UNIT 1 Respiratory Flashcards

1
Q

Which muscles tense & relax the vocal cords? Which muscles abduct & adduct the vocal cords?

STARE AT THIS PHOTO AND KNOW HOW TO LABEL EVERYTHING

A

Tense & Relax:

  • cricothyroid “cords tense”
  • thyroarytenoid “they relax” & vocalis

Abduct & Adduct:

  • thyroarytenoid & lateral cricoarytenoid: adduct
  • posterior cricoarytenoid: abduct
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2
Q

Which muscles abduct & adduct the vocal cords?

A

Abduct: posterior cricoarytenoid: “please come apart”

Adduct: lateral cricoarytenoid: “let’s close the airway”

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3
Q

Name 3 nerves involved in sensory innervation of the upper airway:

REVIEW THIS IN DEPTH! Write it out to make it stick!!!

A

1) Trigeminal (CN V)
V1 (opthalmic): nares & anterior 1/3 of septum
V2 (maxillary): turbinates & septum
V3 (mandibular): anterior 2/3 of tongue

2) Glossopharyngeal (CN IX)
posterior 1/3 of tongue, soft palate, oropharynx, vallecula, anterior of epiglottis- review all of these

3) VAGUS innervates both of these:
- SLN
internal branch: posterior side of epiglottis –> level of vocal cords
external branch: no sensory
- RLN
below vocal cords –> trachea

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4
Q

How does RLN injury affect integrity of the airway?
Where does the right RLN and left RLN loop under?
Which side is more susceptible to injury?

A

Bilateral:
acute = respiratory distress
chronic = no respiratory distress

Unilateral:
no respiratory distress

RLN innervated by Vagus nerves, the right RLN loops under subclavian artery, and the left RLN loops under the aortic arch. The left RLN is more susceptible to injury

Left side RLN injuries from: PDA ligation, left atrial enlargement (mitral stenosis), aortic arch aneurysm, thoracic tumor

Either side (right or left RLN) injury: pressure from ETT/LMA, thyroid surgery, neck stretching, neck tumor

Stare at this picture and be able to label everything

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5
Q

How does SLN injury affect the integrity of the airway?

A

Bilateral:
hoarseness but no respiratory distress

Unilateral:
no respiratory distress

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6
Q

Name 3 airway blocks, and ID the key landmarks for each one.

A
  1. glosspharyngeal block: palatoglossal arch @ the anterior tonsillar pillar.
  2. SLN block: greater cornu of hyoid
  3. Transtracheal block: Cricothyroid membrane, ask pt to take a deep breath and inject 3-5ml of local into tracheal lumen
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7
Q

Where does the adult larynx extend from?

What are the 3 paired & 3 unpaired cartilages of the larynx?

A

Adult larynx extends from C3-C6 ( serves as airway protection, respiration, phonation)
unpaired: epiglottis, thyroid, cricoid
paired: corniculate, cuniform, arytenoid

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8
Q

What is the treatment for laryngospasm?

A
100% FiO2
remove noxious stimuluation
deepen anesthesia
CPAP 15-20cmH2O
open airway w/ head extension, chin lift
Larson's maneuver
succinylcholine I.M. Dose is 4mg/kg for child or adult. For neonates or infants it’s 5mg/kg 
Children < 5 years, give 0.02mg/kg of atropine to avoid bradycardia when giving Sux 

how to reduce risk:
- CPAP 5-10 cm/H2O after extubation
- lidocaine

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9
Q

Describe how the respiratory muscles function during the breathing cycle.

KNOW THIS WELL!

A

Inspiration:
- diaphragm & external intercostals (tidal breathing)
- accessory: sternocleidomastoid & scalene muscles

Expiration:
usually passive, (TIREO!)
- transverse abdominis
- internal rectus abdominis
- external obliques, secondary role: internal intercostals

A vital capacity of at least 15mL/kg

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10
Q

What is the difference between minute ventilation & alveolar ventilation?

A

MV = Vt x RR

AV: only measures the fraction of Ve that is available for gas exchanges

AV = (Vt- dead space) x RR

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11
Q

Define the 4 types of dead space.

A
  1. Anatomic (air confined to the conducting airways)
  2. Alveolar (alveoli that are ventilated but not perfused)
  3. Physiologic (Anatomic + Alveolar Vd)
  4. Apparatus (Vd added by airway equipment)
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12
Q

Provide an example for each type of dead space.

A
  1. Apparatus = face mask/HME
  2. Anatomic = nose/mouth/ trachea/ terminal bronchioles
  3. Alveolar = Zone 1 alveoli
  4. Physiologic = anatomic and alveoli
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13
Q

What does the alveolar compliance curve tell you?

A

alveolar ventilation is a function of alveolar size & it’s position on the alveolar compliance curve.

  • best ventilated alveolar are the most compliant (steep slope of curve)
  • worst ventilated alveoli are the least compliant (flat portion of the curve)
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14
Q

What does the V/Q ratio represent?

A

V/Q is the ratio of ventilation to perfusion

  • normal MV = 4L/min
  • normal CO = 5L/min
  • -> normal V/Q = 0.8

dead space V/Q –> infinity
shunt V/Q –> 0

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15
Q

Define the West zones of the lungs

A

Zone 1
PA>Pa>Pv
dead space (ventilation w/out perfusion)
Normal lung doesn’t have this. The is increased by P.E and hypotension

Zone 2
Pa>PA>Pv
waterfall (normal physiology) more blood flow

Zone 3
Pa>Pv>PA
shunt (perfusion w/out ventilation)
Atelectasis
PA cath tip goes here

Zone 4
Pa>Pist>Pv>PA
pressure in the interstitial space pulmonary edema) impairs ventilation & perfusion

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16
Q

Alveolar gas equation?

A

PAO2 = FiO2(Pb-PH2O) - (PaCO2/RQ) NEED TO KNOW THIS

tells us that hypoventilation can cause hypercarbia & hypoxemia.

