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APEX-CV & Respiratory > RESPIRATORY PATHOPHYSIOLOGY modules 15-23 > Flashcards

RESPIRATORY PATHOPHYSIOLOGY modules 15-23 Flashcards

1
Q

List the monitors of venous air embolism from most sensitive to least

A

TEE
Precordial doppler
EtCO2
CVP

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2
Q

List the positions that increase the risk of venous air embolism from greatest to least

A

Sitting
Supine
Prone
Lateral

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3
Q

Signs and symptoms of venous air embolism

A 
Air on TEE
Mill wheel murmur on precordial doppler
Decreased EtCo2
HoTN
Dysrhythmias
Hypoxia
Cyanosis
CV collapse
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4
Q

What is the treatment for venous air embolism

A 
100% FiO2
Flood the surgical field
D/C insufflation
Left lateral decubitus positioning
Air aspiration via CVC
Hemodynamic support
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5
Q

How does a venous air embolism occur

A

Air is entrained into bloodstream via an open vessel above the level of the heart

Increased risk in spontaneously ventilating patients

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6
Q

What are consequences of air trapped in the pulmonary circulation

A
  1. Increased PA pressure
  2. Increased RV stroke work index
  3. RV failure
  4. Decreased pulmonary venous return
  5. Decreased LV preload
  6. Decreased CO
  7. Asystole and CV collapse
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7
Q

How does air trapped in the pulmonary circulation affect the left side of the heart?

A
  1. Decreases LV preload
  2. Decreases CO
  3. Leads to asystole and CV collapse
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8
Q

What interventions reduce pulmonary vascular resistance

A

Hyperventilation
Nitric oxide
NTG

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9
Q

What interventions increase pulmonary vascular resistance (5)

A 
Hypoxia
Hypercarbia
N2O
hypothermia
PEEP
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10
Q

What is PAP in pulmonary HTN

A

PAP > 25 mmHg

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11
Q

What pathophysiologic alterations increase pulmonary vascular resistance

A

Increased vascular smooth muscle tone
Vascular cell proliferation
Pulmonary thrombi

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12
Q

What effects can pulmonary HTN have on RV workload

A

Increases

Progression to RV failure (cor pulmonale)

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13
Q

Anesthetic considerations for patients with pulmonary HTN

A
  1. Give medications for PVR reduction preoperatively
  2. Preload dependent d/t fixed CO
  3. Aggressive HoTN treatment
  4. Epidural over spinal anesthesia
  5. Inhaled nitric oxide
  6. Jet ventilation
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14
Q

Describe the process of LV preload dependence in the patient with pulmonary HTN

A

Increased RV afterload causes RV dilation, hypertrophy and systolic failure
Decreased output from RV
HoTN d/t decreased LV preload
Intraventricular septum bowing into LV compromises filling

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15
Q

How does tricuspid regurgitation occur d/t pulmonary htn

A

Increased RV volume at end diastole d/t decreased RV stroke volume
Stretches tricuspid annulus leading to regurg

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16
Q

Causes of pulmonary HTN

A 
COPD
Hypoxemia & Hypercarbia
left heart dysfunction
MV disease
CHD
Connective tissue disorders
Thromboembolism
Portal HTN
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17
Q

What is the normal pulmonary vascular resistance

A

150-250 dynes-sec-cm5

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18
Q

Equation for PVR

A

PVR = ([mean PAP - PAOP]/CO x 80)

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19
Q

What can increase pulmonary vascular resistance

A 
Hypoxemia
Hypercarbia
Acidosis
SNS stimulation 
Pain
Hypothermia
Increased intrathoracic pressure
Mechanical ventilation
PEEP
Atelectasis
N2O
Ketamine
Desflurane
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20
Q

Anesthetics that increase pulmonary vascular resistance

A

N2O
Ketamine
Desflurane

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21
Q

Drugs that decrease pulmonary vascular resistance

A 
Nitric oxide
NTG
PDE inhibitors
PGE1/2
CCB
ACE inhibitors
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22
Q

What can decrease pulmonary vascular resistance

A 
Increased PaO2
Hypocarbia
Alkalosis
Decreased intrathoracic pressure
Spontaneous ventilation
Avoid coughing/straining
NO
NTG
PDE inhibitors
PGE1/2
CCB
ACE-i
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23
Q

