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Respiratory Pathophysiology Flashcards

1
Q

What do pulmonary function tests measure?

A

Static Lung Volumes
Dynamic lung volumes
Diffusions Capacity

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2
Q

What is FEV1

A

Forced Expiratory Volume in 1 second

Volume of air that can be exhaled after maximal inhalation in 1 second

Normal = > 80% (this does decline in age)

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3
Q

What is FVC?

A

Forced Vital capacity

Volume of air that can be exhaled after a maximal inhalation

M: 4.8L
F: 3.7L

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4
Q

What is FVC1 to FVC ratio?

A

Compares the volume of air expired in 1 second and total volume of air expired

Normal= 75 - 80%

(Useful in determining obstructive vs. restrictive), < 70 suggests obstructive, but normal with restrictive dx.

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5
Q

What is Forced Expiratory Flow at 25-75% Vital Capacity?

A

Measures airflow in the middle of FEV (FEV 25-75%)

Normal= 100% +/- 25%

Most sensitive indicator of small airway dx, usually reduced with obstructive dx, but normal with restrictive.

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6
Q

What is maximum voluntary ventilation?

A

Maximum volume of air that can be inhaled and exhaled over the course of a minute

Normal:
M = 140-180 mL
F = 80-120 mL

Best test for endurance

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7
Q

What does the diffusing capacity (DLCO) measure?

A

Volume of carbon monoxide that can traverse the alveolocapillary membrane per given partial pressure of CO

Normal= 17-25 mL/min/mmHg
(Based on Ficks Law)

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8
Q

What type of patients are at risk for postoperative pulmonary complications?

A

Age >60
ASA >2
CHF
COPD
Cigarette smoking (> 40 pack years)

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9
Q

In what type of procedures are patients more at risk for postoperative complications?

A

Aortic > thoracic > upper abdominal > neuro > peripheral vascular > emergency

General anesthesia
Surgery > 2 hours

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10
Q

Which lab value may indicate a risk for postoperative complications?

A

Albumin < 3.5 (indicates poor nutritional status)

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11
Q

What are some short term effects of smoking cessation?

A

Carbon monoxide 1/2 =4-6 hrs
P50 returns to near normal in 12 hrs
Short term cessation does not reduce pulmonary complications though

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12
Q

What are some long-term effects of smoking cessation?

A

Return of pulmonary fx takes about 6 wks. This includes:

Airway function
Mucociliary clearance
Sputum production
Pulmonary immune fx
Hepatic enzyme induction also subsides after 6 wks

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13
Q

What is the best way to reduce anesthesia-related atelectasis?

A

Alveolar recruitment maneuvers

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14
Q

What are the dynamic volumes (tests) in obstructive dx?

A

Decreased FEV1
Decreased or increased FEV
Decreased FEV1/FVC ratio
Decreased FEF 25-75%
Normal-increased residual volume
Normal-increased function residual capacity
Normal to increased Total lung capacity

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15
Q

What are the dynamic volumes (tests) in restrictive dx?

A

Decreased FEV1
Decreased FVC
Normal FEV1 to FVC ratio
Normal FEF 25-75%
Decreased residual volume
Decreased function residual capacity
Decreased total lung capacity

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16
Q

What happens with an extra thoracic obstruction?

A

For EXTRATHORACIC ~ EXhalation is normal

Patient inhales and the airway collapses (the obstruction is being pulled towards the airway)

Patient exhales and the obstruction is being pushed away

(Inspiratory limb is flat)

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17
Q

What happens with an intrathoracic obstruction?

A

Remember for an INTRATHORACIC ~ INhalation is normal

The patient inhales and the obstruction is also pulled downwards and away like the rest of the thoracic cavity.

When the patient exhales, the obstruction is push upwards and close, this collapsing the airways

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18
Q

What is asthma?

A

Acute, REVERSIBLE airway obstruction characterized by chronic airway inflammation and bronchial hyperreactivity

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19
Q

What is the greatest risk factor for developing asthma?

A

Atopy “the condition of being hyper-allergic”

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20
Q

What is the most common finding in asthma?

A

Resp alkalosis with hypocarbia (they have tachypnea)

Tachypnea and hyperventilation are result of NEURAL reflexes, not hypoxemia

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21
Q

What does an elevated PaCO2 in asthma show?

A

Air trapping, resp muscle fatigue and impending resp failure.