Pb = 760mmHg sea level
PH2O = 47mmHg
RQ = CO2 elimination/O2 consumption = 200/250 = 0.8 
- RQ = 1 --> over feeding
- RQ < 0.7 --> starvation
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17
Q

What is the A-a gradient, what is the normal range, and what factors increase it?

A

It compares partial pressure of O2 inside the alveolus and the partial pressure of O2 in the arterial circulation to diagnose the cause of hypoxemia. Get an ABG to get the PaO2 and use the Alveolar gas equation
- it is normally 5-15mmHg

It is increased by: (VHARD)
- Vasodilators: decreased hypoxic vasoconstriction
- High FiO2
- Aging
- R–>L shunt: Atelectasis, pneumonia, bronchial intubation, Intracardiac defect
- Diffusion limitation: pulmonary fibrosis, emphysema, interstitial lung disease

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18
Q

List the 5 causes of hypoxemia. Which ones are reversed w/ supplemental oxygen?

A
  1. Reduced FiO2- (A-a gradient is normal)
  2. Hypoventilation- (A-a gradient is normal)
  3. Diffusion Limitation- (A-a gradient is increased)
  4. V/Q mismatch- (A-a gradient is increased)
  5. Shunt- (A-a gradient is increased)

1-4: are reversed w/ supplemental oxygen

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19
Q

Define the 5 lung volumes & give reference values for each.

A
  1. inspiratory reserve volume (3000mL)
  2. tidal volume (500mL)
  3. expiratory reserve volume (1100mL)
  4. residual volume (1200mL)
  5. closing volume (variable - approaches RV in healthy young patients)
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20
Q

Define the lung capacities & give reference values for each.

A
  1. total lung capacity (5800mL): IRV + TV + ERV + RV
  2. vital capacity (4500mL): IRV + TV + ERV
  3. inspiratory capacity (3500mL): ERV + TV
  4. functional residual capacity (2300mL): RV + ERV
  5. closing capacity (variable): RV + CC absolute volume of gas contained in the lungs when the small airways close

Vital capacity is 65-75ml/kg
FRC is 35ml/kg

Spirometry can’t measure RV, CC, and CV. It can’t measure TLC and CC FRC cus there’s RV in it. It CAN measure VC

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21
Q

FRC consists of? What factors influence FRC? Name an example of increased FRC?

A

FRC = RV + ERV (35mL/kg)

conditions that reduce FRC tend to reduce outward lung expansion and/or reduce lung compliance –> zone III (shunt) increases. PEEP restores FRC by reducing zone III

  • position changes
  • increased intraabdominal pressure/contents
  • anesthesia/NMB
  • surgical displacement

COPD or any condition that causes air trapping increases FRC

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22
Q

Why can’t spirometry measure FRC?

A

Spirometry can’t measure residual volume so this includes (FRC and TLC). It also can’t measure closing capacity and closing volume

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23
Q

Which 3 tests can measure FRC?

A

1) nitrogen washout
2) helium wash in
3) body plethysmography

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24
Q

What is closing volume & what increases it?

A

Volume above residual volume where the small airways begin to close during expiration.

CLOSEP:

  • COPD
  • LVF
  • Obesity
  • Supine position
  • Extreme age
  • Pregnancy
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25
Q

State the equation and normal value for oxygen carrying capacity

A

CaO2 = SaO2Hgb1.34 + PaO2*0.003

normal = 20mL O2/dL

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26
Q

State the equation and normal value for oxygen delivery

A

DO2 = CaO2 x CO x 10

normal = 1000mL O2/min

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27
Q

Discuss the factors that alter oxyhemoglobin dissociation curve

A

Left shift (love, increased affinity, decreased offloading to the tissues)

Right shift (release, decreased affinity, increased offloading to the tissues)

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28
Q

What 3 ways is CO2 transported in the blood? Which one is 70%?

A

1) bicarbonate 70%!!!!

2) bound to Hgb by aminos 23%

3) dissolved in plasma 7%

CO2 to = HCO3- requires carbonic anhydrase & release of HCO3- from RBC to plasma, this causes Cl- shift out of the RBC (aka Hamburger shift)

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29
Q

Describe the Bohr effect

A

Bohr effect describes: O2 carriage

increased CO2 & decreased pH = RBC releases O2

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30
Q

Describe the Haldane effect

A

Haldane effect describes CO2 carriage

Increased O2 causes RBC to release CO2 (lungs)

(Where as Bohr effect describes O2 carriage and releases O2)

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31
Q

List the 3 primary causes of hypercapnia and provide examples of each

A
  1. increased CO2 production:
    - sepsis
    - overfeeding
    - malignant hyperthermia
    - shivering
    - seizures
    - thyroid storm
    - burns
  2. decreased CO2 elimination:
    - a/w obstruction
    - increased Vd
    -increased Vd/Vt
    - ARDS
    - COPD
    - respiratory depression
    - drug OD
    - inadequate NMB reversal
  3. rebreathing: incompetent one-way valve, exhausted soda lime
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32
Q

Describe the 4 areas in the respiratory center

A

Medullary Respiratory Centers:
- Dorsal respiratory center: active during inspiration (respiratory pacemaker)
- Ventral respiratory center: active during expiration

Pontine Respiratory Centers:
- Pneumotaxic center: inhibits the DRC
- Apneuristic center: stimulates DRC

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33
Q

Contrast the location & function of the central & peripheral chemoreceptors.

A

Central:

  • located in the medulla
  • responds to the pH [H+] in the CSF
  • CO2 diffuses freely in the BB and is hydrated with H2O (there’s no carbonic anhydrase involvement like in a RBC) = H+ and HCO3. The CSF responds to the H+. Increased H+ causes increase in Minute Ventilation and vice versa

Peripheral:
- located in the carotid bodies, nerves of Hering CN IX (9) glossopharyngeal
- located in the aortic arch CN X (10) vagus
- responds to decreased O2, increased CO2, and increased H+
- Monitors PaO2 < 60mmhg. When it’s lower than this it closes the O2 sensitive K+ channels in the type 1 glomus cells

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34
Q

Which reflex prevents overinflation of the lungs?

