Thoracic/Respiratory/Monitoring Test 5 Flashcards
factors that increase PPC
- preop FEV1 < 2L or < 40% of predicted (greatest risk )
- inability to climb flight of stairs
- desaturation > 4% with exercise
cushings s/s listed on PP
metabolic alkalosis
hypokalemia
hyperglycemia
10 - 25% of tumors secrete this hormone what are Sx
PTH * inc Calcium*
confusion, vomiting, bradycardia, polyuria, abd cramps, neuro changes
COPD findings on Xray
hyperinflation Inc A-P diameter
diaphragm flattening
prominent PA (PHTN)
wide right side border (PHTN)
ECG signs of RV hypertrophy secondary to pulmonary HTN
V1 - tall R wave
Lead I RAD
biphasic P wave (RVH causes R atrial hypertrophy)
ECHO changes in RVH
RV wall thickness
chamber enlargement
septal shift
tricuspid regurgitation
increased PVR
albumin level at risk for PPC
< 3.6 G/dL
this (cardiac function/measurements related) is associated with prolonged mechanical ventilation and greater lung injuries
high filling pressure
(heart)
PAC indication
high severity in any of these
CV
valvular disease
PHTN
consequences if you dont support head while patient is in lateral position
lateral flexion of neck
leads to
compression of jugular veins and vertebral arteries
compromises cerebral circulation
pleural pressure increases by ___ cm H2O per ___ cm of lung dependency
pleural pressure increases by 0.25 cm H2O per 1 cm of lung dependency
this determines flow of blood in Zone 2
arterial - Alveolar pressure gradient
(this increases the further down the lung you go)
pressure gradient that determines blood flow in Zone 3
arterio-venous
(maintains constant blood flow in dependent portions of lungs)
in open chest, why does mediastinum fall
loss of negative intrapleural pressure (ITP) in NDL
diminishes effects of mediastinal shift
diminishes paradoxical respirations
(open chest anesthetized lateral)
PPV
absolute indications for OLA
one lung has to be isolated from the other
- to prevent contamination of healthy lung
- to control distribution of ventilation
- unilateral lung lavage
examples of absolute indications for OLA
deal with preventing contamination
to prevent
absess
hemorrhage
examples of absolute indications for OLA
dealing with controlling distribution of ventilation
to prevent
- bronchopleural fistula
- giant unilateral cyst of bullae (rupture w/ PPV!)
- bronchial disruption or trauma
relative indications for OLA
(generally speaking)
when surgical exposure is improved by deflating lung
relative indications for OLA
give examples of high priority cases
Pneumonectomy
Upper Lobectomy
Repair of Thoracic Aneurysm
Mediastinal exposure
Thoracoscopy
relative indications for OLA
give examples of low priority cases
- middle and lower lobectomy
- esophageal surgery
- T-spine procedures
One-lung ventilation can be accomplished with with use of what?
One-lung ventilation can be accomplished with:
single lumen ETT
double lumen endobronchial tube
use of bronchial blockers
disadvantage of single lumen tubes
inability to ventilate the operative lung if necessary
in right lung placement, upper lobe most usually occludes
left bronchial tubes CI in what conditions?
bronchial lesions
descending thoracic aortic aneurysm
most common complication of DLT
malposition
DLT
Resistance on insertion met for M vs F
F 27
M 29
when would you use bronchial blocker devices
cases w/
difficult AW
tracheostomy
already intubated (dangerous to do tube exchange for DLT)
small children
HPV causes what PVR changes
INC up to 300%
Factors reducing the effectiveness of HPV:
Factors reducing the effectiveness of HPV:
- Alkalosis (hypocapnia)
- Hemodilution and hypervolemia
- Hypothermia
- Excessive TV and PEEP
- Volatiles (>1.5 MAC)
- Vasodilators, PDEI, CCBs
specific drugs that reduce effectiveness of HPV:
specific drugs that reduce effectiveness of HPV:
- nitroglycerin
- dobutamine
- nicardipine
- verapamil
- dopamine
- phenylephrine
- epi
thoracotomy is one of the most painful operations that can lead to 3 things:
decreased respiratory effort
hypoxemia
acidosis
thoracic epidulars for thoracotomy put at what level?
infused with what?
