Adv Principles Week 4: Peg Contrera-Restrictive Pulm. Lecture

Front 1

How are PFT's altered from normal in the pt with restrictive pulmonary disease?

Back 1

All lung volumes are reduced, but flow rates and ratios are preserved!!

Front 2

The following describes what type of restrictive lung disease:

there is a loss of inherent elastic properties and development of pulmonary fibrosis leading to decreased lung compliance. There can be obliteration of the pulmonary vasculature causing pulmonary HTN or cor pulmonale

Back 2

Acute or chronic intrinsic restrictive diseases

Front 3

The following describes what type of restrictive lung disease:

are due to extrinsic disorders that interfere with lung expansion including disorders of the pleura (fibrosis, effusion), thoracic cage (kyphoscoliosis) and diaphram (obesity, ascites, pregnancy)

Back 3

Acute or chronic extrinsic restrictive diseases

Front 4

How are Blood gases altered from normal in the pt with restrictive pulmonary disease?

(Assuming the pt is resting)

Back 4

- decreased PaCO2
- decreased or normal PaO2
- Normal pH

Front 5

How are blood gases altered from normal in the pt with restrictive pulmonary disease?

(assuming the pt is exercising)

Back 5

- decreased PaCO2 (periph chemoreceptors sense decreased PaO2 and stimulate increased resp. rate!

-PaO2 decreased ( due to diffusion impairment and V/Q mismatches)

- pH increased ( due to resp. alkalosis and increased RR)

Front 6

Cardiac Output doesn't normally increase with exercise in the healthy individual. Does it increase with a pt who has restrictive lung disease?

Back 6

Yes

Front 7

Pt's with restrictive lung disease who have hypoxemia will often experience architectural changes in the lungs. this is known as?

Back 7

V/Q mismatches

Front 8

How is lung compliance and airway resistance affected with pt's who have restrictive lung disease?

Back 8

Airway resistance = NORMAL

Lung compliance = Decreases (secondary to fibrosis)

Front 9

How is work of breathing altered in pt's with restrictive lung disease?

Back 9

Increases ( which results in shallow respirations)

Front 10

What is the most sensitive clinical index of lung compliance in pt's with restrictive lung disease?

Back 10

spontaneous respiratory rate!

Front 11

Pt's with restrictive lung disease have decreased lung compliance. In order to create the same Vt as a healthy individual, they require larger changes in?

Back 11

require larger changes in pleural pressure to create the same Vt

Front 12

Are lung blood volumes increased or decreased with fibrosis?

Back 12

decreased. b/c fibrosis causes the obliteration of pulmonary vessels

Front 13

The obliteration of pulmonary vessels caused by fibrosis often causes?

**bold**

Back 13

PHT, increased right heart afterload, and may lead to cor pulmonale!!

Front 14

What are some differential Dx's of ARDS.

a. aspiration
b. barrel chest
c. bronchoconstriction
d. interstitial pneumonia

Back 14

a and d

Front 15

This symptom is a hallmark of ARDS and appears d/t abnormal permeability of the pulmonary ednothelium

Back 15

Protein-rich exudates

Front 16

(statement)

The following describes the clinical course of ARDS

1. Acute onset of resp. failure
2. tachypnea, dyspnea + crackles
3. decreased lung compl.
4. impaired gas exchange
5. diffuse airspace infiltrates on CXR

Back 16

..

Front 17

Acute onset of resp failure in ARDS typically develops over how many hours?

Back 17

4-48 hours

Front 18

Diminished lung compliance of <____ml/cm water is indicative of ARDS.

Back 18

< 40 ml/cm water

Front 19

Impaired gas exchange in ARDS will show a PaO2/FiO2 ratio of <____

Back 19

< 200

Front 20

CXR of a pt with ARDS will typically depict how many whited out lung quadrants

Back 20

atleast 3

Front 21

The following is a less severe case of ARDS with a PaO2/FiO2 ratio <300 mm hg, or O2 saturation < or = to 90% on room air. Onset of signs/symptoms occur within 6 hours after the end of transfusion

Back 21

TRALI

Front 22

What is the name of the scoring system used to classify ARDS

Back 22

Murray's score

Front 23

A Murray's score of 0 indicates what?

Back 23

No lung injury

Front 24

A Murray's score of 0.1-2.5 indicates what?

Back 24

mild-to-moderate lung injury

Front 25

A Murray's score of >2.5 indicates what?

Back 25

Severe lung injury (ARDS)

Front 26

Restrictive lung disease will exhibit:

-thickening of the blood/gas barrier
-V/Q abnormalities
-Fall in blood volume of the pulm. capillaries

These are all related to the limited diffusion of?

