crossing pipelines/tanks
  2. Hypoventilation
    • Esophageal intubation
    • ETT kinking, blockage, herniation
    • Right mainstream intubation
    • Respiratory depression or failure 2/2 meds and paralysis
    • Ventilator failure
  3. Impaired diffusion
  4. V/Q mismatch
  5. Right to left intra-cardiac shunt
  6. Intrapulmonary derangements
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2
Q

Ddx of Hypoxemia (Structural-Anatomical)

A
  1. Alveoli
    • Pulmonary edema
    • Acute lung injury/pulmonary contusion
    • ARDS
    • Pulmonary hemorrhage
    • Pneumonia
  2. Interstitium
    • Pulmonary fibrosis
    • Viral pneumonia
    • Allergic alveolitis
  3. Heart and Pulmonary vasculature
    • PE
    • Intracardiac or intrapulmonary shunt
    • CHF
  4. Airways
    • Asthma
    • COPD
    • Mucus plugging
    • Right main stem intubation
  5. Pleura
    • Pneumothorax
    • Pleural effusion
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3
Q

What is responsive to supplemental O2? Shunt or V/Q mismatch?

A

V/Q mismatch

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4
Q

Steps for Intraoperative Acute Hypoxia

A
  1. Check color of patient
  2. Check for a pulse
  3. Check all Vital Signs
  4. Check for ETCO2
  5. Take patient off ventilator and hand bag with 100% O2
  6. Call for help
  7. Check O2 monitor, peak airway pressure, and capnograph waveform
  8. Listen to chest for bilateral breath sounds
  9. Evaluate ETT (r/o kinking, mucus plug and herniation)
    • Suction catheter and fiberoptic down ETT
  10. Listen for wheezing - give albuterol
  11. Deepen anesthetic if suspect bronchospasm
  12. If deepening anesthetic doesn’t treat, give Epi
  13. Order CXR
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5
Q

DDx for Hypercarbia

A
  1. Increased CO2 production
    • Tourniquet release
    • Aortic cross-clamp release
    • MH
    • Sepsis
    • Thyrotoxicosis
    • Fever
  2. Decreased removal of CO2
    • Hypoventilation
    • Airway obstruction
    • Increased Dead Space
  3. Rebreathing of CO2 d/t mechanical malfunction
    • Faulty valves
    • Exhausted CO2 absorber
    • Low fresh gas flows
  4. Iatrogenic
    • Sodium bicarb administration
    • Increased CO2 during laparoscopy
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6
Q

Indications for Intubation

A
  1. Mechanical funciton
    • RR > 35
    • Vital Capacity < 15 (Adult) or < 10 (Peds)
    • Negative inspiratory force (NIF) < 20-25
  2. Gas exchange function
    • PaO2 < 60 on FiO2 of 50%
    • A-a gradient > 350 on FiO2 of 100%
    • PaCO2 > 55 (unless chronically elevated)
    • Vd/Vt > 0.6 (nrml 0.3)
  3. Unstable vital signs
  4. Inability to protect airway 2/2 agitation, airway burns, facial trauma, Neuro injury
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7
Q

Indications for Extubation

A
  1. Subjective Criteria
    • Resolution of acute disease
    • Adequate cough
    • Pt awake and following commands
    • Cooperative
    • GCS > 13
    • Sustains head lift > 5 sec
    • Gag reflex and cough
    • Able to protect airway from aspiration
    • Minimal end-expiratory concentration of inhaled anesthetic
  2. Objective criteria
    a. Vital signs
    • RR < 30-35
    • Stable BP w/ minimal inotropic support
    • HR < 140
    • Afebrile
      b. Gas exchange function
    • ABG on 40% FiO2 and PEEP < 5-10
      • PaO2 >60, PaCO2 < 55
    • P/F ratio > 150-300
    • A-a gradient < 350
    • Nrml pH (>7.30)
      c. Mechanical Function
    • FVC > 10-15
    • FEV1 > 10
    • Vt > 4-6 mL/kg
    • Negative Inspiratory Force > 20
    • Vital Capacity > 15
    • Rapid Shallow Breathing Index (RSBI) < 60-100 breaths/min
      d. Adequate Hemoglobin (8-10)
      e. No significant Respiratory Acidosis
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8
Q

Conditions that Predispose Difficult Mask Ventilation

A
  1. Beard
  2. Obesity
  3. Lack of Teeth
  4. Obstructive Sleep Apnea
  5. Piercing of tongue, lip, cheek, and chin
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9
Q

Congenital Pathology that Predispose Difficult Intubation

A
  1. Pierre-Robin Syndrome: Micrognathia, Macroglossia, Cleft Palate
  2. Treacher-Collins Syndrome: Mandibular Hypoplasia
  3. Trisomy 21: Maroglossia, Atlantoaxial instability
  4. Kippel-Feil Syndrome: Restricted neck movement 2/2 cervical vertebrae fusion
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10
Q

DDx of Wheezing

A
  1. Bronchospasm, Anaphylaxis
  2. Asthma, COPD
  3. Tracheobronchitis
  4. Restrictive pulmonary Dz: Sarcoidosis
  5. Rheumatoid-Arthritis associated bronchitis
  6. Extrinsic compression: Thoracic aneurysm, mediastinal mass
  7. Intrinsic compression: Epiglotitis, croup
  8. CHF
  9. Pulmonary embolus
  10. Mechanical obstruction of ETT
  11. Inadequate depth of anesthesia
  12. Endobronchial intubation
  13. Pulmonary aspiration and deem
  14. Pneumothorax
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11
Q