A

Hering-Breuer inflation reflex

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35
Q

What is hypoxic pulmonary vasoconstriction?

A
  • It minimizes shunt by reducing blood flow through poorly ventilated alveoli… seen in one lung ventilation
  • a low PAO2 (NOT arterial) is the trigger that activates HPV! LOW PAO2!!! Pay attention to multiple choice questions
  • effect begins immediately & takes 15mins for full effect
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36
Q

What (4) things impair HPV?

A

Anything that inhibits HPV, aka increases shunt (perfusion w/out ventilation)

1) halogenated anesthetics >1-1.5MAC
2) PDE inhibitors
3) dobutamine
4) vasodilators

IV anesthetics DO NOT inhibit HPV

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37
Q

What does the diffusing capacity for CO (DLCO) tell us? Normal range?

A

Using Fick’s law of diffusion, the DLCO tells us:
- surface area (decreased w/ emphysema)
- thickness (increased by pulmonary fibrosis & edema)

It tells us how well the lung can exchange gas.
Normal = 17-25mL/CO/min/mmHg

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38
Q

How is tobacco smoke harmful?

A
  • increases SNS tone
  • sputum production
  • carboxyhemoglobin concentration
  • risk of infection
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39
Q

Describe the short & intermediate term benefits of smoking cessation.

A

Immediate short term benefits (doesn’t reduce risk of postop pulmonary complications)
- SNS stimulation dissipates after 20-30mins
- P50 returns to near normal in 12hrs, CaO2 improves

Intermediate term effects- return of normal pulmonary function requires at least 6 weeks
- improved airway function, mucociliary clearance, sputum production, & pulmonary immune function
- CYP450 induction subsides after 6 weeks

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40
Q

Compare & contrast PFTs in obstructive vs. restrictive lung disease. Name an example of each:

A

Restrictive:
- Decrease in all lung volumes: FRC, RV, TLC, FEV 1 and FVC & FEV1
- normal FEV1/FVC ratio
- normal FEF25-75
- example is obesity

Obstructive:
- decreased FEV1/FVC & FEF25-75
- may have normal other values
- example is COPD

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41
Q

Discuss the following pulmonary flow-volume loops: normal, obstructive, restrictive, and fixed obstruction

A

normal = upside down ice cream cone

obstructive = normal inspiration w/ expiratory obstruction (negative exponential slope)

restrictive = shape similar to normal loop but smaller & shifted to the R

fixed obstructive = inspiration & expiration are affected.

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42
Q

Give an example of a disease the produces the following pulmonary flow-volume loops: obstructive, restrictive, and fixed obstruction

A

obstructive = COPD, asthma

restrictive = pulmonary fibrosis and obesity
(reduced lung volumes, reduced FVC and FEV1, but with normal FEV1 ratio and normal FEF25-75)

fixed obstruction = tracheal stenosis

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43
Q

What is the treatment for acute bronchospasm?

A
- 100% FiO2
- deepen anesthetic (IA, propofol, lidocaine, ketamine)
- inhaled B2 agonist (albuterol)
- inhaled anticholinergic (ipratropium), they’re bronchodilators!
- epi 1mcg/kg IV
- hydrocortisone 2-4mg/kg (takes several hours)
- **aminophylline**
- heliox to reduce airway resistnace
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44
Q

What is alpha-1 antitrypsin deficiency? What is the definitive treatment?

A

alpha-1 antitrypsin is produced in the liver. This deficiency is seen in COPD!!

alpha-1antitrypsin helps break down alveolar elastase enzyme. This alveolar elastase enzyme is like Drano in the lungs and destroys lung tissue.

With alpha-1antitrypsin deficiency, the alveolar elastase builds up and starts destroying more lung tissue = panlobular emphysema

It’s the MOST common metabolic disease affecting the liver

Liver transplant is the definitive treatment

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45
Q

Describe the goals & strategies for mechanical ventilation in the patient w/ COPD.

A

prevent barotrauma & reduce air trapping:

  • low Tv 6-8mL/kg
  • increased expiratory time
  • slow inspiratory flow rate to optimize V/Q matching, like 7bpm! SLOW THEIR RR!!!
  • low PEEP is ok as long as air trapping doesn’t occur
  • avoid regional blocks involving > T6
  • if there’s hyperdynamic inflation (breath stacking): decrease RR, disconnect circuit, decrease inspiratory flow
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46
Q

Define restrictive lung disease

A

characterized by:

  • impaired lung expansion
  • decreased lung volumes
  • normal pulmonary flow rates
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47
Q

Give examples of intrinsic lung diseases (acute & chronic)

A

Acute: aspiration, negative pressure pulmonary edema

Chronic: pulmonary fibrosis, sarcoidosis

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48
Q

Give examples of extrinsic lung diseases (acute & chronic)

A

Chest wall/mediastinum: kyphoscoliosis, flail chest, NM disorders, mediastinal mass

Increased intraabdominal pressure: pregnancy, obesity, ascites

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49
Q

List the risk factors for aspiration pneumonitis.

A
trauma
emergency surgery
pregnancy
GI obstruction
GERD
peptic ulcer disease
hiatal hernia
ascites
difficult airway management
cricoid pressure
impaired airway reflexes
head injury
seizures
residual NM blockade
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50
Q

Describe the pharmacologic prophylaxis of aspiration pneumonitis.

A

antacids: sodium citrate, sodium bicarbonate, magnesium trisilicate

H2 antagonists: ranitidine, cimetidine, famotidine

GI stimulants: metoclopramide

PPI: omeprazole, lansoprazole, pantoprazole

antiemetics: droperidol, ondansetron

routine use of these agents for prophylaxis isn’t recommended

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51
Q

What is Mendelson’s syndrome?