T6 - T8
infused with opioids
dilute locals
benefit of regional in thoracic sx
reduce atelectasis
reduce pneumonia
reduce resp failure
primary goals of OLV
maintain oxygenation
protect individual lung
provide favorable surgical field
this maneuver can reduce cytokine response to support HPV
permissive hypercapnea
keep CO2 < 60 to reduce incidence of 3 things
dysrhythmias
hypotension
pulm HTN
incidence of hypoxemia with OLV
more common in which lung?
5 - 10%
right lung procedures especially
(more baseline perfusion and larger)
diagnosis and treatment for mediastinal mass is made by:
thoracotomy
thoracoscopy
mediastinoscopy
tumors located where (anatomically) in the mediastinum can compress the trachea and inc air resistance, making GA dangerous
tumors in Anterior mediastinum
Sx of SVC syndrome
dilation of collateral veins in upper body
rubor and edema in upper body
edema around eyes
head ache
visual disturbance
altered mentation
also: low CO, low cerebral perfusion
Complications in Mediastinoscopy:
- hemorrhage
- pneumothorax
- dysrhythmias
- bronchospasm
- nerve damage
- tracheal or esophageal laceration
- chylothorax
Mediastinoscopoy
Scope passes near which structures?
Scope passes near the
- left common carotid
- left subclavian,
- innominate artery and veins
- vagus nerve
- left recurrent laryngeal nerve
- thoracic duct
- superior vena cava
- aortic arch
ETCO2: measuring CO
ETCO2: measuring CO
capnometry
ETCO2: recording of the measurement
ETCO2: recording of the measurement
capnography
ETCO2: Visual display of continuous CO2 monitoring
ETCO2: Visual display of continuous CO2 monitoring
Capnogram
- ____ _____ of gas mixtures determines the amount of CO2 relative to other gases
- what law is this
- Infrared analysis of gas mixtures determines the amount of CO2 relative to other gases
- Beer-Lambert Law
- ETCO2 Disadvantages
- need for scavenging of sampled gas and risk of contamination from secretions or condensation
EtCO2
- Can be inaccurate during certain situations such as: (2) reasons
- Can be inaccurate during certain situations such as:
- large increases in deadspace (low CO2 concentration)
- small tidal volumes (low CO2 readings reflecting inadequate alveolar ventilation)
- Oxyhemoglobin absorbs more infrared light at a wavelength of __ nm
- Deoxyhemoglobin absorbs more red light at a wavelength of __ nm
- Oxyhemoglobin absorbs more infrared light at a wavelength of 940 nm
- Deoxyhemoglobin absorbs more red light at a wavelength of 660 nm
- The ___ the ratio of red/infrared absorption, the ___ the oxygen saturation
- The greater the ratio of red/infrared absorption, the lower the oxygen saturation
- inverse relationship
- These dyes result in a significant but transient drop in measured oxygen saturation because the dye alters absorption of infrared light
Injectable dyes
- methylene blue
- indigo carmine
-
transient change in O2 sat
- typically, last 15 – 30 seconds
- Factors that alter O2 binding
- H+ concentration (acid base)
- CO2 tension
- Temperature
- 2,3-diphosphoglycerate
- Abnormal hemoglobin
Pulmonary Risk Factors
- Albumin level <3.5 g/dL
- Advanced age
- ASA class > 2
- Alcohol use
- Abnormal chest exams
- CHF
- Cigarette use
- COPD
- Emergency sxUpper abdominal and thoracic sx
- GA
- Head and neck sx
- Impaired cognition
- Neuro sx
- Prolonged procedures
- Vascular sx
elimination t 1/2 of CO
4 - 6 hrs
- Mucociliary and pulmonary immune function improves significantly __ to __ weeks after smoking cessation
- Mucociliary and pulmonary immune function improves significantly 6-8 weeks after smoking cessation
- Airway management may be made more difficult if cessation occurs prior to this amount of time (4- 8 weeks) because why?