How is preload managed in the patient with pulmonary HTN

A

Requires adequate preload, therefore treat HoTN aggressively

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24
Q

In a gravid patient with pulmonary HTN, what are the CV effects of uterine contractions and the treatment

A

Effects = Too much preload, PA HTN, RV dysfunction

Treatment = NTG

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25
Hgb has an affinity for carbon monoxide that is ___ times greater than O2
200 times
26
Carbon monoxide shifts the oxyhemoglobin dissociation curve which direction
Left
27
What is the treatment for carboxyhemoglobinemia?
Supplemental O2
28
How does soda lime affect carbon monoxide levels
If it is desiccated the risk of CO formation is greatest
29
What type of metabolism is a result of carboxyhemaglobinemia
Anaerobic metabolism because O2 is not released at tissues This leads to metabolic acidosis due to impaired oxidative phosphorylation and reduced ATP production
30
Hyperbaric O2 is indicated if CoHgb exceeds what percent of total hgb?
25%
31
When treating CoHgb, 100% O2 should be administered until the CoHgb is less than __%
5%
32
``` What are strong indications for mechanical ventilation VC __ Inspiratory force __ PaO2 __ A-a gradient __ PaCO2 __ RR __ ```
``` VC <15 mL/kg Inspiratory force <25 cmH2O PaO2 <200 mmHg on 100% FiO2 A-a gradient >450 mmHg on 100% FiO2 PaCO2 >60 mmHg RR >40 or <6 bpm ```
33
What drugs can be administered via an ETT
``` NAVEL Narcan Atropine Vasopressin Epinephrine Lidocaine ```
34
What is the normal A-a gradient
<10 - 15 mmHg
35
What are the benefits of endotracheal intubation
1. Patent airway 2. Controlled ventilation 3. Ventilate with high airway pressure 4. Secure airway 5. Removal of secretions 6. Lung isolation 7. Medication administration
36
What are the best predictors of postop pulmonary complications for patient undergoing pulmonary surgery FEV1 __ DLCO __ VO2 max __
FEV1 <40% predicted DLCO <40% predicted VO2 max <15 mL/kg/min
37
What are the 3 categories of predictors of postop pulmonary complications following pulmonary surgery.
``` Lung parenchymal function (gas exchange) Respiratory mechanics (airflow) Cardiopulmonary reserve ```
38
If a VO2 max is not available to assess postop pulmonary complications, what question can give similar information
Ask if patient can climb 2 flights of steps If no, the patient is at risk
39
What are the 3 categories for absolute indications for OLV
Isolation to avoid CONTAMINATION Control of ventilation distribution Unilateral bronchopulmonary lavage
40
What are absolute indications for OLV
``` Infection Massive hemorrhage Bronchopleural fistula Surgical opening of major airway Large unilateral cyst/bullae Hypoxemia d/t lung dz Pulmonary alveolar proteinosis ```
41
What high priority relative indications for OLV and surgical exposure
``` Thoracic aortic aneurysm Pneumonectomy Thoracoscopy Upper lobectomy Mediastinal exposure ```
42
DLT size for males and females based on height
Female: <160 cm = 35 french >160 cm = 37 french Male: <170 cm = 39 french >170 cm = 41 french
43
Approximate DLT insertion depth for males and females
``` Males = ~29 cm Females = ~27 cm ```
44
What data can aid in choosing the proper DLT size
CXR and CT to assess for abnormalities in tracheobronchial anatomy
45
At what age do we use DLT for pediatric patients
at 8 years
46
Why are DLT not manufactured for pediatric patients <8 yo
Because the lumens would be so narrow that resistance to airflow would be incredibly high
47
What are the options for lung isolation in children <8 years
Bronchial blocker | Single lumen ETT in mainstem bronchus
48
What is the cause of shunt during OLV. | What does this cause
Mixing blood from non-dependent (non-ventilated) lung and dependent (ventilated) lung Causes hypoxemia
49
Which lung is better ventilated in the lateral decubitus position
Non-dependent lung (which is not ventilated)
50
Which lung is better perfused in the lateral decubitus position
The dependent (ventilated) lung
51
What is the cause of V/Q mismatch in the lateral decubitus position for OLV