A

chemical aspiration pneumonitis

risk factors:
- gastric pH <2.5
- gastric volume >25mL (0.4mL/kg)

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52
Q

Describe the treatment of aspiration.

A

tilt head downward or to the side (first action)

  • upper airway suction
  • lower airway suction is only useful for removing particulate matter (not helpful for acidic burn)
  • secure airway
  • PEEP to reduce shunt
  • bronchodilators to reduce wheezing
  • lidocaine to reduce neutrophil response
  • steroids probably don’t help
  • Abx only if WBC or fever >48hrs
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53
Q

Discuss the pathophysiology and treatment of flail chest.

A

Consequence of blunt chest trauma with multiple rib fractures. The key characteristic is paradoxical movement of the chest wall at the site of the fractures

Inspiration: injured ribs move inward & collapse affected region
Expiration: injured ribs move outward & affected region doesn’t empty

Treatment: epidural catheter or intercostal nerve blocks

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54
Q

Discuss pulmonary HTN, and discuss goals of anesthetic management.

A

mean PAP>25mmHg
causes: COPD, L heart disease, connective tissue disorders

goals: optimize PVR
- increase PaO2
- hypocarbia
- alkalosis
- decreased intrathoracic pressure (prevent coughing, normal lung volumes, spontaneous ventilation)

  • drugs: inhaled NO, NTG, phosphodiesterase inhibitors, PGs, CCB, ACEI
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55
Q

Discuss the pathophysiology of CO poisoning

A
  • reduces O2 carrying capacity of the blood (L shift)
  • CO binds O2 binding site of HgB w/ 200x affinity of O2
    –> oxidative phosphorylation & metabolic acidosis
  • Co-oximeter NOT pulse ox measures CO
  • cherry red appearance
    -if soda lime is desiccated then volatile anesthetics can produce CO (Des > Iso > Sevo) Des produces CO the most
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56
Q

Discuss the treatment of CO poisoning

A

100% FiO2 x6hrs

hyperbaric oxygen if COHgb >25% or if the patient is symptomatic

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57
Q

List the absolute & relative indications for OLV

A

Absolute indications:

  1. Isolation of one lung to avoid contamination
  2. Control of Distribution of ventilation
  3. Unilateral bronchopulmonary lavage

Relative:

  1. surgical exposure
  2. pulmonary edema s/p CABG
  3. severe hypoxemia r/t lung disease
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58
Q

Discuss how anesthesia in the Lateral Dependent position affects the VQ relationship.

A

So think of this like blood flow

Nondependent lung:
- moves from flatter region (less compliant) to an area of better compliance (slope)
- ventilation is optimal in this lung

Dependent lung:
- moves from the slope to the lower, flatter area of the curve (less compliant)
- perfusion is best in this lung (gravity)
- reduction of alveolar volume contributes to atelectasis

net effect: ventilation is better in nondependent lung & perfusion is better in dependent lung. This creates VQ mismatch & increases the risk of hypoxemia during OLV

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59
Q

Discuss the management of hypoxemia during OLV

A

100% FiO2
confirm DLT position w/ bronchoscope
CPAP 10cmH2O to nonventilated lung
PEEP 5-10 to ventilated lung
alveolar recruitment maneuver
clamp pulmonary artery to non-ventilated lung
resume two-lung ventilation

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60
Q

What is mediastinoscopy, and why is it performed, any complications? Absolute contraindications?

A

performed to obtain biopsy of the paratracheal lymph nodes at the level of the carina. Helps to stage the tumor prior to lung resection

Complications #1 hemorrhage it’s near thoracic aorta, #2 pneumo

Absolute contraindications: previous mediastinoscopy due to scarring

know how to label the arteries on this!!!

Also the risk of a venous embolism is most likely to occur during spontaneous ventilation

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61
Q

What are the potential complications of mediastinoscopy. What is most common?

A

hemorrhage & pneumothorax are most common

others:
- impaired cerebral perfusion
- dysrhythmias
- air embolism
- chylothorax
- hoarseness and/or VC paralysis

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62
Q

describe the mallampati score

A

assesses teh oropharyngeal space, helps quantify the size of the tongue relative to the volume in the mouth

I: pillars, uvula, soft palate, hard palate
II: uvula, soft palate, hard palate
III: soft palate, hard palate
IV: hard palate

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63
Q

describe the interincisor gap. What is normal?

A

ability to open the mouth directly affects ability to align the oral, pharyngeal, and laryngeal axes. A small interincisor gap creates a more acute angle b/n the oral & glottic openings, increasing the difficulty of intubation

normal = 2-3FB or 4cm

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64
Q

what is the thyromental distance & what values suggest an increased risk of difficult intubation?

A

helps estimate the size of the submandibular space

w/ neck extended & mouth closed, you can measure the distance from the tip of the thyroid cartilage to the tip of the mentum.

DL may be more difficult if the TMD is <6cm (3FB) or greater than 9cm

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65
Q

What is the mandibular protrusion test and what values suggest an increased risk of difficult intubation?

A

assesses the function of the TMJ.

Pt is asked to sublux the jaw, and the position of the lower incisors is compared to the position of the upper incisors

Class I: LI past UI & bite the vermilion of the lip
Class II: LI in line w/ UI
Class III: LI cannot move past UI (increased risk of difficult intubation)

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66
Q

What conditions impair atlanto-occipital joint mobility?