- Airway management may be made more difficult if cessation occurs prior to this amount of time (4- 8 weeks) because there is an increase in pulmonary secretions during the first month of smoking cessation
- Patients that continue to smoke have a ____the risk postop complications and ___the risk of pneumonia; for patients that have smoked 60 pack years or more.
- Patients that continue to smoke have a Double the risk postop complications and 3X the risk of pneumonia; for patients that have smoked 60 pack years or more.
- Pack years: formula
- 30 years @ 2 PPD
- 30 years @ 5 cig per week
- Pack years: # of years smoked x number of packs per day
- 30 years @ 2 PPD
- PPD=60 pack years
you guys correct me if im wrong
- PPD = 30 x 5/20
- 5 cigs per 5 days would be 1 cig per day
- so
- 5 cig per 7 days would be 5/7 = 0.71 cig per day
- convert from cigs to packs
- 0.71 / 20 = 0.035 Packs per day
- 0.035 x 30 years = 1.065 pack years
-
95% of all acute URI are result of some infectious cause like ____ or ____ ______
- diagnosis is made from ___ ___
-
95% of all acute URI are result of some infectious cause like viral or bacterial nasopharyngitis
- diagnosis is made from clinical s/s
- Airway hyper-reactivity may require__ weeks to improve
Airway hyper-reactivity may require >6 weeks to improve
Intraoperative management of acute URI should include:
- Intraoperative management should include:
- adequate hydration
- reduction in secretions w/ suction
- limiting manipulation of the airway
- LMA may be good choice as alternative to ETT b/c reduces manipulation of airway and reduces risk of bronchospasm
- Reported adverse events in an acute URI case include:
- Reported adverse events include:
- laryngospasm
- airway obstruction
- bronchospasm
- desaturation
- atelectasis
- post-intubation croup
OHS triad of Sx
- obesity
- daytime hypoventilation with hypercapnia
- sleep-disordered breathing without an alternative cause
- (OHS and OSA) chronic ____ and ______ lead to an inflammatory state and secondary disorders such as (4):
- (OHS and OSA) chronic hypoxemia and hypercarbia lead to an inflammatory state and secondary disorders such as:
- hypertension
- stroke
- diabetes
- atherosclerosis
- Hallmark of OSA is ___ ____ and ___ ____, which can lead to daytime somnolence
- Hallmark of OSA is habitual snoring and fragmented sleep, which can lead to daytime somnolence
- ___% of OSA have OHS
- 5% of OSA have OHS
-
Obstruction incidence w/ OSA:
- __% of pediatric patients with OSA after tonsillectomy
- __% in those without OSA after tonsillectomy
-
Obstruction incidence w/ OSA:
- 25% of pediatric patients with OSA after tonsillectomy
- 1% in those without OSA after tonsillectomy
obstructive disorders (examples)
difficulty taking air out
low airflows
COPD
asthma
bronchiectasis
restrictive dz examples
stiffness inside lung tissue or chest wall cavity
difficulty taking air in
low lung volumes
interstitial lung disease
scoliosis
neuromuscular cause
Marked obesity
- Asthma Characterized by (3):
- Characterized by:
- chronic airway inflammation
- reversible airflow obstruction
- bronchial hyper-reactivity
Asthma
- __ to __ % of population
Asthma
- 5-7% of population
- single greatest risk factor for development of asthma
- genetic tendency to develop allergic diseases
- Atopy
- Asthma Results from ___ and ___ factors.
