T4- Obstructive Lung Disease Flashcards
1
Q
What is Bronchitis?
A
Increased mucus and inflammation
2
Q
What is emphysema?
A
Destruction and enlargement of air spaces
3
Q
What are the four groups of obstructive respiratory diseases regarding their influence on anesthetic management?
A
- Acute upper respiratory tract infection (URI)
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Miscellaneous respiratory disorders
4
Q
What role do pulmonary complications play in long-term postoperative mortality?
A
Pulmonary complications play a major role in long-term postoperative mortality.
5
Q
How can the incidence of perioperative pulmonary complications be decreased?
A
Patient optimization prior to surgery can significantly decrease the incidence of these complications.
6
Q
What is the annual rate of experiencing the “common cold” for individuals aged 25-44?
A
19% per year
7
Q
What fraction of scheduled surgery patients may have an active upper respiratory infection (URI)?
A
Consequently, a fraction of scheduled surgery patients will have an active URI
8
Q
What accounts for approximately 95% of all URIs?
A
Infectious nasopharyngitis
9
Q
What are the most common associated viral pathogens with URIs?
A
Rhinovirus, coronavirus, influenza, parainfluenza, and respiratory syncytial virus (RSV).
10
Q
How is the diagnosis of nasopharyngitis usually made?
A
Diagnosis is usually based on clinical symptoms
11
Q
What are some perioperative respiratory adverse events associated with acute URI in pediatric patients?
A
- transient hypoxemia
- laryngospasm
- breath holding
- coughing.
12
Q
How long should surgery be postponed if cancelled due to acute URI?
A
Surgery should not be rescheduled within 6 weeks
13
Q
What factors does the COLDS scoring system take into account?
A
The COLDS scoring system takes into account current symptoms, onset of symptoms (higher risk within 2 weeks), presence of lung disease, airway device (endotracheal tube = higher risk), and type of surgery (major airway surgery = higher risk).
14
Q
What are some components of anesthetic management for patients with acute URI?
A
Adequate hydration, reducing secretions, and limiting airway manipulation.
15
Q
How might nebulized or topical local anesthetic on the vocal cords aid in anesthetic management?
A
It may reduce upper airway sensitivity.
16
Q
How can the risk of laryngospasm be reduced in patients with acute URI?
A
Using a laryngeal mask airway (LMA) instead of an endotracheal tube (ETT).
17
Q
What technique might be considered for smoother emergence in patients with acute URI, if there are no contraindications?
A
Deep extubation.
18
Q
What are some adverse respiratory events associated with acute URI?
A
Bronchospasm, laryngospasm, airway obstruction, postintubation croup, desaturation, and atelectasis.
19
Q
How can intraoperative and postoperative hypoxemia in patients with acute URI be managed?
A
They are common and treatable with supplemental oxygen.
20
Q
What is asthma characterized by?
A
Asthma is characterized by chronic inflammation of the mucosa of the lower airways.
21
Q
What is the result of activation of the inflammatory cascade in asthma?
A
Activation of the inflammatory cascade leads to infiltration of the airway mucosa with eosinophils, neutrophils, mast cells, T cells, B cells, and leukotrienes, resulting in airway edema, especially in the bronchi.
22
Q
What are the main inflammatory mediators implicated in asthma?
A
Histamine, prostaglandin D2, and leukotrienes.
23
Q
What are some asthma-provoking stimulators?
A
24
Q
How is asthma characterized in terms of symptom presentation?
A
Asthma is an episodic disease with acute exacerbations and asymptomatic periods.
25
What are some common symptoms of asthma?
Symptoms include expiratory wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia.
26
How long do most asthma attacks typically last?
Most attacks are short-lived, lasting minutes to hours.
27
What is "status asthmaticus"?
Status asthmaticus refers to dangerous, life-threatening bronchospasm that persists despite treatment.
28
What aspects of a patient's history should be focused on when obtained from an asthma patient?
Attention should focus on previous intubations, ICU admissions, 2+ hospitalizations for asthma in the past year, and the presence of coexisting diseases.
29
How is asthma diagnosed?
Asthma is diagnosed based on clinical history, symptoms, and objective measurements of airway obstruction.
30
What criteria are used to diagnose asthma?
Asthma is diagnosed when a patient reports wheezing, chest tightness, or shortness of breath and demonstrates airflow obstruction on pulmonary function tests (PFTs) that is at least partially reversible with bronchodilators.
31
How is asthma severity classified?
Asthma severity is classified based on the symptoms, PFTs, and medication usage.