Back 26

diffusion capacity for carbon monoxide

Front 27

What are the predisposing conditions of ARDS

Back 27

3 main =
1. shock, trauma, pulm infections

Others:
pancreatitis, amniotic fluid emboli, smoke inhalation, near drowning, O2 toxicity, Drug O.D. (heroin, crack, salicylates)

Front 28

Death from ARDS that occurs early in the course is typically due to?

Back 28

The underlying cause of lung impairment

Front 29

Death from ARDS that occurs late in the clinical course is typically due to?

Back 29

MODS following a nosocomial infection and sepsis

Front 30

The Acute phase of ARDS is also known as?

a. proliferative phase
b. exudative phase
c. fibrotic pahse

Back 30

b

Front 31

The Sub-acute stage of ARDS is also known as?

a. exudative phase
b. proliferative phase
c. fibrotic phase

Back 31

proliferative phase

Front 32

The chronic stage of ARDS is also known as?

a. exudative phase
b. proliferative phase
c. fibrotic phase

Back 32

fibrotic phase

Front 33

The following phase of ARDS is characterized by:

- damage to B/G barrier

-extensive damage to type 1 alveolar cells

-increased endothelial permeability with interstitial edema

- protein rich fluid

Back 33

acute stage (exudative phase)

Front 34

The following phase of ARDS is characterized by:

-thickening of endothelium, epithelium, and interstitial space

-proliferation of type II alveolar cells

-interstitial space greatly expanded with edema

-impaired production and Fx of surfactant

Back 34

sub-acute stage: (proliferative phase)

Front 35

The following phase of ARDS is characterized by:

- Total lung collagen increases

- Lung becomes densely fibrotic

Back 35

Chronic stage (fibrotic phase)

Front 36

How many days does the Exudative stage of ARDS usually last?

Back 36

7-8 days

Front 37

How are the following affected by ARDS ( increased or decreased)

a. lung compliance
b. alveolar/cap permeability
c. FRC
d. Diffusion capacity
e. A-a O2 difference
f. Shunt > 40%
g. Dead space
h. O2 Consumption

Back 37

Lung comp = decreased
A/C perm = increased
FRC = decreased
DC = decreased
A-a = increased
shunt = increased
Dead Space = increased
O2 consumption = increased

Front 38

All of the following are considered causative factors (theory's) of ARDS (except 1)

a. compliment-neutrophil theory

b. Humoral Mediators

c. "baby lung" concept

d. Cellular mediators

Back 38

c

Front 39

The theory considered to be the mechanism of direct lung injury is?

a. compliment-neutrophil theory

b. humoral mediators

c. cellular mediators

Back 39

a

Front 40

The following describe what theory of ARDS:

Endotoxin, tumor necrosis factor, interleukins, and thromboxane

Back 40

humoral mediators

Front 41

The following describe which theory of ARDS:

macrophage-monocyte system - release cytokines, oxygen radicals and proteases that damage endothelial and epithelial cells and acitvate the arachidonic acid cascade

Back 41

cellular mediators

Front 42

The main goal of treatment/management of ARDS is?

Back 42

support ventilation while minimizing pulmonary barotrauma and voloutrauma

Front 43

Which of the following conditions occurred in up to 40% of pt's with ARDS

a. pneumothorax
b. pulmonary interstitial air
c. shunt
d. emboli

Back 43

a,b,d

Front 44

Direct injury to the alveoli from over distention

a. voluotrauma
b. barotrauma
c. biotrauma
d. atelectrauma

Back 44

a

Front 45

Results from high pulmonary pressures.

a. voluotrauma
b. barotrauma
c. biotrauma
d. atelectrauma

Back 45

b

Front 46

inflammatory mediators are released into the systemic circulation causing direct injury to the lung and other end organs

a. voluotrauma
b. barotrauma
c. biotrauma
d. atelectrauma

Back 46

c

Front 47

results from cyclic opening and closing of alveoli

a. voluotrauma
b. barotrauma
c. biotrauma
d. atelectrauma

Back 47

d

Front 48

Philosophy of "open lung ventilation" **PCV**

-keep PIP < ______
-Plateau Press <________
-Maintain Vt < ________
-Accept PaO2 >_______
-Allow PaCO2 ________if pH>7.2
-Peep _____cm H2O

Back 48

PIP < 40
Plateau < 30
Vt <10 cc/kg (5-10cc/kg)
PaO2 >55
PaCO2 55-65
Peep 10-18

Front 49

T or F

in order to reduce stretch injury in ARDS patients you should lower your Vt

Back 49

False: it is reduced by lowering RR

Front 50

What position has shown improvement in oxygenation with pt's who have ARDS

Back 50

prone

Front 51

Do you want to give pt's with ARDS tons of fluids?