- Results from genetic and environmental factors (Viruses, allergies, occupational exposure etc)
Asthma may manifest as (5):
Asthma may manifest as
- dyspnea
- eosinophilia
- cough
- tachypnea
- hyperventilation
- (in asthma) these can flare up an attack:
can flare up an attack
- Beta antagonists
- NSAIDs
- exercise
- respiratory infection
- emotional stressors
- Mild asthma is usual accompanied by what changes to PaO2 and PaCO2
- Mild asthma is usual accompanied by a normal PaO2 and PaCO2
-
Severe asthma
- PaO2 and PaCO2 changes
- Severe asthma
- PaO2 <60 (hypoxia), PaCO2 >50
- (asthma) Chest radiographs may show:
(asthma) Chest radiographs may show hyperinflation of the lungs
___ and ___ are direct spirometry readings that can be used to measure severity of expiratory airflow obstruction (asmtha main issue)
- FEV1 and MMEF (maximum mid expiratory flow rate) are direct spirometry readings that can be used to measure severity of expiratory airflow obstruction (asmtha main issue)
- Typical asthmatic patient presenting for treatment will have what FEV1 and MMEF changes
- Characteristic flow volume loop shown
- Typical asthmatic patient presenting for treatment will have
- FEV1 <35% of normal
- MMEF 20% or less of normal
- Characteristic flow volume loop shown with “downward scooping”
Treatments fall into 2 categories (asthma)
controller
rescue
Asthma Controller treatments:
- Asthma Controller treatments:
-
Control of the disease with
- corticosteroids
- antileukotrienes
- theophylline
- Modify airway environment so acute narrowing will occur less frequently
-
Control of the disease with
- Rescue treatments:
- Rescue treatments:
- Relief or rescue of symptoms with
- beta2 agonists
- Albuterol
- Abluterol + anticholinergics
- Relief or rescue of symptoms with
The goal of preoperative evaluation (asthma)
- The goal of preoperative evaluation
- formulate an anesthetic plan that prevents or blunts expiratory airflow obstruction
- Prevent bronchoconstriction dt airway stimulation
- maximize lung fx (continue any therapy)
who may benefit from preop steroid supplementation
goal of this is to prevent what suppression
- Pay attention to doses however or high frequency.
- If taking oral steroids such as prednisone then they probably will need preop steroid administration.
- prevents hypothalamic pituitary adrenal axis suppression
- Asthma Increased perioperative risk related to recent hospitalizations
-
Increased perioperative risk
- more than 2 hospitalizations in 12 months
- Incidence of clinically significant bronchospasm reported at __ to __% of all procedures performed in asthma patients
- Incidence of clinically significant bronchospasm reported at 0.2-4.2% of all procedures performed in asthma patients
- Bronchospasm Signs include
- Bronchospasm Signs include
- wheezing
- increased peak pressure
- decreasing exhaled TV
- slowly rising ETCO2 waveform
non asthma bronchospam causes
- mechanical obstruction in circuit
- pulm aspiration
- edema
- PE
- pneumothorax
aminophylline and theophylline MOA
(PDEi)
inhibit cAMP breakdown
lots of cAMP = Bronchodilation
drugs and doses of steroid tx for status asmaticus
- Cortisol 2mg/kg followed by 0.5 mg/kg/hr infusion
- Methylprednisolone 60-125 mg IV Q6 hours
can improve lung function and reduce hospitalization rate for status asthmaticus
(drugs for status other than steroids)
- Some studies show that IV Mag sulfate can improve lung function and reduce hospitalization rate for status asthmaticus
- How does Prolonging expiratory phase help in bronchospasm
- Prolong expiratory phase
- allows complete exhalation to overcome the spasm
- prevents auto-peep (initiation inspiration prior to full expiration)
- Most common pulmonary d/o encountered in anesthesia
COPD
COPD
- Mainly caused by ___and more common in ___ patients
- Mainly caused by smoking and more common in male patients
5 COPD consequences:
- 5 COPD consequences:
-
Deterioration of elasticity and loss of recoil within lung parenchyma
- Normally parenchyma helps to maintain airway in the open position; in COPD, now more likely to collapse
- Decreased rigidity of the bronchiolar wall predisposing them to collapse during exhalation
- Increased gas velocity in narrowed bronchioli favoring collapse
- Due to lowered pressures inside alveoli