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22
Q

What is the anesthetic management of asthma? ( Think airway and vent)

A

Suppression of airway reflexes!
Avoidance of intubation
Deep extubation should be considered
Vent ~ limit inspiratory time, prolong expiratory time (ok with permissive hypercapnia)
Use an HME filter ~ retains humidity

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23
Q

What is the anesthetic management of asthma (think drugs)

A

Volatile agents (dilation)
Ketamine (dilation)
Propofol (suppresses reflexes)
Lidocaine (suppresses reflexes)
Avoid histamine-releasing drugs (six, morphine, Demerol)
Iv hydration (reduces viscosity)

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24
Q

How does bronchospasm present?

A

Decreased breath sounds
Wheezing
Increased peak pressures
Increased alpha angle on EtCO2 (shark fin)

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25
How do you treat bronchospasm
100% FiO2 Deepen the anesthetic Beta 2 agonist Inhaled ipratropium (anticholinergic) Epi Aminophylline Helium-oxygen mixture Hydrocortisone
26
What is COPD
Umbrella term for chronic bronchitis and emphysema ~ reduction in maximal expiratory flow and a slower forced emptying of the lungs
27
What are the origins of COPD
Cigarettes Resp infection Exposure to dust (coal mining, gold mining) Alpha 1 antitrypsin deficiency
28
What are some of the main pathological symptoms of COPD
Loss of elastic components in lung ( decreased recoil —> air trapping) Reduced airway rigidity ( collapse during exhalation —> air trapping) Increased gas velocity through narrow airways (decreased pressure in airways —> airway collapse —> air trapping) Secretions (airflow obstruction and bronchospasm)
29
What are some common findings with COPD
Flattened diaphragm Increased AP diameter Pulmonary bull ar Increased work of breathing
30
what is another term for chronic bronchitis?
“ Blue bloaters”
31
What are some symptoms of chronic bronchitis and how is it defined?
Defined as presence of cough and sputum > 3 months for 2 years Cigarette common cause RBCS are over produced (increases blood viscosity) Chronic hypoxemia and hypercapnia increases PVR —> cor pulmonale Left heart fx is normal Weak RV causes back pressure (ascites and liver congestion) Oxygen therapy is most efficacious therapy
32
What is another name for emphysema?
“Pink puffers” Associated with enlargement and destruction of the airways distal to the terminal bronchioles —> reduces surface area for gas exchange—> increase in dead space
33
What are some common traits associated with emphysema?
Pt has normal (or slightly reduced) PaO2. The PaCO2 is normal or decreased (as result of hyperventilation) Hypoxemia and hypercarbia can increase PVR later —> RV failure Alpha-1 antitrypsin deficiency can cause emphysema
34
What is alpha 1 Antitrypsin Deficiency?
It is a dx where an abnormal variant of the enzyme is produced. The hepatocyte is unable to secrete this enzyme into the blood so it accumulates inside the hepatocyte. This leads to cell death and cirrhosis.
35
What does alpha-1 antitrypsin Deficiency do to the Lungs?
So alveolar elastase (an enzyme that breaks down pulmonary connective tissue) is kept in check by alpha-1….lack of alpha -1 leads to overactivity of alveolar elastase —> destruction of pulmonary tissue and development of panlobular emphysema.
36
Where should we maintain a the SaO2 in a patient with severe COPD?
88-92%
37
Which gas is associated with rupture of pulmonary blebs?
Nitrous oxide
38
How should you set up your vent for a patient with severe COPD?
Tidal volumes 6-8 mL/kg IBW Slow inspiratory flow PEEP Increase expiratory time to minimize air trapping and auto-PEEP I.e reduce 1:E ration ~ 1:3, reduce resp rate, and reduce flow resistance by using a larger ETT or frequent suctioning.
39
What are some etiologies to dynamic hyperinflation with COPD?
High minute ventilation (not enough time to get air out) Reduced expiratory flow Increased airway resistance
40
What are contributing factors to a high minute ventilation?
Large tidal volume Fast resp rate
41
What are some factors to reduced expiratory flow?
Bronchoconstriction Airway collapse Inflammation
42
What are some examples of increased airway resistance?
Secretions Obstructed ETT Fighting the vent
43
What are some pulmonary consequences of hyperinflation seen in COPD
Alveolar overdistension Barotrauma Pneumothorax Increased PIP Increased PP Increased WOB
44
What are some cardiac consequences of hyperinflation seen in COPD?
Impaired venous return Hypotension Overestimation of CVP and PAOP
45
What is a restrictive lung dx?