The non-dependent lung is better ventilated but poorly perfused and it is also the non-ventilated lung
52
``` Mechanical ventilation considerations for OLV initiation FiO2 __ Vt __ RR __ PEEP __ ```
FiO2 100% Vt 6-8 mL/kg ibw RR 12-15 bp, PEEP 5-10 cmH2O
53
What maneuver is helpful before initiating OLV
Alveolar recruitment maneuver
54
How can the I:E ratio be adjusted to improve OLV
Adjust if the patient has an expiratory air flow limitation | i.e. increase I:E to allow for full exhalation
55
What type of anesthetic may be beneficial for OLV
TIV because volatile anesthetics can inhibit the HPV response
56
What steps are taken to address hypoxemia in OLV
1. 100% FiO2 2. Confirm position of DLT w/ fiber 3. r/o physiologic causes (mucus plug, PTX etc) 4. Apply CPAP to NON-dependent lung 5. PEEP 5-10 cm H2O to DEPENDENT lung
57
What steps may be taken if initial efforts to address hypoxemia are unsuccessful
1. Intermittently reinflate non-dependent lung 2. Ligate pulmonary artery 3. Eliminate drugs that inhibit HPV response
58
What is the result of the DLT being in too far
Upper lobe is NOT ventilated, increasing hypoxemia
59
What is the result of DLT not being deep enough
Failure to achieve lung separation BS bilateral
60
What is the result of DLT in the wrong bronchus
The wrong lung is collapsed
61
How does hypoxemia affect the A-a gradient
INCREASES gradient
62
How does PPV affect V/Q mismatch
PPV increases alveolar pressure and makes it part of West zone 1, increasing dead space
63
What is seen when confirming DLT placement with a fiber bronchoscope
``` Tracheal lumen = incomplete C-rings open posteriorly Blue cuff -in correct bronchus -not herniating Right bronchus has 3 takeoffs Left bronchus has 2 takeoffs ```
64
Left-sided DLT confirmation by auscultation Clamp TRACHEAL lumen with both cuffs inflate ``` Describe BS in each condition: Correct In too far (left) In trachea In too far (right) ```
Correct: left = yes, right = no In too far (left): left = yes, right = no In trachea: left = yes, right = yes In too far (right): left = no, right = no
65
Left-sided DLT confirmation by auscultation Clamp BRONCHIAL lumen with both cuffs inflate ``` Describe BS in each condition Correct In too far (left) In trachea In too far (right) ```
Correct: left = no, right = yes In too far (left): left = no, right = no In trachea: left = no, right = no In too far (right) left = no, right = no
66
Left-sided DLT confirmation by auscultation Clamp BRONCHIAL lumen and deflate cuff ``` Describe BS in each condition Correct In too far (left) In trachea In too far (right) ```
Correct Left = yes, right = yes In too far (left): left = yes, right = no In trachea: left = yes, right = yes In too far (right): left = no, right = yes
67
Steps for lung isolation with OLV
1. Inflate bronchial cuff 2. Clamp lumen distal to y-piece of operative lung 3. Open lumen to operative side 4. Adjust FiO2 5. Vt 6 ml/kg to keep PIP20 6. Adjust RR to maintain PaCO2 35-45 7. Perform alveolar recruitment before OLV 8. Check ABG 9. Add PEEP 10. Adjust I:E for COPD pts 11. Limit volatile gas to <1.5 to prevent HPV impairment
68
How does PEEP improve FRC in the OLV pt
It increases FRC by pushing the lung up the alveolar compliance curve
69
Is hypoxemia during OLV more common during surgery on the right or left lung?
Right lung | There is less are for gas exchange when the left lung is the only one ventilated
70
How do the DLT and bronchial blockers differ (5)
1. BB cannot prevent contamination 2. BB cannot ventilate isolated lung 3. BB cannot suction 4. BB can be used in peds <8 yo 5. BB can be used with NT tubes
71
Advantages of using a BB over DLT
Don't need to be reintubated Can be used with NT tubes Can be used in kids <8 y
72
Which lung is ventilated when using a bronchial blocker?
The lung on the opposite side of the BB
73
What are the uses of the lumen in the BB
1. Insufflating O2 into non-ventilated lung | 2. Suctioning air (NOT secretions) from non-ventilated lung
74
What are the 2 most common and serious complications of mediastinoscopy
Hemorrhage | PTX