- Bronchospasm and obstruction from increased secretions
- Enlargement of air sacs and destruction of parenchyma
-
Deterioration of elasticity and loss of recoil within lung parenchyma
COPD Risk factors
COPD Risk factors
- Smoking
- frequent
- respiratory infections
- occupational exposure to dust ( mining and textiles)
- genetic factors (alpha-1 antitrypsin deficiency)
-
___ _____
- A substance that protects the elastic tissue of the lungs from neutrophil elastase. The defective form accumulates in the___resulting in ____ and the lack of the normal form in the lungs results in pulmonary disease like___ and ____
- The deficiency is a rare ______condition
-
Alpha-1 antitrypsin
- A substance that protects the elastic tissue of the lungs from neutrophil elastase. The defective form accumulates in the liver resulting in cirrhosis and the lack of the normal form in the lungs results in pulmonary disease like asthma and emphysema
- The deficiency is a rare homozygous condition
chronic bronchitis
- mechanism of obstruction:
- dyspnea (mild, mod, severe)
- FEV1
- PaO2
- PaCO2
- Diffusion capacity
- Hct
- Cor pulmonale
- prognosis (good, poor)
chronic bronchitis
- mechanism of obstruction: dec AW lumen dt mucus/inflammation
- dyspnea (mild, mod, severe) moderate
- FEV1 decreased
- PaO2 marked decrease
- PaCO2 increased
- Diffusion capacity normal
- Hct INCREASED
- Cor pulmonale makred
- prognosis (good, poor) Poor
emphysem’er
- mechanism of obstruction: loss of elastic recoil
- dyspnea (mild, mod, severe) severe
- FEV1 decreased
- PaO2 modest decrease
- PaCO2 normal to decreased
- Diffusion capacity decreased
- Hct normal
- Cor pulmonale mild
- prognosis (good, poor) good
emphysem’er
- mechanism of obstruction:
- dyspnea (mild, mod, severe)
- FEV1
- PaO2
- PaCO2
- Diffusion capacity
- Hct
- Cor pulmonale
- prognosis (good, poor)
characteristic of COPD (3)
- characteristic of COPD
- Chronic productive cough
- progressive exercise limitation
- expiratory airflow obstruction
- COPD: As the expiratory airflow increases in severity in these patients, you will starts to see some common symptoms such as: (4)
- As the expiratory airflow increases in severity in these patients, you will starts to see some common symptoms such as:
- Tachypnea
- Prolonged expiratory phases
- Decreased breath sounds
- Expiratory wheezes
- Main mechanism of airway obstruction
- Chronic bronchitis → main cause
- Emphysema → main cause
- Main mechanism of airway obstruction
- Chronic bronchitis → is a decrease in diameter of airway lumen due to mucus and inflammation
- Emphysema → loss of elastic recoil
COPD
- 2 most important therapies
- help alter the natural progression of COPD
- Smoking cessation
- long-term oxygen supplementation
-
COPD: Long term 02 supplementation recommended for:
- Pa02 <55
- Hct > 55%
- Evidence of Cor Pulmonale.
- Pa02 <55
- Hct > 55%
- Evidence of Cor Pulmonale.
-
________ are the predominant drug therapy in COPD
- Decrease the hyperinflation and decrease dyspnea
- Can improve exercise tolerance
-
Bronchodilators are the predominant drug therapy
- Decrease the hyperinflation and decrease dyspnea
- Can improve exercise tolerance
- indication for diuretics in COPD
- used if any evidence of
- cor pulmonale
- RVF resulting in peripheral edema
- Median sternotomy or VATS for overdistended emphysema cases
- Improvements after procedure:
-
increase in elastic recoil
- increases expiratory airflow
-
decreased hyperinflation
- improved diaphragmatic and chest wall mechanics
-
improvement of V/Q matching
- improve alveolar gas exchange
- People with COPD that present to the operating room with any type of procedure assess these to predict risk/pulm complications:(4)
- People with COPD that present to the operating room with any type of procedure assess to predict risk/pulm complications:
- Exercise tolerance
- Chronic coughing
- Unexplained Dyspnea
- Wheezing
COPD: Regional anesthesia is suitable for ____ _____ and ____ ____ procedures as long as large doses of sedatives are not needed
Regional anesthesia is suitable for lower intra-abdominal and lower extremity procedures as long as large doses of sedatives are not needed
- ______ is the choice if upper abdominal or thoracic procedures are to be performed.
- General is the choice if upper abdominal or thoracic procedures are to be performed (COPD).