It’s an umbrella term for a collection of disorders that impair normal lung expansion during inspiration
46
What are some main characteristics of a restrictive lung dx?
Decreased lung volumes and capacities Decreased compliance Intact pulmonary flow rates
47
What airway tests are diagnostic of restrictive lung disease?
FEV1 and FEV < 70% The FEV1/FVC reaction will be normal
48
What are some examples of an acute intrinsic restrictive dx?
(Aka Pulmonary edema) Upper airway obstruction Aspiration Cocaine overdose Neurogenic
49
What are some examples of a chronic intrinsic restrictive dx?
(Interstitial lung dx) Sarcoidosis Drug induced pulmonary fibrosis
50
What are some dx of the chest wall, mediastinum, and Pluera in terms of restrictive dx processes?
Kyphoscoliosis Ankylosing spondylitis Flail chest Pneumothorax Pleaural effusion Mediastinal mass Neuromuscular disorders
51
What are some examples of some other restrictive ventilatory defects? (Think more basic)
Obesity Pregnancy Ascites
52
What are some vent strategies for patients with a restrictive dx process?
Smaller tidal volume (6 mL/kg IBW) Faster resp rate Keep peak inspiratory pressures below 30 cm H2O Prolong inspiratory time ( I:E of 1:1)
53
When is aspiration most common?
During anesthetic induction/intubation Or within 5 minutes of extubation
54
What are 3 potential problems of aspiration?
Gastric contents in airway —> obstruction Gastric contents cause a chemical burn to lung parenchyma —> risk of laryngospasm and impaired gas exchange Infectious material enters the airway —> bacterial infection
55
What is Mendelson’s syndrome?
Gastric pH < 2.5 Gastric volume > 25 mL
56
What are some risk factors to aspiration?
Trauma Pregnancy Emergency GI obstruction GERD PUD Head injury Seizures Ascites Hiatal hernia
57
What is the hallmark symptom of aspiration?
Hypoxemia
58
What is the best method to prevent Ventilator associated pneumonia (VAP)?
Avoid intubation
59
What is the treatment if you have an aspiration?
Head down first! Upper airway suction Secure the airway PEEP to reduce shunt Bronchodilators IV lidocaine Abx if patient develops fever or increase in WBC
60
What are some other methods to reduce VAP?
Hand washing HOB > 30 degrees Daily spontaneous breathing trials Limit sedation Oropharyngeal decomination Subglottic suctioning
61
What are the three types of pneumos?
Closed Open Tension
62
What does a closed pneumo mean?
There is no communication b/t pleural cavity and atomosphere Defect is usually in the pulmonary tree or lung tissue, and air enters and exits the pleural space via the defect
63
What does an open pneumo mean?
The defect is in the chest wall. Air passes b/t the pleaural space and the atmosphere Lung collapses on inspiration and re expands on expiration
64
What does a tension pneumo entail?
Can be a closed or open defect Air is allowed to enter, but not exit the pleural space This increase in intrathoracic pressure causes a mediastinal shift towards the contralateral side. This compresses the heart and vasculature and reduces venous return
65
What are the hallmark signs of a tension pneumo?
Hypoxemia, increased airway pressures, tachycardia, hypotension, and increased CVP.
66
What is the emergency tx of a tension pneumo?
Insertion of a 14g a hip cath in the 2nd intercostal space (mid clavicular) or the 4th/5th intercostal space (anterior axillary)
67
What is the definite treatment for a tension pneumo?
Chest tube insertion
68
What gas should be discontinued immediately followed by a pneumo?
Nitrous oxide
69
What is lymph in the chest called?
Chylothorax
70
What is blood in the chest called?
Hemothorax
71
What is an organized blood clot in the chest called?
Fibrothorax
72
What is pus called in the chest?
Pyothorax (empyema)
73
What is serous fluid in the chest called?
Pleural effusion.
74
What are indications for a thoracotomy?
Initial drainage > 1,000 Continued bleeding > 200 mL/h White lung on X-ray Large air leak
75
Where is injury to the thoracic duct most likely to occur?
Usually happens during CVL insertion and it is more likely to occur on the left side
76
What happens to a flail chest on inspiration? What happens on expiration?
Inspiration: injured ribs move inward Expiration: injures ribs move outward Consequences: alveolar collapse, Hypoventilation, hypercarbia, hypoxia
77
What is the treatment for a flail chest?
Reducing pain (epidural catheter) or block May need mechanical vent/surgical fixation
78
In patients at risk for venous air embolism, what positions are the highest risk and what are the lowest? From high to low?
Sitting > supine > prone > lateral
79