A
DJD
RA
ankylosing spondylitis
trauma
surgical fixation
Klippel-Feil
Down syndrome
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67
Q

Describe the Cormack & Lehanne score

A

helps measure the view we obtain during DVL

Grade I: full view
Grade II: partial cords, arytenoids
Grade III: epiglottis
Grade IV: soft tissue

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68
Q

5 risk factors for difficult mask ventilation

A
BONES
beard
obese (usually BMI>26)
no teeth
elderly (age >55)
snoring
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69
Q

list 10 risk factors for difficult tracheal intubation

A
small mouth opening
narrow palate w/ high arch
long upper incisors
interincisor distance <3cm
MP class 3 or 4
mandibular protrusion class 3
poor compliance of submandibular spce
TM distance <6cm or >9cm
neck is thick &amp; short
poor AO joint mobility
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70
Q

list 6 risk factors for difficult supraglottic device placement

A
limited mouth opening
upper airway obstruction 
altered pharyngeal anatomy
poor airway compliance
increased airway resistance
lower airway obstruction
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71
Q

list 5 risk factors for difficult invasive airway placement

A
abnormal neck anatomy
obesity
short neck
limited access to CT membrane
laryngeal trauma
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72
Q

what is angioedema?

A

result of increased vascular permeability that can lead to swelling of the face, tongue and airway: airway obstruction is an extreme concern

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73
Q

what are two common causes of angioedema? what is the treatment for each?

A

ACEI:
treat = epi, antihistamines, steroids (just like anaphylaxis)

Hereditary angioedema (C1 esterase deficiency):
treat = C1 esterase concentrate or FFP (NOT epi, antihistamines, or steroids)

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74
Q

What is Ludwig’s angina?

A

bacterial infection characterized by a rapidly progressing cellulitis in the floor of the mouth. Inflammation & edema compress the submandibular, submaxillary, and sublingual spaces.

the most significant concern is posterior displacement of the tongue resulting in complete, supraglottic airway obstruction

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75
Q

What is the best way to secure the airway in the patient w/ Ludwig’s angina?

A

awake nasal intubation or awake trach

76
Q

Describe the practice guidelines for preoperative fasting & use of pharmacologic agents to reduce the risk of pulmonary aspiration.

A
2hrs = clear liquids
4hrs = breast milk
6hrs = nonhuman milk, formula, solid food
8hrs = fried or fatty foods

ingestion of clear liquids 2hrs before surgery reduces gastric volume & increases gastric pH

77
Q

list the 4 types of oropharyngeal airways. which are best suited for fiberoptic intubation?

A

Williams & Ovassapian

best for fiberoptic intubation

78
Q

What is the best time to use an ESchmann introducer?

A

best time to use is when grade 3 view is obtained during DL (grade 2 is the next best time).

Likelihood of successful intubation is unacceptably low when a grade 4 view is obtained.

79
Q

When is a nasopharyngeal airway contraindicated?

A
cribiform plate injury (LeFort II or III, basilar skull fx, CSF rhinorrhea, raccoon eyes, periorbital edema)
coagulopathy
previous transsphenoidal hypophysectomy
previous Caldwell-Luc procedure
nasal fracture
80
Q

contrast the maximum recommended cuff pressures for an ETT vs. LMA

A

ETT <25cmH2O

LMA <60cmH2O

81
Q

contrast the maximum recommended PIP for an LMA-unique vs. LMA-proseal vs. LMA-supreme

A

LMA-unique <20cmH2O
LMA-proseal <30cmH2O
LMA-supreme <30cmH2O

82
Q

what is the largest size ETT that can be passed through each LMA size?