- Do not want a sensory level above _____, can impair muscle that add in adequate exhalation. This is the problem with COPD, long expiratory phase and air trapping.
- Do not want a sensory level above T-6, can impair muscle that add in adequate exhalation. This is the problem with COPD, long expiratory phase and air trapping.
Postop therapy for COPD:
- lung expansion maneuvers
- positive pressure
- chest physiotherapy
- Extremely useful for upper abdominal and inter-thoracic surgeries
- recommended for high risk thoracic, abdominal or major vascular surgeries.
NA opioids
cuation w/ sedation from rostral spread with duramorph
- Continued Mechanical Ventilation in Severe COPD post op for what procedures and preop FEV1/FVC ratio/PaCO2
- esp. major abdominal or thoracic procedures
- preoperative FEV1/FVC ratios of less than 0.5
- preoperative PaCO2 of more than 50 mmHG
risks associated with lowering I:E ratio
- can lower TV and MV
- –> exacerbate hypercapia, hypoxia and acidosis
- ↑ PVR — more strain on the RV.
- Another cause of expiratory air obstruction
- Similar to expiratory airflow obstruction seen in COPD.
- Chronic disease of the airways characterized by localized, irreversible dilation of a bronchus caused by destructive inflammatory processes involving the bronchial wall
Bronchiectasis
Bronchiectasis accounts for a significant number of cases of ____ _____ which may require surgical resection of the involved lung segment or arterial embolization
- Massive hemoptysis
- Bronchiectasis: Massive hemoptysis: how many mL/ 24 hours
- > 200 ml in a 24 hr period.
- Cystic fibrosis: Autosomal ______ disorder caused by a mutation on chromosome __
- resulting in defective _____ ion transport in the _____ cells of the___, ___, ___ , ___, and ___ (organs)
-
Autosomal recessive disorder caused by a mutation on chromosome 7
- resulting in defective chloride ion transport in the epithelium cells of the lungs, pancreas, liver, GI tract and reproductive organs.
CF: clinical manifestations (3)
- cough
- chronic purulent sputum
- exertion dyspnea
- _____ is present in almost all adults with CF
- COPD is present in almost all adults with CF
- CF: ways to maintain secretions in a less viscous state
- Humidification of inspired gases
- adequate hydration
- avoidance of anticholinergics
- frequent suctioning
- helps to ↓ complications post op and intra op
Triad of Ciliary Dyskinesia we talked abou wth Ciliary Dyskinesia
Kartagener’s syndrome
Kartagener’s syndrome triad
- chronic sinusitis
- bronchiectasis
- situs inversus
how many patients with congenitally nonfunctioning cilia manifest situs inversus?
1/2
(198 co-exisiting)
childhood disease most often the result of respiratory syncytial virus (RSV) and rare caues of COPD
- Bronchiolitis obliterans
- Tracheal stenosis - most often the result of ____ ____ ____
- most common due to prolonged ET tracheal intubation
- minimized with ____________ Cuffs
tracheal mucosal ischemia
minimized with High Volume-Low pressure Cuffs
- Tracheal stensis: Symptomatic in adults with trachea ___in diameter
Symptomatic in adults with trachea < 5 mm in diameter
Tracheal Stenosis: Flow-Volume loops will have what characteristics?
- Flow-Volume loops will be flattened (inspiratory and expiratory phases)
Treatment for Tracheal Stenosis
- Surgical resection of the stenotic segment and re-anastomosis is often required
Pulmonary Edema (causes)
- acute intrinsic restrictive lung disease
- aspiration
- opioid overdose
- re-expansion of collapsed lung
- CHF
- negative pressure, etc.