32
What are some direct measures of the severity of expiratory obstruction in asthma?
Forced expiratory volume in 1 second (FEV1), forced expiratory flow (FEF), and mid expiratory phase flow.
33
What is a typical FEV1 value in symptomatic asthmatic patients who come to the hospital?
FEV1 <35%.
34
What do flow-volume loops show in asthma?
Flow-volume loops show a downward scooping of the expiratory limb of the loop.
35
What change may occur in functional residual capacity (FRC) during moderate or severe asthma attacks?
FRC may increase substantially.
36
How can relief of obstruction after a bronchodilator aid in diagnosing asthma?
Relief of obstruction after a bronchodilator suggests the diagnosis of asthma in patients with expiratory obstruction.
37
Just a graph to look at
38
Just another graph to look at
39
What are the ABG findings typically associated with mild asthma?
Mild asthma is usually accompanied by a normal PaO2 and PaCO2.
40
What causes tachypnea and hyperventilation during an asthma attack?
Tachypnea and hyperventilation during an asthma attack are caused by neural reflexes of the lungs, not hypoxemia.
41
What are the most common ABG findings of symptomatic asthma?
Hypocarbia and respiratory alkalosis.
42
What may result in a PaO2 of <60 mmHg as the severity of expiratory obstruction increases?
Ventilation/perfusion mismatching
43
When is the PaCO2 likely to increase in asthma?
The PaCO2 is likely to increase when the forced expiratory volume in 1 second (FEV1) is <25% of predicted.
44
What are some CXR findings in patients with severe asthma?
Hyperinflation and hilar vascular congestion due to mucous plugging and pulmonary hypertension.
45
How can CXRs be helpful in asthma management?
CXRs can be helpful in determining the cause of an asthma exacerbation and ruling out other causes.
46
What cardiac findings may be present on an EKG during an asthma attack?
Signs of right ventricular strain or ventricular irritability.
47
What are some conditions included in the differential diagnosis of asthma?
Viral tracheobronchitis, sarcoidosis, rheumatoid arthritis with bronchitis, extrinsic or intrinsic airway compression, vocal cord dysfunction, tracheal stenosis, chronic bronchitis, COPD, and foreign body aspiration.
48
What is the primary aim of asthma treatment?
The primary aim of asthma treatment is to control symptoms and reduce exacerbations.
49
What is the first-line treatment for patients with mild asthma?
A short-acting inhaled β2 agonist.
50
When are daily inhaled corticosteroids recommended in asthma management?
Daily inhaled corticosteroids are recommended following short-acting β2 agonist treatment to improve symptoms, reduce exacerbations, and decrease the risk of hospitalization, especially in patients with <2 exacerbations/month.
51
What other therapies are available for asthma management besides inhaled corticosteroids and short-acting β2 agonists?
Inhaled muscarinic antagonists, leukotriene modifiers, and mast cell stabilizers.
52
When are systemic corticosteroids typically reserved for in asthma treatment?
Systemic corticosteroids are reserved for severe asthma that is uncontrolled with inhalational medications.
53
What is bronchial thermoplasty (BT)?
Bronchial thermoplasty (BT) is a recently approved nonpharmacologic treatment for refractory asthma.
54
How does bronchial thermoplasty work?
BT uses bronchoscopy to deliver radiofrequency ablation of airway smooth muscles to all lung fields except the right middle lobe.
55
How is bronchial thermoplasty typically performed?
The procedure is performed in three sessions and uses intense heat, which carries a risk of airway fire.
56
What is the purpose of bronchial thermoplasty in asthma treatment?
Loss of airway smooth muscle mass is thought to reduce bronchoconstriction.
57
How can serial pulmonary function tests (PFTs) be useful in asthma treatment?
Serial PFTs can be useful for monitoring the response to treatment.
58
What characterizes acute severe asthma?
Acute severe asthma: bronchospasm doesn’t resolve despite usual tx; considered life-threatening
59
What is the emergency treatment for acute severe asthma?
Emergency tx consists of high-dose, short-acting β2 agonists and systemic corticosteroids.
60
How frequently can inhaled β2 agonists be administered in acute severe asthma?
INH β2 agonists can be administered every 15-20 min for several doses w/o adverse hemodynamic effects.
61
What is the target oxygen saturation level in acute severe asthma, and how is it maintained?
Supplemental 02 is given to help maintain 02 saturation >90%.
62
Look at this cool chart
63
What percentage of asthmatics undergoing general anesthesia (GA) experience bronchospasm?