Back 51

NO...allow permissive dehydration

Front 52

Statement:

newer hopes for definitive therapy in ARDS include:

-Nitric oxide
-anti-endotoxin antiboides
-monoclonal antibody
-TNF
-Cytokine, IL-1
-Ketoconazole
-Surfactant Rx

Back 52

..

Front 53

**_______ can be a critical step in the management of ARDS and showed a 29% incidence of resp complications/

a. Volume ventilation
b. Excessive Peep
c. Transporting pt
d. Fluid volume replacement

Back 53

c

Front 54

What pt populations are at increased risk for Aspiration Pneumonitis?

Back 54

GI obst
Emergency surgery
increased ASA status
difficult upper airway
recent solid food uptake
abdominal distention
depressed LOC
diabetes

Front 55

Is aspiration pneumonitis acute intrinsic or acute extrinsic

Back 55

acute intrinsic

Front 56

When is aspiration pneumonitis most likely to occur during the management of Anesthesia

Back 56

induction/emergence

or within 5 mins of extubation

Front 57

________ results in:

- destruction of surfactant producing cells

- damage to the pulmonary capillary endothelium

- Atelectasis occurs and intravascular fluid leaks into the lungs

Back 57

aspiration

Front 58

What is the most consistent and reliable clinical finding in pt's who aspirate?

Back 58

arterial hypoxemia

Front 59

How do we treat Aspiration?

Back 59

sx
O2
Treatment of bronchospasm
CPAP
Peep
Corticosteroids

Front 60

This type of pneumothorax has no communication with outside air.

Back 60

simple/closed

Front 61

This type of pneumothorax has air in the pleural cavity that exchanges with atmospheric air. (sucking chest wound)

Back 61

Communicating

Front 62

Type of pneumothorax where air progressively accumulates under pressure w/in the pleural cavity causing the mediastinum to shift.

Back 62

Tension

Front 63

A tension pneumo is decompressed by placing a needle in the _______ ICS anteriorly or the ________ ICS laterally

Back 63

2-3 ICS anteriorly

4-5 ICS laterally

Front 64

Brain injury in the area of the hypothalamus causes massive outpouring of catecholamines from the SNS. This results in marked vasoconstriction which in turn causes the blood volume to shift into the lower pressure pulm. system.

What type of Edema is this?

Back 64

neurogenic pulmonary edema

Front 65

Illicit drug-induced pulm. edema:

a. alter's pulmonary capillary permeability (what drug?)

b. causes pulmonary HTN, interstitial pneumonitis, fever, hemoptysis (what drug?)

c. may cause foreign body reaction in the lungs (what drugs?)

Back 65

a. overdose with opioids
b. cocaine
c. talwin, heroin, MS

Front 66

Which patients are at highest risk for Negative Press. Pulm Edema

a. elderly
b. young women
c. young kids
d. young muscular patients

Back 66

d

Front 67

Occurs when patients with renal failure or insufficiency are overhydrated

Back 67

uremic pulmonary edema

Front 68

What may occasionally occur following evacuationi of a pneumothorax or pleural effusion

Back 68

bilateral pulmonary edema

Front 69

characterized by progressive pulmonary fibrosis with anatomical loss of the pulmonary vascular bed leading to pulm HTN and cor pulmonale.

Back 69

Chronic intrinsic restrictive pulmonary disease

Front 70

Pneumothroax is common in:

a. acute intrinsic restrictive pulm disesase

b. chronic intrinsic restrictive
pulm disease

Back 70

b

Front 71

The following is a primary feature of what?

-thickening of the interstitium of the alveolar walls with firbotic infiltrates...**results in a small lung cage with a raised diaphragm**

Back 71

chronic intrinsic restrictive pulm disease

Front 72

Are the following (initial or late) signs of chronic intrinsic pulm disease:

- infiltration of the interstitium with lymphocytes

- clinical pic can look like ARDS

- desquamination is a cellular exudate found in some pt's

Back 72

initial

Front 73

Are the following (initial or late) signs of chronic intrinsic pulm disease:

-fibroblast lay down thick collagen bundles

- scarring destroys the architecture of the lung causing air filled cystic spaces

- Honey comb lung

Back 73

Late

Front 74

What is the mean survival of someone with pulmonary fibrosis

Back 74

4-5 years

Front 75

The characteristics of this CXR describe what?

a. small lung cage with a raised diaphragm

b. ground glass appearance

c. patchy shadows near the diaphragm

d. Honeycomb lung

Back 75

pulmonary fibrosis

Front 76

What are two frequent complications of pulmonary fibrosis?