- Cardiogenic pulmonary edema is characterized by: (3)
- extreme dyspnea
- tachypnea
- signs of SNS activation
- Aspiration Pneumonia is best treated by
supplemental oxygen and PEEP
- Aspiration pneumonitis occurring during anesthesia in which the greatest risk is associated with __ ml or more of __ pH
- Mendelson’s Syndrome
- Aspiration pneumonitis occurring during anesthesia in which the greatest risk is associated with 25 ml or more (0.4 ml/kg) of < 2.5 pH
pathophys of pulm edema
High negative intrapleural pressure:
- decreases the interstitial hydrostatic pressure
- increases venous return
- increases left ventricular afterload
- increases the transcapillary pressure gradient
- produces edema
- Pulm Edema: May occur after relief of acute upper airway obstruction due to:
- Laryngospasm
- Tumors
- Epiglottitis
- hiccups
- OSA in spontaneously breathing patients
Vent management: Pulm Edema
- Low TV (6 ml/kg) with a compensatory increase in rate (14-18) is usually appropriate
Patients with restrictive lung disease typically have this breathing pattern
Patients with restrictive lung disease typically breath rapid and shallow
- Chronic intrinsic restrictive lung disease
- General basis- Inflammatory disease with the presence of abnormal cells called granulomas.
Sarcoidosis
Sarcoidosis involves many tissues with predilection for these:
- intrathoracic lymph nodes
- lungs
most common form of neurologic involvement in sarcoidosis is what? (trivia from co-existing)
unilateral facial nerve palsy
classic manifestation (sarcoidosis)
hypercalcemia
<10 % of patients
(soliosis/kyphosis) respiratory failure failure most likely in patients with _____ associated with a vital capacity of less than __ % of predicted value and scoliotic angle of more than __ degrees
(stoelting)
(soliosis/kyphosis) respiratory failure failure most likely in patients with kyphoscoliosis associated with a vital capacity of less than 45 % of predicted value and scoliotic angle of more than 110 degrees
(stoelting)
- scoliotic angle is greater than 100 degrees may cause these
- Chronic Alveolar hypoventilation
- Hypoxemia
- secondary erythrocytosis
- PHTN
- Cor pulmonale
- Increased risk of PNA and hypoventilation post op especially when exposed to CNS depressants
- Flail chest. Results from multiple rib fractures most often, especially from __ or ___ orientation
Flail chest. Results from multiple rib fractures most often, especially from parallel or vertical orientation
imaging confirmation of pleural effusion
- Most confirmed by chest x-ray of 25-50 ml seen
- Can be diagnosed with ultrasound or CT scan as well
- Cigarette smoking increases the risk of primary spontaneous pneumothorax by ___-fold
- Mediastinal Mass: A large tumor that can be associated with:
- progressive airway obstruction
- loss of lung volumes
- pulmonary artery or cardiac compression
- SVC obstruction
- Usually will develop after a Valsalva maneuver or after some kind of increase in intrathoracic pressure like from major coughing or emesis
pneumomediastinum
- Fluid or air-filled cysts in the mediastinum or the lung parenchyma
Bronchogenic cysts
- Gas enters pleural space during inspiration and is prevented from exiting during expiration
- Evacuation of gas can be life saving
Tension Pneumothorax
most common sign Sx of pneumothorax
- tachycardia (most common physical finding)
- Dyspnea
- ipsilateral chest pain
- cough
- arterial hypoxemia
- hypotension
- hypercarbia
managing severe aw obstruction (tracheobronchial compression)
may alleviate by lateral or prone position
maintain spontaneous ventilations!
avoid general
LA best option
sitting position may help minimize obstruction by tracheal compression
in restrictive dz avoid sensory block above ___ to maintain adequate ventilation (associated with impairment of respiratory muscle activity)
Stoelting p204
avoid regional > T 10
(restrictive dz)
- Is characterized by the inability to maintain adequate arterial oxygenation and/or adequate elimination of CO2
- PaO2 < 60 mmHg despite oxygen supplementation in the absence of a right to left intracardiac shunt
and/or
- PaCO2 > 50 mmHg in the absence of respiratory compensation for metabolic alkalosis
Acute respiratory failure
- Chronic respiratory failure, the pH is normally maintained in normal value range 7.35-7.45 due to compensation by:(3)
- renal tubular reabsorption of bicarbonate
- ammonia production
- H+ ion excretion
if respiratory failure persists what are some cardiac consequences
RV strain from:
- inc PVR
- P HTN
several different things that can result in ARDS
- PNA
- fat emboli
- pulmonary contusions
- drug overdose
- trauma associated with shock
- pancreatitis
- Associated with the highest risk of progression of acute lung injury to ARDS
sepsis
- Patients that die from ARDS typically do so as a result of sepsis or multiple organ failure rather than the actual respiratory failure itself.