Bronchospasm has been reported in 0.2-4.2% of asthmatics undergoing GA.
64
What factors correlate with the risk of bronchospasm during GA?
The type of surgery (higher with upper abdominal and oncologic surgery) and how recent the last asthma attack occurred.
65
What are some mechanisms by which general anesthesia increases airway resistance?
Mechanisms include depression of the cough reflex, impairment of mucociliary function, reduction of palatopharyngeal muscle tone, depression of diaphragmatic function, and increased fluid in the airway wall.
66
Besides anesthesia, what are other factors that contribute to bronchospasm during surgery?
* airway stimulation by intubation
* activation of the parasympathetic nervous system
* release of neurotransmitters such as substance P and neurokinins
67
What factors should be assessed during preoperative evaluation of patients with asthma?
Disease severity, effectiveness of current treatment, and the need for additional therapy before surgery.
68
What aspects of the patient's history are important to note during preoperative assessment for asthma?
History of symptom control, frequency of exacerbations, need for hospitalization or intubation, previous anesthesia tolerance.
69
What physical signs should be noted during preoperative assessment for asthma?
Physical appearance and use of accessory muscles should be noted.
70
What diagnostic tests may be indicated for preoperative assessment of asthma?
Preoperative PFTs (especially FEV1) before and after bronchodilator may be indicated.
71
What interventions can often improve reversible components of asthma before surgery?
Preoperative chest physiotherapy, antibiotics, and bronchodilators.
72
When are arterial blood gases (ABGs) indicated during preoperative assessment for asthma?
ABGs are indicated if there is any question about the adequacy of ventilation or oxygenation
73
What medications should be continued until induction during preoperative management of asthma?
Anti-inflammatories and bronchodilators.
74
What is the recommended PEFR (peak expiratory flow rate) before surgery in patients with asthma?
Patients should be free of wheezing and have a PEFR of >80% of predicted or their personal best value before surgery.
75
What is COPD?
COPD is a disease of chronic airflow obstruction
76
What are the symptoms of COPD?
Symptoms include emphysema characterized by lung parenchymal destruction, chronic bronchitis, productive cough, and small airway disease.
77
What is lost in COPD due to bronchio-alveolar destruction?
Pulmonary elastic recoil is lost.
78
What is the worldwide prevalence of COPD, and what rank does it hold in terms of causes of death?
Worldwide, COPD has a prevalence of 10% and is the 3rd leading cause of death.
79
What are the consequences of COPD?
1. Pathologic deterioration in elasticity or recoil within the lung parenchyma, which normally keeps the airways open.
2. Pathologic changes that decrease bronchiolar wall structure, allowing them to collapse during exhalation.
3. Increased velocity through the narrowed bronchioles, which lowers intrabronchial pressure and favors airway collapse.
4. Active bronchospasm and obstruction resulting from increased pulmonary secretions.
5. Destruction of lung parenchyma, enlarged air sacs, and development of emphysema.
80
What are some symptoms of COPD?
Symptoms of COPD vary with severity but usually include dyspnea at rest or exertion, chronic cough, and chronic sputum production.
81
What characterizes COPD exacerbations?
COPD exacerbations are characterized by acute worsening in airflow obstruction
82
What respiratory signs become evident as expiratory obstruction increases in COPD?
As expiratory obstruction increases, tachypnea and prolonged expiratory times become evident.
83
What changes are likely to be heard upon auscultation of the lungs in COPD?
Breath sounds are likely decreased, and expiratory wheezes are common in COPD.
84
What should healthcare providers consider when diagnosing COPD?
Providers should have a high degree of suspicion and a low threshold to test for COPD in patients with dyspnea and chronic cough or environmental exposures.
85
How is a definitive diagnosis of COPD made?
A definitive diagnosis is made with spirometry.
86
What do pulmonary function tests (PFTs) typically show in COPD?
PFTs typically show a decrease in the FEV1:FVC ratio and an even greater decrease in the forced expiratory flow (FEF) between 25% and 75% of vital capacity.
87
What are some common findings in pulmonary function tests for COPD?
Common findings include FEV1:FVC <70%, an increased functional residual capacity (FRC) and total lung capacity (TLC), and reduced diffusing lung capacity for carbon monoxide (DLCO).
88
Look at this
89
What may be observed on a chest X-ray (CXR) in COPD?
Abnormalities may be minimal even with severe COPD. Hyperlucency in the lung periphery suggests emphysema, and bullae confirm emphysema, although only a small percentage of patients with emphysema have bullae.