What are the S&S of an air embolism?
Air observed on the TEE Mill wheel murmur Decreased EtCO2 Hypotension Increased pulmonary artery pressures Dysrhythmias Hypoxia Cyanosis
80
How can you detect an air embolism? From most sensitive to least sensitive.
TEE > precordial Doppler > EtCO2 > CVP > BP/HR/stethoscope
81
What is the tx for a venous air embolism?
100% FiO2 Flood surgical field with saline Discontinue insufflation if used Place patient in Durant’s position Aspirate air with Central line
82
How do you determine pulmonary vascular resistance?
PVR = (mean PAP - PAOP) / CO x 80
83
What are some things that increase PVR?
Hypoxemia Hypercarbia Acidosis SNS stimulation Pain Hypothermia Mechanical vent PEEP Atelectasis Drugs (nitrous oxide, ketamine, desflurane)
84
What are some things that decrease PVR?
Increased PaO2 Hypocarbia Alkalosis Spontaneous vent Prevention of coughing or straining Drugs: nitric oxide, nitroglycerin, sidenafil, prostaglandins PGE1/PGE2, calcium channel blockers, ACE inhibitors
85
What is the tx for carboxyhemoglobin?
Oxygen therapy ~ it’s continued until CoHgb is < 5% or for 6 hours Hyperbaric oxygen is indicated if CoHgb exceeds 25% or if the pt is symptomatic
86
What is the risk of CO formation with volatile anesthetic? From greatest to least
Des > Iso >>> Sevo
87
What drugs can you administer via ETT?
NAVEL Narcan, atropine, vasopressin, epi, lidocaine
88
What are indications for mechanical ventilation?
Vital capacity < 15 ml/kg Inspiratory force < 25 PaO2 < 55 @ room air A-a gradient > 55 @ room air PaO2 < 200 on 100% FiO2 A-a gradient > 450 on 100% FiO2 PaCO2 > 60 Resp rate > 40 or < 6
89
What are absolute indications for OLV?
Infection Hemorrhage Bronchopleural fistual Surgical opening of major airway Large unilateral cyst or bulla Life threatening hypoxia d/t lung dx Pulmonary alveolar proteinosis
90
What size double lumen ETT should you use with a child?
8-9 ~ 26 10 years + ~ 28 or 32 Kids younger than 8 will require a blocker or single lumen ETT advanced into main stem bronchus
91
What is the most realizable method for identifying the correct double lumen tube placement?
Fiberoptic
92
How should you set your ventilator for one lung ventilation?
80-100% FiO2 6 mL/kg tidal volume Inspiratory pressure < 20 cm H2O Resp rate 12-15 PEEP 5-10
93
What procedures (right or left) have a higher incidence of hypoxemia?
Procedures that rely on the LEFT lung have a higher incidence. The right lung is larger.
94
What is the stepwise approach to hypoxemia during OLV?
100% FiO2 Check position of tube/bronchial blocker via fiberoptic R/o other causes of hypoxemia Apply CPAP to non-dependent lung Apply PEEP
95
Unlike the DLT, a bronchial blocker cannot?
Prevent contamination from contralateral lung, provide ventilation Suction secretions from isolated lung
96
What are the most serious side effects of a mediastinoscopy?
#1 hemorrhage #2 pneumothorax
97
What is an absolute contraindication to mediastinoscopy?
Previous mediastinoscopy (d/t scarring)
98
The compression of what artery can lead to cerebra vascular effects during mediastinoscopy?
Innominate artery
99
Where do you place the SpO2 (or Aline) and where do you place the non-invasive blood pressure cuff during a mediastinoscopy?
SpO2/arterial line on the right( will dampen if innominate artery is compressed) BP cuff on left (can still take BP if innominate artery is compressed)
100
What are the degrees of severity for ARDS?
Mild: PaO2/FiO2 ratio < 200-300 Moderate: PaO2/FiO2 ratio < 101-200 Severe: PaO2/FiO2 ratio < 100
101
What are some vent tactics for ARDs?
Pressure control if avaible Low tidal volumes 4-6 mL/kg Plateau pressure of < 30 cm Resp rate of 6-35 (aim to keep pH 7.3-7.45) PEEP (whatever is best for oxygenation) Target SpO2 88-95% Permissive hypercapnia may be required
102
What is a class 1 mallampati?
Remember PUSH Pillars, uvula, soft palate, hard palate
103
What is a class 2 mallampati
Remember PUSH Uvula, soft palate, hard palate
104
What is a class 3 mallampati
Remember PUSH Soft and hard palate
105
What is a class 4 mallampati
Hard palate only
106
What is a normal incisor gap?
2-3 finger breadths or 4 cm
107
Laryngoscopy may be more difficult if the thryomental distance is what?
< 6 cm or > 9 cm
108
What is class 1 of the mandibular protrusion test?
Patient can move lower incisors past upper incisors and bite the upper lip
109
What is class 2 of the mandibular protrusion test?
Patient can move lower incisors in line with upper incisors
110
What is class 3 mandibular protrusion test?
Pt cannot move lower incisors past upper incisors

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