A
1 = 3.5
1.5 = 4
2 = 4.5
2.5 = 5
3 = 6
4 = 6
5 = 7
83
Q

list 6 indications for the Bullard laryngoscope

A

PITTS

Pierre Robins
Impaired C-spine mobility
Treacher Collins
Thick neck
Small mouth opening (minimum 7mm)

~~~

84
Q

Describe the proper placement of the lighted stylet

A
  • look at the quality of the light shining through the neck to determine if the tip is in the trachea or the esophagus
  • looking for a well-defined circumscribed glow below the thyroid prominence
  • if it’s diffuse, then it’s in the esophagus
  • it’s a blind intubation technique
85
Q

5 indications for the use of a bronchial blocker

A

indicated for lung separation in the following patients

  • age <8
  • requires nasotracheal intubation
  • have a trach
  • have a single lumen ETT in place
  • require intubation after surgery & you want to avoid changing the DLT out
86
Q

How can the lumen of the bronchial blocker be used during OLV?

A

insufflate O2 into the nonventilated lung (DLT can do this too)
&
suction air only from the nonventilated lung to improve surgical exposure

cannot do any of this
- ventilate
- suction blood, pus, or secretions
- does not prevent contamination from contralateral lung infection because it can easily slip in trachea &, it’s super positional

87
Q

2 indications for retrograde intubation

A

Unstable C-spine

Upper airway bleeding (cannot visualize glottis)

Only use if ventilation is possible, it takes longer like 5-7 mins for experienced users

88
Q

compare & contrast the benefits of awake vs. deep extubation

A

awake:
- airway reflexes intact
- ability to maintain a/w patency
- decreased risk of aspiration

deep

  • decreased CV & SNS stimulation
  • decreased coughing
89
Q

when is the best time to use an airway exchange catheter, and what can you do with it?

A

maintains direct access to the airway following tracheal extubation, thus is helpful during extubation of the difficult airway

what else can you do with it?
EtCO2 measurement
Jet ventilation
O2 insufflation

90
Q

Things that increase A-a gradient

A
  • high fio2
  • aging
  • vasodilators
  • R- L shunting
  • diffusion limitation
91
Q

Small underdeveloped mandible

A

“Please Get That Chin”
-Pierre Robin
- Goldenhar
-Treacher Collin’s
- Cri du chat

92
Q

Large tongue

A

“Big Tongue”
-Beckwith Syndrome
-Trisomy 21 (downsyndrome)

93
Q

Cervical spine anomaly

A

“Kids Try Gold”

  • Klippel- Fleil
  • Trisomy 21
  • Goldenhar
94
Q

Know where SLN and RLN are located

A
95
Q

Where is the needle inserted for Glossopharyngeal nerve block?

A

Palatoglossal arch (anterior tonsillar pillar)
Inject 1-2ml of local on both sides

There’s a 5% incidence of intracarotid injection (risk of seizure)

96
Q

Where is the needle injected at for SLN block?

A

Inferior border of the greater Cornu of the hyoid bone
One ml injected outside thyrohyoid membrane, and 2ml injected deep to the thyrohyoid membrane
Repeat on both sides. Aspiration of air means needle is too deep

97
Q

Transtracheal approach (RLN block) Where does the needle go?

A

Puncture the cricothyroid membrane
Advance needle in caudal direction to reduce risk of vocal cord injury.
3-5ml of local into tracheal lumen

98
Q

What are all the letters blocking?

A

A is Glossopharyngeal nerve

B is SLN

C is RLN (transtracheal)

99
Q

Kyphoscoliosis is expected to have a reduced:

A

FRC and FEV1

It’s restrictive disease

100
Q

Is this example Extrathoracic obstruction or Intrathoracic obstruction?

The pt inhales and airway collapses and reduces flow. Pt exhales and pushes obstruction open, flow is normal, inspiratory limb is flat

A

Extrathoracic obstruction

101
Q

Is this example Extrathoracic obstruction or Intrathoracic obstruction?

Pt inhales and pulls open the obstruction, flow is normal. Pt exhales and collapses airway, this reduces flow. Expiratory limb is flat

A

Intrathoracic obstruction

102
Q

Extrinsic muscles that depress the larynx

A

O, Stern, Stern

103
Q

Intrinsic laryngeal muscles:

Extrinsic laryngeal muscles:

A

Intrinsic laryngeal muscles: phonatation, and vocal cords (vocal cords are ligaments and are not innervated)

Extrinsic laryngeal muscles: support the larynx and swallowing

104
Q

Discuss the 3 trigeminal nerves

A

There’s 3 CN that innervate the airway

1) Trigeminal CN5 (V1-V3, review the image below and know how to label it)
2) Glossopharyngeal CN 9
3) Vagus CN X (SLN & RLN)

105
Q

Glossopharyngeal CN 9

A
106
Q

Bilateral injury to the RLN

A
107
Q

Topical anesthesia for upper airway

A

You need to anesthetize base of the tongue, oropharynx, hypopharynx, larynx. You don’t need to do the mouth

5 techniques:

1) Cotton soaked pledgets in the nares- Don’t use cocaine in PChE deficiency, increased SNS tone, or MAOI drugs

2) Instill topical local in each nare

3) Swish and swallow- but risk of N/V

4) Local anesthetic spray with 20% benzocaine- risk of methemoglobinemia tx with methylene blue

5) Nebulize

6) Atomization- works better than nebula

108
Q

Glossopharyneal nerve block:

Where do you insert the needle?
What if you aspirate air or blood?

A

Insert needle at the base of the palatoglossal arch (anterior tonsillar pillar)

Aspiration of air = needle is too deep

Aspiration of blood = withdraw the needle and redirect medially. The carotid artery is very close. There is a 5% incidence of intracarotid injection, risk of seizure!

109
Q

Superior laryngeal block:

Where is the anesthetic injected?

A

At the inferior border of the greater Cornu of the hyoid bone, then deep into thyrohyoid membrane. Repeat on the contralateral side

Aspiration of air = needle is too deep

110
Q

Transtracheal block:

Where does the needle go?

A

Aka RLN block

Puncture the cricothyroid membrane in caudal direction to reduce vocal cord injury. After aspiration tell the patient to take a deep breath. During inspiration inject 3-5 mL in the tracheal lumen.

The patient will cough, spraying the local anesthetic upwards through the cords

111
Q

How to insert nasal device?

A

Direct it between the inferior turbinate and the floor of the nasal cavity. Or orient the bevel (angled region) towards the turbinates

112
Q

How does anesthesia affect airway patency?

  1. Obstruction at the level of the tongue
  2. Obstruction at the level of the soft palate
A
  1. Obstruction at the level of the tongue- genioglossus muscle relaxation
  2. Obstruction at the level of the soft palate- tensor palatine muscle relaxation