Back 76

Cor pulmonale and pneumonia

Front 77

What will the spirometry values look like in pulmonary fibrosis:

(increased or decreased)

a. VC
b. FEV1
c. FEV1/FVC
d. FEV 25-75
e. TLC, FRC, RV
f. Airway resist
g. compliance

Back 77

VC = decreased
FEV1 = decreased
FEV1/FVC = normal or increased
FEV 25-75 = normal or increas
TLC, FRC, RV = decreased
Resistance = increased
compl = decreased

Front 78

How is gas exchange affected in pulmonary fibrosis in the normal resting patient

Back 78

Normal blood gas

CO2 may be decreased

Front 79

How is gas exchange affected in pulmonary fibrosis with exercise

Back 79

PaO2 = decreased
PaCO2 = decreased
pH = Increased

Front 80

What happens to physiologic dead space and shunt in pulm fibrosis

Back 80

IIIIIncreased!

Front 81

What disease is characterized by the presence of granulomatous tissue having a characteristic histological appearance, often occuring in several organs, but with a predilectation for the lung

Back 81

sarcoidosis

Front 82

What stage of sarcoidosis is the following?

no obvious intrathoracic involvement except lymph adenophathy

Back 82

Stage 0

Front 83

What stage of Sarcoidosis is the following:

-Bilateral hilar and paratracheal adenopathy arthritis, uveitis, and parotid gland enlargement. PFT's are normal

Back 83

stage 1

Front 84

What stage of sarcoidosis is the following?

-The pulmonary parenchyma is involved, PFT's and CXR show a restrictive pattern

Back 84

Stage 2

Front 85

What stage of sarcoidosis is the following:

-pulmonary infltrates occur

Back 85

stage 3

Front 86

What is the treatment for sarcoidosis?

Back 86

steroids

Front 87

Diffuse interstitial granulomatous reaction in the lungs after inhalation of dust containing fungus, spores, asbestos, etc. The alveolar walls are thickened and infiltrates form? What condition does this describe?

Back 87

Hypersensitivity pneumonitis

Front 88

Does the following describe the "Acute or Chronic" form of Hypersensitivity Pneumonitis:

-dyspnea, fever, hypoxemia
-cough occurs 4-6 hours after exposure
-symptoms continue for 24-48 hours

Back 88

acute form

Front 89

The following are all causes of?

-Eosinophilic Granuloma
-Alveolar Proteninosis
-Collagen Diseases
-Chemotherapy agents
-Oxygen
-Antibiotics
-Lymphangitis carcinomatosa
-Radiation of lung fields

Back 89

all conditions that can cause chronic intrinsic restricitive pulmonary disease

Front 90

What are two antidysrhythmics known to cause chronic intrinsic restrictive pulm. disease (bold)

Back 90

amiodarone

tocainide

Front 91

An overdose of what common over-the-counter medication is know to cause chronic intrinsic restrictive pulm. disease (bold)

Back 91

ASA overdose

Front 92

These occur in the absence of any abnormalities of the elastic properties of the lungs and most often reflects disorders that interfere with the expansion of the lung

Back 92

Acute and Chronic extrinsic restrictive pulmonary diseases

Front 93

The following describe what lung condition:

-diseases of the pleura
-diseases of thoracic cage
-obesity, ascites, pregnancy
-neuromuscular disorders
-mediastinal mass

Back 93

acute and chronic extrinsic

Front 94

* high protein content often seen with CA and sepsis

Back 94

exudates

Front 95

* low protein content often seen with CHF and other edemoatous states

Back 95

Transudate

Front 96

The following are clinical conditions seen with which condition:

-bronchitis, decreased lung volumes with normal flows.

Back 96

scoliosis/kyphosis

Front 97

results in immobility of the vertebral and rib joints. The diaphragm is preserved therefore resp. failure is rare

Back 97

ankylosing spondylitis

Front 98

Mediastinal mass is also known as?

Back 98

superior vena cava syndrome

Front 99

The following are characteristics of what?

- dilation of collateral veins of the head and neck

- Edema and cyanosis of the head, face, neck, and upper chest

- edema of the conjunctiva

- evidence of increased ICP

Back 99

Mediastinal mass (superior Vena Cava Syndrome)

Front 100

The preoperative goal in pt's with restrictive pulmonary disease is?

Back 100

to assess the severity and treat any reversible components

Front 101

What test is indicated with a pt suspected of having a mediastinal mass

Back 101

CT scan

Front 102

Pt's with restrictive pulm disease are at higher risk of anesthetic complications if:

V.C. is decreased to ______

or

Resting PaCO2 _______

Back 102

VC decreased to 15ml/kg

PaCO2 is increased

Front 103

What airway and ventilation methods are ideal with patients who have restrictive pulm disease. (choose two)

a. LMA
b. Et-tube
c. Mechanical ventilation
d. spontaneous ventilation

Back 103

a, d

Front 104

Should we use NMB's in pt's with restrictive pulm. disease?

Back 104

careful and vigilant use of muscle relaxants...use as little as possible