75
What is an absolute contraindication to mediastinoscopy
Prior mediastinoscopy
76
Where should pulse oximetry and NIBP be placed when monitoring a patient having mediastinoscopy and why
Pulse ox = RUE NIBP = LUE pulse ox/a-line are on RUE. The waveform will dampen or disappear if the innominate artery is compressed during mediastinoscopy
77
What are indications for tracheal resection
``` Tracheal stenosis Tracheomalacia Tumor Vascular lesions Congenital malformation ```
78
A patient is 2 days s/p tracheal anastomosis and requires reintubation. What is the best technique and why
Use flexible fiberoptic bronchoscopy Pts neck must maintain flexed position so extension for intubation is contraindicated
79
Complications of mediastinoscopy include injury to which structures
Thoracic aorta = hemorrhage and bradycardia Innominate artery = decreased carotid BF, decreased CBF Trachea = airway obstruction Thoracic duct = chylothorax Phrenic/RLN = paresis
80
What are 3 relative contraindications for mediastinoscopy
1. Tracheal deviation 2. Thoracic aortic aneurysm 3. SVC obstruction
81
What patient history considerations must be assessed prior to an anesthetic for mediastinoscopy
1. Type of lung CA. Eaton-Lambert syndrome means sensitivity to SUX and ND-NMBD 2. CV disease 3. History of stroke
82
During mediastinoscopy, what can result if the innominate artery is compressed?
Compromises right carotid and therefore cerebral blood flow
83
Importance of proper IV access in patients undergoing mediastinoscopy
Large bore LE access helps avoid loss of fluids or blood through vascular injury
84
You are pre-oping a patient for tracheal resection, what are important history and assessment considerations
1. Are there airflow limitations 2. Is there a CT to review 3. Evaluate flow-volume loops
85
What type of induction would be appropriate for a patient undergoing tracheal resection and why
Awake intubation or inhaled induction Obstruction during induction can occur. Must preserve spontaneous ventilation to prevent obstruction
86
Which artery is at risk for compression during tracheal resection
Innominate (brachiocephalic) artery
87
What lung protective methods are taken in mechanically ventilating a patient with ARDS
1. Low Vt | 2. PEEP
88
What is the cause of ARDS
Inflammatory injury that leads to diffuse alveolar destruction
89
What are 4 key pathophysiologic features of ARDS
1. Protein-rich pulmonary edema 2. Loss of surfactant 3. Hyaline membrane formation 4. Possible long-term lung injury
90
``` Mechanical ventilator setting for a patient with ARDS Setting __ Vt __ PEEP __ Plateau pressure __ RR __ I:E __ O2 goal __ ```
``` Setting = pressure control Vt = 4-6 ml/kg ibw PEEP = titrate to keep FiO2<50% Plateau pressure <30 cmH2O RR = 6 - 35 bpm I:E = 1:1 - 1:3 O2 goal = PaO2 55-80 mmHg ```
91
What is ARDS
A form of non-cardiogenic pulmonary edema
92
What etiologies contribute to ARDS
Pulmonary causes: PNA, COVID, aspiration, smoke inhalation injury, near-drowning Extra-pulmonary causes: SEPSIS, hematologic, trauma/shock, burns
93
What are the 3 stages of ARDS
Exudative = initial injury and inflammatory cascade Proliferative = pathophysiologic process continues but body is trying to heal itself Fibrotic = changes that cause irreversible damage to lung architecture and pulmonary HTN
94
How are PA pressures affected by cor pulmonale
They aren't PA pressures should be normal Cor pulmonale is d/t pulmonary HTN not LV failure
95
A patient in the PACU exhibits signs of recurarization despite reversal with neostigmine and glycopyrrolate. What patient assessment can contribute to impaired reversal
Hypoventilation Respiratory acidosis potentiates NMB and reduces efficacy of anticholinesterase worsening hypoventilation
96
Describe fluid management recommendations for patient undergoing pneumonectomy
Since pt is dependent on a single lung, it is best to limit crystalloid to replacement of volume deficit and maintenance requirement Recommendations <3 L in 24 hours

APEX-CV & Respiratory (8 decks)

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