90
What imaging modality is more sensitive than CXR at diagnosing COPD?
CT (computed tomography) is much more sensitive at diagnosing COPD than CXR.
91
Why has there been interest in expanding CT protocols for COPD cases?
Although CT is not routinely used for COPD diagnosis, the additional information it provides has prompted interest in expanding the protocol for all COPD cases.
92
What are the characteristics of the multiorgan loss of tissue (MOLT) phenotype of COPD?
The MOLT phenotype is associated with airspace enlargement, alveolar destruction, loss of bone, muscle, and fat tissues, and carries higher rates of lung cancer.
93
What is the BODE index used for in COPD diagnosis?
The BODE index is a grading system that looks at BMI, degree of obstruction, level of dyspnea, and exercise tolerance to assess prognosis. Higher BODE scores indicate greater risk of exacerbations, hospitalizations, and pulmonary death.
94
What is α1-antitrypsin deficiency, and how is it associated with COPD?
α1-antitrypsin deficiency is an inherited disorder associated with COPD. Low α1-antitrypsin requires lifelong replacement therapy.
95
Why should eosinophils be measured in patients with uncontrolled COPD despite bronchodilator treatment?
High eosinophils indicate the need for inhaled glucocorticoids, while low levels are associated with an increased risk of pneumonia.
96
How do arterial blood gas (ABG) values typically appear in COPD?
ABGs often remain normal until COPD is severe. PaO2 doesn't usually decrease until the FEV1 is <50% of predicted, and PaCO2 may not increase until the FEV1 is even lower.
97
What is the primary goal of COPD treatment?
COPD treatment is designed to alleviate symptoms and slow disease progression.
98
What is the first step in COPD treatment?
The first step is reducing exposure to smoke and environmental pollutants. Smoking cessation can decrease disease progression and lower mortality by up to 18%.
99
What is the initial medication used in COPD treatment?
Treatment begins with long-acting inhaled muscarinic antagonists.
100
When is inhaled glucocorticoid therapy most effective in COPD treatment?
Inhaled glucocorticoid therapy is most effective in patients with associated asthma, rhinitis, elevated eosinophils, and a history of exacerbations.
101
How do inhaled treatments contribute to COPD management?
Inhaled treatments can improve symptoms, increase FEV1, and reduce exacerbations in COPD.
102
What are some additional treatments besides inhalers used for COPD management?
Other treatments include flu and pneumonia vaccines to prevent respiratory infections.
103
When are diuretics helpful in COPD management?
Diuretics are helpful if right heart failure (RHF) or congestive heart failure (CHF) has developed.
104
What treatments are typically administered during COPD exacerbations?
During exacerbations, antibiotics, corticosteroids, and theophylline may be necessary.
105
What are the benefits of pulmonary rehabilitation programs in COPD management?
Pulmonary rehabilitation programs are beneficial as they can increase exercise capacity in COPD patients.
106
When is long-term home oxygen therapy recommended in COPD?
Long-term home oxygen therapy is recommended when the PaO2 is <55 mmHg, the hematocrit (HCT) is >55%, or if there is evidence of cor pulmonale.
107
What is the goal of supplemental oxygen therapy in COPD?
The goal of supplemental oxygen therapy is to achieve a PaO2 >60 mmHg, which can usually be accomplished with nasal cannula at 2 L/min.
108
How should the oxygen flow rate be adjusted during therapy?
The oxygen flow rate can be titrated as needed according to arterial blood gas (ABG) or oxygen saturation (SpO2) levels.
109
How does supplemental oxygen therapy compare to drug therapy in COPD management?
Supplemental oxygen therapy is more effective than drug therapy in decreasing pulmonary vascular resistance and pulmonary hypertension, and in preventing erythrocytosis.
110
What advice should be given to COPD patients to improve respiratory function postoperatively?
Patients should be advised to do deep breathing exercises or incentive spirometry, which may improve respiratory function postoperatively.
111
Chart to look at
112
Chart to look at
113
In what situation may lung volume reduction surgery be required for COPD treatment?
Lung volume reduction surgery may be required in patients with severe refractory COPD and overdistended lung tissue.
114
What are the mechanisms for improvement in lung function after lung volume reduction surgery?
Mechanisms for improvement include increased elastic recoil, decreased hyperinflation, and decreased ventilation/perfusion mismatch.
115
How is lung volume reduction surgery commonly performed?
Lung volume reduction surgery is most commonly performed via a median sternotomy or a video-assisted thoracoscopic surgery (VATS).
