Restrictive Lung Disease Flashcards
➢___ surrounds the lungs includes
-parietal pleura, skeletal structure
-muscles (intercostals, diaphragm, accessory muscles of respiration)
➢___ determine position and mobility of both diaphragm and thoracic cage
➢Disease in any of these locations can reduce the patient’s overall ___
-Create a V/Q mismatch and result in ___
Thoracic cage
Abdominal wall and contents
compliance
restrictive disease
Restrictive disease is characterized by proportional decreases in?
ALL lung volumes
Restrictive Lung Disease:
➢Reduction in : •Total lung capacity •Functional Residual Capacity
•Reserve Volume •Vital capacity •Total volume exhaled
•FEV1 (forced expiratory volume 1 second) •FVC (forced vital capacity)
•___ BREATHING
➢___ leads to low lung compliance and arterial hypoxemia due to V/Q mismatch
➢No change in ?
RAPID SHALLOW
Reduced FRC
•FEV1/FVC ratio normal
Restrictive Disease:
➢___ is limited by the reduced compliance of the lung or chest wall
aka “___”
➢Reduction in lung compliance results in increased ___ and ___
➢Breathing pattern
-Rapid, shallow which increases?
-Lower ___ during apnea
Inspiration "stiff lungs" work of breathing and dyspnea -dead space ventilation -oxygen stores
Restrictive Disease: ➢Normal gas exchange exists until advanced disease then: -increased ? -decreased ? -\_\_\_ -\_\_\_
PaCO2
PaO2
pulmonary HTN
cor pulmonale
Restrictive Disease Characterized by: ➢ Decreased \_\_\_, Increased \_\_\_ and Increased \_\_\_ ➢ Vital Capacity LESS than ? ➢ Expiratory flow rate \_\_\_ ➢ \_\_\_ NORMAL ➢ Breathing pattern? ➢Decreased \_\_\_
TLC PaCO2, work of breathing 70 ml/kg normal FEV1/FVC ratio Rapid, shallow lung compliance
Classification of Restrictive Diseases:
➢___ = pulmonary edema, ARDS
➢___ = diseased lung parenchyma - sarcoidosis
➢___ = chest wall, intra-abdominal & neuromuscular diseases
➢Disorders of the Pleura and Mediastinum
➢Acute Intrinsic
➢Chronic Intrinsic
➢Chronic Extrinsic
Acute Intrinsic Pulmonary Edema:
*Leakage of ___ - Fluid moves from the ___ into the ___ and into ___
•Increased ___ (example: cardiogenic)
•Increased ___ (inflammatory process)
•Seen as ___ on CXR
•If ___ will see accompanying dyspnea, tachypnea SNS activation (hypertension, tachycardia and diaphoresis)
*intravascular fluid pulmonary vasculature into the lung interstitium alveoli capillary/hydrostatic pressure capillary permeability bilateral symmetrical opacity cardiogenic
Acute Intrinsic Aspiration Pneumonitis
➢___ is rapidly distributed through-out
➢Acidic gastric fluid destroys ___ cells & injures the ___ of the capillaries in the lungs
➢Produces capillary permeability with resultant ___ and ___ (like ARDS)
➢S/S = Arterial Hypoxia, Tachypnea, Bronchospasm
-Pulmonary vascular constriction can develop into ___
-CXR changes ___ later – usually ___
Aspirate surfactant-producing endothelium atelectasis and edema formation pulmonary HTN 6-12 hours later - right lower lobe
Treatment of Aspiration Pneumonitis:
- Treatment is aimed at delivery of ___
- ___
- ___ for bronchospasm
- ___ = if suspected solid material aspirated
- Evidence does not support prophylactic antibiotics
- Steroid use is controversial some may give dexamethasone or methylprednisolone
- increased FIO2
- PEEP
- B-2 agonists
- Fiberoptic bronchoscopy
Negative Pressure Pulmonary Edema:
➢Occurs minutes to 2-3 hours after ___ in a spontaneously breathing patient
➢Causes: There are 4 start naming betchhhh
acute upper airway obstruction
- Post-extubation laryngospasm
- Obstructive sleep apnea
- Epiglotitis
- Tumors
Negative Pressure Pulmonary Edema:
➢Development related to generation of highly negative intrapleural pressures against a ___
➢Highly negative intrapleural pressures cause:
•Decreased ___ •Increased ___ •Increased ___ on left ventricle
•Increased ___ = HTN, central displacement of blood volume
➢Resultant?
- closed glottis/upper airway
- interstitial hydrostatic pressure
- venous return
- afterload
- SNS outflow
- Acute Pulmonary Edema
Negative-Pressure Pulmonary Edema:
- Presents with: ___, ___, ___
- Usually self-limited ___ duration
- Treatment includes:
- Supplemental O2
- Maintenance of ___
- Occasionally ___ for brief periods
- Tachypnea
- Cough
- Failure to maintain SaO2 >95%
- 12-24 hour
- patent upper airway
- mechanical ventilation
Systematic granulomatous disorder that changes the intrinsic properties of the lung due to pulmonary fibrosis?