DDx of Bronchospasm

A
  1. Kinked ETT
  2. Solidified secretion or blood
  3. Pulmonary edema
  4. Tension Pneumothorax
  5. Aspiration Pneumonitis
  6. PE
  7. Endobronchial intubation
  8. Persistent cough or strain
  9. Negative pressure expiration
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12
Q

Symptoms of Intraoperative Bronchospasm

A
  1. Wheezing
  2. Increasing peak airway pressures
  3. Decreasing exhaled tidal volume
  4. Slowly rising waveform on capnograph
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13
Q

Intraoperative Tx of Bronchospasm

A
  1. 100% FiO2
  2. Deepend anesthetic: IV propofol
  3. Albuterol
  4. IV or SQ Epinephrine
  5. Consider IV Mg
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14
Q

Tx of Laryngospasm

A
  1. 100% FiO2
  2. Remove irritating factor
  3. Apply jaw thrust
  4. Continuous positive pressure ventilation
  5. Increase depth of anesthesia
  6. IV/topical lidocaine
  7. Call for help
  8. Succinylcholine (10-50mg IV, IM, sublingual)
  9. Attempt to intubate

**Hypoxia results in less vigorous glottic closure and therefore reversal of laryngospasm

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15
Q

Tx of Post-op Stridor

A
  1. O2 by facemark
  2. Head-up positioning: 45 to 90 degrees
  3. Nebulized racemic epinephrine
  4. Intravenous dexamethasone: 4-8 mg given every 8-12 hours
  5. Heliox (70% Helium, 30% Oxygen)
    a. 1/3 as dense as air or oxygen
    b. Can lead to dramatic decrease in airway resistance and therefore improved ventilation
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16
Q

Apnea-Hypopnea Index (AHI)

A

Avg number of apneas and hypopnea per hour during the formal sleep study. Used to determine severity of OSA

a. Mild OSA: 5-15
b. Moderate OSA: 16-30
c. Severe OSA: >30

17
Q

Peri-operative Concerns with OSA

A
  1. Increased risk of difficult intubation
  2. Post-operative hypoxemia
  3. Post-operative airway obstruction requiring reintubation
  4. MI
  5. Arrhythmia
  6. Death
18
Q

What is Bernoulli’s Principle?

A

As the velocity of a fluid (liquid or gas) increases, the pressure decreases

19
Q

What is the Venturi Effect?

A

As a fluid flows through a narrowed orifice, the velocity of the fluid increases with a concomitant decrease in the pressure

20
Q

Cautions of High Frequency Jet Ventilation

A
  1. Inadequate humidification of delivered gas
    a. Tracheal mucosal damage
    b. Thickened secretions
  2. Patient requires TIVA
  3. Barotrauma
  4. Alveolar overdistension
  5. Injection injury
  6. Tension Pneumothorax
  7. Should never be used if expiratory outflow of gas is impeded
  8. Inadequate ventilation (hypercarbia)
21
Q

Absolute Indications for One Lung Ventilation

A
  1. Isolation to prevent spillage or contamination
    a. Infection
    b. Massive hemorrhage
  2. Control of ventilation
    a. Bronchopleural fistula
    b. Bronchopleural cutaneous fistula
    c. Surgical opening of a major conductive airway
    d. Tracheobroncheal tree disruption
    e. Giant unilateral lung cyst or bulla
    f. Life threatening hypoxemia from unilateral lung disease
  3. Unilateral bronchopulmonary lavage
    a. Pulmonary alveolar proteinosis
22
Q

Relative Indications of One Lung Ventilation

A
  1. Surgical exposure
    a. Thoracic aortic aneurysm
    b. Pneumonectomy
    c. Upper lobectomy
    d. Mediastinal exposure
    f. Throracoscopy
    g. Middle and Lower lobectomies
    h. Esophageal resection
    I. Thoracic Spine Surgery
  2. Severe hypoxemia from unilateral lung disease
23
Q

Indications for Bronchial Blocker

A
  1. Critically ill patient in whom it may not be feasible to place a DLT
  2. Intubated patients
  3. Patients with a known difficult airway
  4. Need for post-operative ventilation
    a. May avoid a risky post-operative change from a DLT to SLT
24
Q

Tx of Hypoxemia in One Lung Ventilation

A
  1. If severe, switch to two-lung ventilation immediately
  2. Check position of DLT with fiberoptic bronchoscopy
  3. Apply CPAP 5-10 cmH2O to nondependent lung
    a. Overcomes atelectasis in non ventilated lung, decreasing shunt fraction
  4. Apply PEEP 5-10 cmH2O to dependent lung
  5. Adjust CPAP and PEEP in attempt to find optimal end-expiratory pressure for each lung
  6. Intermittently ventilate both lung
  7. If an emergency, have surgeon clamp the pulmonary artery
25
Q

What is predicted postoperative FEV1 (ppoFEV1)?

A

Predictor of patient’s tolerance of pneumonectomy

ppoFEV1 = preoperative (chosen PFT)% x
(1 - % functional lung tissue removed / 100)

ppoFEV1 > 40% - low risk
ppoFEV1 < 40% - increased risk
ppoFEV1 < 30% - high risk
ppoFEV1 < 20% - unacceptably high risk

**Patient’s w/ ppoFEV1 < 40% have increased risk of Right Heart Failure after pneumonectomy

*2Topics Anesthesia Oral Boards (10 decks)

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