116
What are some anesthesia management considerations for lung volume reduction surgery?
Anesthesia management includes using a double-lumen endotracheal tube, avoiding nitrous oxide, and minimizing excessive airway pressure.
117
Why is central venous pressure (CVP) an unreliable guide for fluid management during lung volume reduction surgery?
CVP is unreliable due to surgical alterations that affect intrathoracic pressures.
118
What aspects of a patient's history should be investigated for anesthesia management in COPD?
A complete history should include investigation of the causes, course, and severity of COPD, smoking history, current medications (especially recent corticosteroids), exercise tolerance, exacerbation frequency, and need for hospitalizations.
119
Why is it important to determine if a patient has previously required noninvasive positive-pressure ventilation (NIPPV) or mechanical ventilation?
Determining if a patient has previously required NIPPV or mechanical ventilation is important as it provides insights into the severity and management of their COPD
120
What comorbidities should be assessed in COPD patients prior to anesthesia?
Patients should be questioned about the presence of other diseases such as diabetes mellitus (DM), hypertension (HTN), peripheral vascular disease (PVD), ischemic heart disease, heart failure, dysrhythmias, and lung cancer.
121
How should inhalation therapies be managed prior to surgery in COPD patients?
Inhalation therapies should be continued until the morning of surgery to maintain optimal respiratory function.
122
What preoperative interventions can help reduce postoperative pulmonary complications in COPD patients?
Preoperative chest physiotherapy such as deep breathing, coughing, incentive spirometry, and pulmonary physical therapy can reduce postoperative pulmonary complications.
123
1. Hypoxemia on room air or the need for home oxygen without a known cause
2. A bicarbonate >33 mEq/L or PCO2 >50 mmHg without diagnosed pulmonary disease
3. A history of respiratory failure due to an existing problem
4. Severe shortness of breath attributed to respiratory disease
5. Planned pneumonectomy
6. Difficulty assessing pulmonary function by clinical signs
7. The need to distinguish causes of respiratory compromise
8. The need to determine the response to bronchodilators
9. Suspected pulmonary hypertension
124
Do COPD patients undergoing peripheral surgery require preoperative pulmonary function tests (PFTs)?
No, patients with COPD undergoing peripheral surgery do not require preoperative PFTs.
125
What assessment can be sufficient to evaluate lung disease when in doubt?
When in doubt, spirometry with forced expiratory volume in 1 second (FEV1) can be sufficient to assess lung disease.
126
How can ventilatory function be assessed under dynamic conditions?
Ventilatory function can be assessed under dynamic conditions by measuring airflow related to lung volume.
127
How are flow-volume curves produced?
Expiratory flow rates can be plotted against lung volumes to produce flow-volume curves.
128
What information do flow-volume loops provide?
Flow-volume loops provide information about airflow during both inspiration and expiration.
129
What changes are observed in the flow-volume loop of a patient with COPD?
In COPD, there is a lower expiratory flow rate at any given lung volume. The expiratory curve is concave, and residual volume (RV) is increased due to air trapping.
130
Look at this
131
Strategies to reduce post-op complications
132
What percentage of smokers undergo general anesthesia (GA) annually?
5-10% of smokers undergo general anesthesia (GA) annually.
133
Why is the period before surgery considered an opportunity for smoking intervention?
The period before surgery offers a window of opportunity for smoking intervention as it encourages patients to stop smoking before surgery and permanently if possible.
134
What does evidence suggest about the timing of smoking cessation before surgery?
Evidence shows that the earlier the intervention, the more effective it is in reducing postoperative complications and maintaining cigarette abstinence. The maximum benefit of smoking cessation is not usually seen unless smoking is stopped at least 8 weeks prior to surgery.
135
What is the significance of smoking cessation in relation to COPD and lung disease?
Smoking is the single-most important risk factor for developing COPD and death caused by lung disease.
136
What are the short-lived adverse effects of carbon monoxide and nicotine on the body?
The adverse effects of carbon monoxide on oxygen-carrying capacity and of nicotine on the cardiovascular system are short-lived.
137
How long do the sympathomimetic effects of nicotine on the heart last?
The sympathomimetic effects of nicotine on the heart last 20-30 minutes
138
What is the elimination half-life of carbon monoxide?
The elimination half-life of carbon monoxide is 4-6 hours.
139
What changes occur within 12 hours after cessation of smoking?
Within 12 hours after cessation of smoking, the PaO2 at which hemoglobin is 50% saturated with oxygen (P50) increases, and plasma levels of carboxyhemoglobin decrease. Specifically, the P50 increases from 22.9 to 26.4 mmHg, and plasma levels of carboxyhemoglobin decrease from 6.5% to 1%.