- Results in ___ and ___
- Often found in ___ and ___
Sarcoidosis (Chronic Intrinsic)
- cor pulmonale and pulmonary HTN
- thoracic lymph nodes and lungs
Chronic Intrinsic-Sarcoidosis:
➢___ = can interfere with passage of adult sized tubes
➢___ = rare conduction defects (heart block, dysrhythmias, restrictive cardiomyopathy)
➢Liver, spleen, optic, and unilateral facial nerve palsy
- Laryngeal sarcoid
* Myocardial sarcoid
Chronic Intrinsic: Sarcoidosis
- Patients present with ___ and ___
- Patients present for ___ for diagnosis via lymph node tissue
- Patients are often treated with ___
- Consider a stress dose of steroids peri-operatively
- dyspnea and rapid shallow breathing
- mediastinoscopy
- corticosteroids
Chronic Extrinsic Restrictive Lung Disease:
➢Compressed lungs result in ___
-Decreased lung volumes with corresponding increase in ___
-Abnormal chest wall mechanics
➢___ = Right ventricular dysfunction common with chronic compression of pulmonary vasculature
➢Impaired cough results in ?
- increased work of breathing
- airway resistance
- Thoracic deformity
- chronic infection
Neuromuscular Disorders: Review
➢Spinal cord, peripheral nerve, neuromuscular junction, or skeletal muscle pathology that prevents normal respiratory pressures
-Diaphragmatic paralysis -Spinal cord transection
-Guillian-Barre syndrome -Myasthenia gravis
-Myasthenic syndrome -Muscular dystrophy
➢Results in: ~\_\_\_ cough ~impaired \_\_\_ ~pneumonia ~respiratory failure may result ~Very sensitive to ?
~ineffective
~clearance of secretions
~CNS depressants
Pre-operative Assessment and Optimization for NM Disorders:
- ___ and baseline ___
- PFTs, flow-volume loops and ABG may be useful to grade severity
- **Factors that signal increased risk:
- Decrease in ___
- Resting ___
-Exercise tolerance and baseline dyspnea
VC less than 15 ml/kg
resting hypercarbia
Preoperative Assessment and Optimization for NM Disorders:
- Treat ___
- Improve ___
- Treat cardiac dysfunction
- Attempt to improve ___ w/ respiratory therapy techniques
- Smoking cessation
- pulmonary infection
- sputum clearance
- respiratory muscle strength
Anesthetic Management with Neuromuscular Disorders:
➢___ results in high airway pressures in order to expand stiff lungs
➢Overall mechanical ventilation should combine ___ and ___
- Positive-pressure ventilation
- lower tidal volumes
- rapid rates
Anesthetic Management for Neuromuscular Disorders:
➢Pre-Induction = Titrate pre-medications carefully to reduce ___ – very little reserve
➢Regional anesthesia = at ___ level, pt will have a loss of accessory respiratory muscles which may be crucial to spontaneous ventilation in these patients
➢___ = must be used w/caution s/t risk of barotrauma (pneumothorax)
➢IV/maintenance agents =shorter acting agents preferred to minimize?
➢Volatile Agents = ___ (decreased FRC and often increased RR)
ventilatory depression >T10 level N2O post-operative respiratory depression accelerated uptake
Anesthetic Management NM Disease: Ventilation
- ___ will help maintain optimal oxygenation and ventilation
- Pre-oxygenation very important = decreased ___-lower ___
- ___ drops quickly with apnea
- Expect increased __ as poorly compliant lungs ventilated mechanically -Decrease ___(?) -Increase ___(?) -Consider the risk for ?
- Attempt to keep end-inspiratory plateau pressure ?
- Mechanical ventilation w/ETT
- FRC-lower oxygen stores
- SaO2
- Peak airway pressures
- Decrease volume (4-8 ml/kg)
- Increase rate (14-18 breaths per minute)
- Barotrauma
- less than 30 cm of water
Post -Anesthetic Management of Patient with NM Disease:
➢Post-op Pulmonary problems are primarily ___
-Decreased ?
-Consider abdominal impingement on movement of ___
-Abnormal resp pattern with ?
-Consider ___ = this is an important risk factor for development of Post-operative pulmonary complications
- Restrictive
- lung volumes
- diaphragm
- shallow breathing with rapid respirations
- surgical site
Post-Anesthetic Management of the Patient with NM Disorders:
➢Decreased lung volumes and impaired cough put patient at risk for post-operative ___
➢Supplemental O2 for transport
➢Treat pain adequately but avoid excessive respiratory depression
➢Low threshold for - ?
-Monitored post-operative bed
- respiratory failure
- Post-op mechanical ventilation
Anesthetic Management-Acute Restrictive Disease: Critically Ill Patients
➢Elective surgery should be canceled if ? (ARDS, pulmonary edema)
➢If Emergency surgery is indicated = -___ for fluid overload
-___ and ___ for cardiac failure
-Consider drainage of pleural effusions/ascites pre-op
-May require ___
-Aggressive hemodynamic monitoring (a-line, CVP, pulm art cath)
acute intrinsic restrictive disease
- Diuretic therapy
- Vasodilators and inotropes
- ICU ventilator
Anesthetic Management Neuromuscular Disorders: Extubation criteria
Adequate PaO2? PaCO2? RR? TV? VC?
*Adequate LOC and muscle strength - head lift for greater than 5 secs
*Full reversal of neuromuscular blockade
greater than 60 mmHg less than 50 mmHg less than 30 bpm greater than 300 mL greater than 10-15 ml/kg