- First sign of ARDS
- Arterial hypoxemia resistant to treatment with supplemental O2
- other signs: PHTN can occur due to pulmonary artery vasoconstriction
PaO2/FiO2 ratio in ARDS
and ALI
ARDS < 200 mmHg*
ALL(less severe ARDS) is < 300 mmHg*
Normal ratio (500 - 600)
* with diffuse infiltrates, normal PCWP, appropriate mechanisms
- The three principle goalsof treatment (ARDS)
- Correcting hypoxemia
- removing excess CO2
- securing a patent airway
- (other) O2 supplementation, tracheal intubation, mechanical ventilation, application of PEEP, inotropic support, nutritional support, beta agonists
- ____ is one of the most beneficial treatments for ARDS
- PEEP is one of the most beneficial treatments for ARDS
- PEEP doesn’t decrease the amount of fluid in the lungs it redistributes the edematous fluid to different interstitial lung regions which causes the previously flooded alveoli to be better ventilated
Dx: Dependent on presence of:
- acute refractory hypoxemia
- diffuse infiltrates on chest x-ray that signify PE
- PCWP < 18
- Not a reliable guide for monitoring intravascular fluid volume in a patient with ARDS (use urine output instead)
CVP
Sx may suggest tension pneumo
- hypotension
- worsening hypoxemia
- increased airway pressure
Barotrauma may present as:
- subcutaneous emphysema
- pneumomediastinum
- pulmonary interstitial emphysema
- pneumoperitoneum
- gas embolism
- tension pneumothorax
- The most consistent symptom of acute PE
dyspnea
- PE: Suggest pulmonary infarction from embolism near the pleural surface
- Pleuritic chest pain
- cough
- hemoptysis
EKG changes with PE
- RBBB
- Afib
- Peaked p waves
why would/could cardiac enymes be elevated with PE
RV strain
most common cause of PE
DVT from venous stasis
venous stasis dt
- immobility
- GA
- CHF
- Obestiy
- Varicose veins
- Under anesthesia PE may present as:
- unexplained arterial hypoxemia
- hypotension
- tachycardia
- bronchospasm
treatment for PE and cornerstone tx
- anticoagulation
- thrombolytic therapy
- IVC filter
- surgical embolectomy
-
Heparin is cornerstone treatment
- Initial dose of 5,000-10,000 units IV followed by infusion
Induction (PE management)
Avoid
- hypoxemia
- hypotension
- PHTN
Fat emoblism:
- Obstruction of blood vessels and release of __ __ __ cause acute diffuse ___especially in ____ and ___ vasculature
Fat emoblism:
- Obstruction of blood vessels and release of free fatty acids cause acute diffuse vasculitis especially in pulmonary and cerebral vasculature
- Syndrome with fat embolism is typically seen around __ to __ hours
- Usually after a __ __ fracture
- Especially fractures of the ___and the ___
- Source is most likely what?
- Syndrome with fat embolism is typically seen around 12 to 72 hours
- Usually after a long bone fracture
- Especially fractures of the femur and the tibia
- Source is most likely disruption of adipose tissue in bone marrow
other causes of fat embolism
- acute pancreatitis
- cardiopulmonary bypass
- parenteral infusion of lipids
- liposuction
Fat embolism triad:
- hypoxemia
- mental confusion
- petechia
association with arterial hypoxemia (fat embolism)
always present
- Oxygen is carried in the blood in two forms
- give formulas as well
- Bound to Hgb (Hgb x 1.34 x SaO2)
- dissolved in the blood (PaO2 x 0.003)
- Hemoglobin carries___ml of O2 per __g of hemoglobin at 100% saturation
Hemoglobin carries 1.34 ml of O2 per 1g of hemoglobin at 100% saturation
- To calculate the amount of CO2 dissolved in the blood:
- multiple the PaCO2 by 0.067
- answer in mL/dL