140
Despite the favorable effects on plasma carboxyhemoglobin, what has not been proven about short-term abstinence from cigarettes?
Despite the favorable effects on plasma carboxyhemoglobin, short-term abstinence from cigarettes has not been proven to decrease postoperative pulmonary complications.
141
What are the effects of cigarette smoking on the respiratory system?
Cigarette smoking causes mucous hypersecretion, impairment of mucociliary transport, and narrowing of small airways.
142
How long does it take for improved ciliary and small airway function and decreased sputum production to be observed after smoking cessation?
It takes weeks of abstinence from smoking to see improved ciliary and small airway function and decreased sputum production.
143
How does smoking interfere with normal immune responses?
Smoking may interfere with normal immune responses and the ability to respond to pulmonary infection following surgery.
144
How long does it take for normal immune function to return after smoking cessation?
Return of normal immune function requires at least 6 weeks of abstinence from smoking.
145
What effect does smoking have on liver enzymes?
Some components of cigarette smoke stimulate liver enzymes. It may take 6 weeks or longer for hepatic enzyme activity to return to normal after smoking cessation.
146
What is the optimal timing of smoking cessation before surgery to reduce postoperative pulmonary complications?
The optimal timing of smoking cessation before surgery to reduce postoperative pulmonary complications is 6-8 weeks, with maximum benefit observed at 8 weeks.
147
What interventions should be offered to smokers scheduled for surgery in less than 4 weeks?
Smokers scheduled for surgery in less than 4 weeks should be advised to quit and offered interventions such as behavioral support and pharmacotherapy.
148
What are some forms of nicotine replacement therapy?
Nicotine replacement therapy (NRT) includes patches, inhalers, nasal sprays, lozenges, and gum, and is generally well tolerated.
149
How can sustained release bupropion aid in smoking cessation?
Sustained release bupropion can also help in smoking cessation. The drug is typically started 1-2 weeks before smoking is stopped.
150
What are some disadvantages of smoking cessation in the immediate preoperative period?
Disadvantages of smoking cessation in the immediate preoperative period include an increase in sputum production, inability to handle stress, nicotine withdrawal, irritability, restlessness, sleep disturbances, and depression.
151
What are the characteristics of bronchiectasis?
Bronchiectasis is associated with irreversible airway dilation, inflammation, and chronic bacterial infection.
152
Who are the most affected demographics by bronchiectasis?
The prevalence of bronchiectasis is highest in patients over 60 with chronic pulmonary diseases such as COPD and asthma, and in women.
153
What are the common symptoms of bronchiectasis?
The common symptoms of bronchiectasis include chronic productive cough with purulent sputum, hemoptysis, and clubbing.
154
What leads to the vicious cycle in bronchiectasis?
Poor mucociliary activity and mucous pooling lead to a vicious cycle of recurrent bacterial infection causing further inflammation, bronchial dilation, airway collapse, airflow obstruction, and the inability to clear secretions. Once a bacterial superinfection is established, it is nearly impossible to eradicate, and daily expectoration of sputum persists.
155
What diagnostic tests should be conducted for suspected bronchiectasis?
Baseline chest X-ray (CXR) and pulmonary function tests (PFTs) should be obtained on all suspected patients. Sputum culture should also be checked for any active infection.
156
What is the gold standard for diagnosing bronchiectasis?
Computed tomography (CT) is the gold standard for diagnosis of bronchiectasis. It usually shows dilated bronchi.
157
What are the key treatments for bronchiectasis?
Key treatments for bronchiectasis involve antibiotics and chest physiotherapy to improve expectoration. Other treatments include yearly flu vaccine, bronchodilators, systemic corticosteroids, and oxygen therapy.
158
What is cystic fibrosis?
Cystic fibrosis is an autosomal recessive disorder characterized by abnormal production and clearance of secretions, primarily affecting the chloride channels.
159
How many people in the US are affected by cystic fibrosis?
Approximately 30,000 people in the US are affected by cystic fibrosis.
160
What causes cystic fibrosis?
Cystic fibrosis is caused by a mutation of a gene on chromosome 7 that encodes the cystic fibrosis transmembrane conductance regulator (CFTR).
161
What are some manifestations of cystic fibrosis?
Manifestations of cystic fibrosis include bronchiectasis, COPD, sinusitis, diabetes, cirrhosis, meconium ileus in children, and azoospermia.