113
Q

When compared to the trachea, which factor is GREATER in the terminal bronchioles?

A. Total cross-sectional area

B. Airflow velocity

C. Amount of cartilage

D. Quantity of goblet cells

A

A. Total cross-sectional area

The lower airway begins as a single tube (the trachea) and it bifurcates along 23 generations.

Things that increases as air bifurcates:
- number of airways
- total cross-sectional area

Things that are variable as airway bifurcates:
- muscular layer

114
Q

What vertebral level corresponds with the adult trachea?

A

C6

115
Q

Name 2 landmarks that correspond with the carina

A

T4-5

Angle of Louis

116
Q

What structures permit air movement between alveoli?

A

Pores of Kohn

117
Q

Type 1 and type 2 pneumocytes

A

Type 1= provides surface area for gas exchange

Type 2 = produces surfactant

118
Q

What structures are anesthetized by injecting lidocaine at the base of the palatoglossal arch? (Select 2)

A. Oropharynx

B. Anterior 2/3 of tongue

C. Posterior side of the epiglottis

D. Vallecula

A

A. Oropharnx

D. Vallecula

119
Q

Signs of laryngospam

A
  • inspiratory strider
  • suprasternal and Supraclavicular retraction during inspiration
  • rocking horse chest, paradoxical movement
  • increased diaphragmatic excursion
  • lower rib flailing
  • absent or altered EtCO2 wave form
120
Q

Review the conducting, transitional, and respiratory zones

Know which one has Deadspace

A

Conducting zone- anatomic dead space Begins at the nares and ends with the Terminal bronchioles

Transitional zone- contains Respiratory bronchioles. Air conduit and gas exchange

Respiratory zone- where gas exchange takes place. Beings at alveolar ducts and extends to the alveolar sacs

121
Q

What is the primary determinant of carbon dioxide elimination?

A. MV
B. TV
C. Alveolar ventilation
D. RR

A

C. Alveolar ventilation- determines removal of CO from the body

Alveolar ventilation = (tidal volume - dead space) x RR

122
Q

An_______in PaCO2- EtCO2 gradient and causes CO2 retention

A

Increase

Increased PaCO2-EtCO2 gradient, think of = increased dead space

Examples of conditions that will most likely increase the PaCO2 to EtCO2 gradient:
- PPV- increases alveolar pressure which increases ventilation relative to perfusion, dead space increases
- Hypotension- reduces pulmonary blood flow which increases alveolar dead space
- Atropine- it is a bronchodilator, and increases anatomic dead space by increasing the volume of the conducting zone
- Hemorrhage
- Amniotic fluid embolism

123
Q

What is the most common cause of increase Vd/Vt under GA?

A

Reduction in cardiac output. If the EtCO2 acutely decreases. You should rule out hypotension!

Vd/Vt ratio = the fraction of the tidal volume that contributes to dead space.

Vd= dead space = ventilation but no perfusion!

124
Q

Things that increase Vd (dead space volume)

A
  • face mask, HME
  • PPV
  • anticholinergics (bronchodilator increases the volume in the conducting airway)
  • neck EXTENSION it opens the hypopharynx and increases it’s volume
  • decreased cardiac output
  • COPD
  • P.E
  • Sitting
125
Q

3 ways to anesthetize the vocal cords

A

1) inject local through nasal airway or ETT positioned ABOVE the vocal cords

2) Spray as you go with FOB

3) Inject local anesthetic through multi-orifice epidural catheter that’s inserted into the suction port of a flexible Fiberoptic catheter

126
Q

Nondependent lung V/Q ratio:

A
  • V/Q ratio is higher, there’s more air here
  • PAO2 is higher, there’s more air here but not perfusion so the alveoli just have a higher amount of O2 and lower PACO2
  • More vascular resistance
  • Perfusion and ventilation is LOWER, less compliance
127
Q

Dependent lung

A

-V/Q ratio is lower here
- Better ventilation and perfusion
- Less vascular resistance
- PAO2 is lower and PACO2 is higher here= more blood flow so it’s diluted this is ALVEOLAR

128
Q

V/Q mismatch

A
  • Bronchioles constrict to minimize Zone 1
  • Blood passing through underventilated alveoli tends to retain CO2
  • A-a gradient is usually increased
  • HPV minimizes shunt NOT dead space
129
Q

What does the vocalis do?

A

Shorts and relaxes

130
Q

Things that decrease FRC:

A
  • GA
  • Obesity
  • Pregnancy
  • Neonates
  • Positioning: Supine, Lithotomy, T-burg
  • Neomuscular blockade
  • Light anesthesia
  • Excessive IV fluids
  • High Fio2 = absorption atelectasis
  • Reduced pulmonary compliance
131
Q

Things that increase FRC:

A
  • Aging
  • Prone
  • Sitting
  • Lateral
  • Obstructive lung disease
  • PEEP
  • Sigh breaths
132
Q

Closing capacity = sum of

A

Closing volume + residual volume

133
Q

Which muscles participate in phonation and control the vocal cords (tension and position)?

A

Intrinsic muscles

134
Q

Which muscles support the larynx inside the neck and assist with swallowing?

A

Extrinsic muscles

135
Q

Are the true vocal cords innervated?

A

No, they are ligaments! They attach to the thyroid anteriorly and Arytenoids posterior

136
Q

What does the thyroarytenoid do?

A

They relax and shorten and ADDucts vocal cords

137
Q

What does the Aryepiglottic do?

A

Closes laryngeal vestibule

138
Q

What does interarytenoid do?

A

Closes posterior commisure of glottis

139
Q

Borders of laryngospasm notch (Larson’s maneuver)

A

Skull base, ramus of mandible, mastoid process

Pressure is applied towards the skull base. It displaces mandible anteriorly to open up the airway, and breaks the spasm so the pt will sigh.

Apply pressure for 3-5 seconds and released for 5-10 seconds. Repeat till spasm breaks

140
Q

Distance from incisors to the larynx, what about to carina?

A

13cm to larynx

26 cm to carina

141
Q

Deadspace = increased PaCO2 to EtCO2 gradient, list some examples

A

Think Deadspace = ventilation but no perfusion

-hemorrhage and hypotension- it reduces pulmonary blood flow and it increased alveolar dead space

  • P.E.
  • Atropine- bronchodilator, it increases the volume of the conducting zone (dead space area with nares and terminal bronchioles) so it reduces airway resistance
  • PPV
142
Q

Where are the peripheral chemoreceptors located and what does it respond to? What is its purpose?

A

Transverse aortic arch and carotid bodies.
They respond to PaO2 < 60mmhg, goal is to restore PaO2: Review how it does this

  1. When PaO2 < 60, it closes O2 sensitive K+ channels in type 1 glomus cells