162
What are the diagnostic criteria for cystic fibrosis?
The diagnostic criteria for cystic fibrosis include a sweat chloride concentration >60 mEq/L along with clinical symptoms (cough, purulent sputum, exertional dyspnea) or a family history of the disease.
163
How is cystic fibrosis diagnosed genetically?
Genetic diagnosis of cystic fibrosis involves DNA analysis, which can identify over 90% of patients with CFTR mutation.
164
What are some common manifestations of cystic fibrosis?
Common manifestations of cystic fibrosis include chronic pansinusitis, pancreatic exocrine insufficiency, obstructive azoospermia, and COPD.
165
What are some treatment options for cystic fibrosis?
Treatment for cystic fibrosis includes symptom control, pancreatic enzyme replacement, oxygen therapy, nutritional support, and prevention of intestinal obstruction. Additionally, gene therapy is currently being investigated.
166
How does cystic fibrosis contribute to airway obstruction?
Cystic fibrosis causes viscoelastic abnormalities in sputum, leading to retention and airway obstruction.
167
What is the main nonpharmacologic approach to enhancing clearance of secretions in cystic fibrosis?
The main nonpharmacologic approach is chest physiotherapy with postural drainage.
168
What are some alternative methods of physiotherapy for cystic fibrosis?
Alternative methods include high-frequency chest compression with an inflatable vest and airway oscillation devices.
169
When are bronchodilators considered for cystic fibrosis patients?
Bronchodilators are considered if patients have a beneficial response, defined as an increase of 10% or more in FEV1 after administration.
170
What contributes to the thick viscosity of secretions in cystic fibrosis?
The presence of neutrophils and degradation products leads to the thick viscosity of secretions.
171
How does DNA released from neutrophils contribute to the viscosity of secretions in cystic fibrosis?
DNA released from neutrophils forms long fibrils that add to the viscosity of secretions.
172
What is the role of recombinant human deoxyribonuclease in cystic fibrosis treatment?
Recombinant human deoxyribonuclease can cleave the DNA released from neutrophils, reducing viscosity and increasing sputum clearance.
173
How are antibiotics chosen for cystic fibrosis patients?
Antibiotics are given based on the identification of bacteria isolated from sputum cultures. If cultures show no pathogens, bronchoscopy may be indicated for lower airway secretion removal.
174
What are some anesthesia implications for patients with cystic fibrosis?
1. Elective surgery should be delayed until optimal pulmonary function is ensured by controlling infection and facilitating removal of airway secretions.
2. Vitamin K may be necessary if hepatic function is poor or exocrine pancreatic function is impaired. 3. Humidification of inspired gases, hydration, and avoidance of anticholinergic drugs are important steps in maintaining less-viscous secretions.
4. Frequent tracheal suctioning may be necessary.
5. Patients should regain full airway reflexes, adequate tidal volume, and respiratory rate prior to extubation. 6.Postoperative pain control is important to allow for deep breathing, coughing, and early ambulation to minimize pulmonary complications.
175
What is Primary Ciliary Dyskinesia (PCD) characterized by?
Congenital impairment of ciliary activity in respiratory tract, epithelial cells, sperm tails, and ciliated ovary ducts.
176
What are the common manifestations of Primary Ciliary Dyskinesia (PCD)?
Chronic sinusitis, recurrent respiratory infections, bronchiectasis, and infertility.
177
What is Kartagener syndrome?
Triad of chronic sinusitis, bronchiectasis, and situs inversus (chest organ position is inversed).
178
What is the association between situs inversus and Primary Ciliary Dyskinesia (PCD)?
Approximately half of patients with congenitally nonfunctioning cilia exhibit situs inversus.
179
What is the preferred approach for preoperative preparation in patients with Primary Ciliary Dyskinesia (PCD)?
Preoperative preparation involves treating pulmonary infection and determining if significant organ inversion is present.
180
What anesthesia considerations are important for patients with Primary Ciliary Dyskinesia (PCD)?
Regional anesthesia is preferable to general anesthesia to help decrease postoperative pulmonary complications.
181
How should the positioning of central venous catheterization (CVC) be adjusted in patients with dextrocardia?
In the presence of dextrocardia, the left internal jugular vein should be selected for CVC placement, as the usual right internal jugular vein may not lead straight to the superior vena cava (SVC).
182
What considerations should be made regarding uterine displacement and choice of double-lumen endotracheal tube (DLT) in pregnant women with Primary Ciliary Dyskinesia (PCD)?
Uterine displacement should be to the right in pregnant women with PCD, and if a double-lumen endotracheal tube is needed, right DLT placement may be considered, although left DLT is typically preferred.
183
What are the risk factors for Bronchiolitis Obliterans?
Risk factors include viral respiratory infections, environmental exposures, lung transplant, and stem cell transplant.
184
What are the symptoms associated with Bronchiolitis Obliterans?
Symptoms are nonspecific and include dyspnea and nonproductive cough.
185
How do pulmonary function tests (PFTs) typically appear in patients with Bronchiolitis Obliterans?
PFTs usually show obstructive disease, including a reduced FEV1 and FEV1:FVC ratio that is unresponsive to bronchodilators.
186
What imaging findings are commonly seen in severe cases of Bronchiolitis Obliterans?
High-resolution CT shows air trapping and bronchiectasis in severe cases.
187
What is included in central airway obstruction?
Central airway obstruction includes obstruction of airflow in the trachea and mainstem bronchi.
188
What percentage of lung cancer patients can be affected by airflow obstruction?
Approximately 20-30% of lung cancer patients can be affected by airflow obstruction
189
What are some causes of central airway obstruction?
Causes include tumors, granulation from chronic infection, and airway thinning from cartilage destruction.
190
How can tracheal stenosis develop after prolonged intubation?
Tracheal stenosis can develop after prolonged intubation with either an endotracheal tube (ETT) or a tracheostomy tube, leading to tracheal mucosal ischemia and subsequent destruction of cartilaginous rings.
191
When does tracheal stenosis become symptomatic?
Tracheal stenosis becomes symptomatic when the lumen is decreased to less than 5mm in diameter.
192
What are some symptoms of tracheal stenosis?
Symptoms include dyspnea, which is prominent even at rest, and audible stridor.
193
How are accessory muscles utilized in patients with tracheal stenosis?
Accessory muscles are utilized throughout all phases of the breathing cycle in patients with tracheal stenosis
194
What is characteristic of flow-volume loops in patients with tracheal stenosis?
Flow-volume loops typically display flattened inspiratory and expiratory curves, which is characteristic of a fixed airway obstruction.
195
What is the most successful treatment for tracheal stenosis?
The most successful treatment is surgical resection and reconstruction with primary re-anastomosis.
196
How can tracheal dilation be performed as a temporizing measure for tracheal stenosis?
Tracheal dilation can be done bronchoscopically using balloon dilators, surgical dilators, or laser resection of the tissue at the stenotic site.
197
What anesthesia technique is necessary for surgical resection and reconstruction of tracheal stenosis?
For this procedure, translaryngeal intubation is necessary.
198
How can anesthesia be maintained during tracheal resection?
Maintenance of anesthesia with volatile anesthetics is useful for ensuring maximal FiO2.
199
What should be the focus of anesthesia management for a patient with a recent upper respiratory infection (URI)?
Anesthesia management should focus on reducing secretions and limiting manipulation of a potentially hyperresponsive airway.
200
How is asthma treatment classified?
Asthma treatment is classified into immediate and long-term therapy. Immediate therapy for bronchospasm consists mainly of short-acting β-agonists, whereas long-term relief may include inhaled corticosteroids, long-acting bronchodilators, leukotriene inhibitors, monoclonal antibodies, and bronchial thermoplasty.
201
What is the goal during induction and maintenance of anesthesia in asthmatic patients?
The goal during induction and maintenance in asthmatic patients is to depress airway reflexes and avoid bronchoconstriction.
202
What are the two interventions in COPD that may slow progression?
Smoking cessation and long-term oxygen therapy are the only two interventions that may slow progression in COPD.
203
Why is regional anesthesia preferred over general anesthesia in patients with COPD?
Regional anesthesia is preferred over general anesthesia in patients with COPD to decrease the incidence of bronchospasm, barotrauma, and the need for positive pressure ventilation.
204
How should COPD patients be ventilated during general anesthesia?
COPD patients receiving general anesthesia should be ventilated at slow respiratory rates to allow sufficient time for exhalation, minimizing the risk of air trapping and auto-PEEP.
205
What is the goal of prophylaxis against postoperative pulmonary complications in COPD patients?
The goal of prophylaxis against postoperative pulmonary complications in COPD patients is to restore lung volumes, especially FRC, and facilitate effective coughing.
206
How should intraoperative bronchospasm due to obstructive lung disease be treated?
Intraoperative bronchospasm due to obstructive lung disease should be treated by deepening the anesthesia, administering bronchodilators, and suctioning secretions as needed.