  2. Raises RMP and opens Ca2+ channels to release = ATP and Ach!
  3. AP goes down hering nerve to glossopharyngeal nerve 9
  4. Afferent pathway terminates in inspiratory center in the MEDULLA
  5. Minute ventilation increases to restore PaO2!

We avoid bilateral CEAs because it severs the afferent limb

143
Q

J-receptors in the lungs

A

Activated by things that JAM TRAFFIC like a P.E. Or CHF. Once stimulated it causes tachypnea

144
Q

What medications increase intrapulmonary shunt?

A. Etomidate
B. Ketamine
C. Desflurane
D. Propofol

A

C. Desflurane > 1.5 MAC, CCB, vasodilators, Dobutamine = increase shunt by inhibiting HPV

HPV reduces shunt by diverting blood flow from under ventilated alveoli, occurs in seconds and lasts for 15 minutes. it’s a protective mechanism during atelectasis and OLV

Inhaled volatile agents increase shunt fraction and reduce PaO2

IV anesthetics do not affect shunt

145
Q

Name some things that increase intrapulmonary shunt

A

Increase in shunt means = they impair hypoxic pulmonary vasoconstriction

  • inhaled volatile anesthetics > 1.5 MAC
  • CCB,Dobutamine, vasodilators
  • Cardiac output elevation like hypervolemia LAP < 25 mmHg = distend constricted vessels and increase shunt flow
  • PEEP and high tidal volumes = increase zone 1 Deadspace and cause V/Q mismatch
146
Q
A

Anemia and CO poisoning = evening though CaO2 is reduced in both, PaO2 is usually normal. So this is why it doesn’t stimulate the hypoxic ventilatory drive.

Hypoxic ventilator drive is stimulated by low PaO2

because peripheral chemoreceptors only respond to low PaO2 < 60mmHg and NOT SaO2 and CaO2

147
Q
A

PACO2

148
Q
A

Des and sodium Nitroprusside

HPV during OLV reduces shunt do giving things that inhibit HPV will promote hypoxemia

149
Q
A

Bronchoconstriction occurs by:
1) PNS supplied by vagus nerve: Phospholipase C activates ionositol triphosphate (IP3) = contraction
2) Mast cell release: leukotrines, complement, cytokines, IgE
3) Non cholinergic C fibers

150
Q

Review what bronchoconstricts and bronchodilates

A

These are involved in bronchoconstriction:

151
Q
A
152
Q

Review this chart

What is the best indicator for small airway disease

A

Mid maximal expiratory flow rate MMEF, also known as FEF 25-75%

If it’s <70% = obstructive disease!!!!!

153
Q
A

READ THIS AND KNOW HOW TO LABEL IT!!!!

154
Q
A
155
Q

Obstructive vs. Restrictive lung disease

REVIEW

A
156
Q
A

Vagal stimulation

Airway smooth muscle is not innervated by SNS so a reduction in SNS can’t cause a bronchospasm.

Bronchospam is caused by a direct PNS stimulation, the intubation activated a vagal response leading to bronchospasm

157
Q

Name things that can precipitate and things that can occur in Asthma:

A
  • esosinophila
  • vagal stimulation due to PNS stimulation
  • cold air
  • BB, sulfites, NSAIDS

Obstructive diseases: low FEV 1, FEV1/FVC ratio, FEF 25-75%, respiratory alkalosis

  • right heart strain axis deviation
  • PFTs not a predictor of post op complications
  • TLC is NORMAL but FRC is increased
  • CXR: hyperinflated with diaphragm flattening

Ventilator: you want to prolong expiratory time with permissive hypercapnia

Avoid: sux, atracurium, Mivacurium, meperidine, morphine = histamine release. Cisatracurium is fine!

Anticholinesterases can also cause bronchospasm

158
Q

Bronchospasm

A
159
Q

Dynamic hyperinflation seen in COPD/ aka breathing stacking or auto-peep

List 3 causes of auto-peep:

List 2 body systems affected by it:

A

Auto-peep:
1) high minute ventilation
2) reduced expiratory flow
3) increased airway resistance

2 systems affected by dynamic hyperinflation/autopeep:
Cardiac and pulmonary

160
Q

Ventilator associated pneumonia

A

Caused by contamination, so you want to limit sedation, oropharyngeal contamination, want HOB > 30 degrees, want to do subglottic suctioning

Prophylaxis for GI bleed is not recommended bc it increases bacterial stomach growth. Routine prophylaxis is also not recommended for pts not a risk of aspiration

Know that magnesium trisilicate is a anatacid

Common culprits are pseudomonas aeruginosa and s. aureus

161
Q

List things that can increase and decrease PVR

A

Iloprost can help decrease PVR

162
Q

Carbon monoxide ABG and tx:

A

Metabolic acidosis (reduces ATP production)

Tx: 100% Fio2 for 90 minutes until COhgb is less than 5%, hyperbaric O2 if symptomatic if Cohgb exceeds 25% of hgb

Affinity of CO for O2 is 200x that of O2

163
Q

When would you need to mechanically ventilate?

A
164
Q

Absolute contraindications for OLV:

KNOW THIS IN DETAIL! Matching question

A
165
Q

Double lumen tube

A
166
Q

DLT sizing

A

8 year old - 26

10 year old- 28-32

167
Q

DLT positioning

A
168
Q

OLV hypoxia management

A

Know these exact steps

169
Q

3 nerves that could be injured with an LMA

A
  • Lingual
  • hypoglossal
  • RLN
170
Q

LMA

Proseal and Supreme have gastric port and a bite block. Supreme is the single use disposable version in this photo

A
171
Q

LMA

A
172
Q

Combitube

A
173
Q

Benefits of combitube

A

Contraindications of combitube

174
Q

King laryngeal tube

A
175
Q

FOB
- hold it in the non dominant hand and use thumb to control it. Pressing down moves it up

What are some contraindications?

A
176
Q

Keys points about FOB

A
177
Q
A

Requires minimum mouth opening of 7mm
Useful for Pierre Robin and Treacher Collin’s

This is a Bullard scope (rigid Fiberoptic device) you can use it on kids. There is a disposable tip extender for tall patients

Cricoid pressure helps with intubation, glottic exposure when the handle is pulled anteriorly

There are no contraindications for it

178
Q

Eschman introducer

A

Advance into trachea at 23-25cm, hold up sign is resistance at carina, feeling clicks of trachea rings confirms proper placement

179
Q
A

Microstomia- small mouth opening

Mandibular hypoplasia

It’s good for oral bleeding- cus it’s hard to visualize

180
Q

Lighted stylet

A

Don’t use it in short thick fat necks, tumors, can’t’ ventilate scenarios

181
Q
A

Unstable cervical spine

Upper airway bleeding

182
Q

Retrograde intubation

Most important thing is to clamp with a hemostat at the skin of the neck so the wire doesn’t dislodge, before attempting to thread the ETT over the wire

A

Contraindications

183
Q
A

Call for help

184
Q
A
185
Q

Airway fire steps:

A

1) remove airway
2) stop FGF
3) pour saline
4) re-establish ventilation