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118 Cards in this Set
- Front
- Back
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A condition that results from chest trauma with the hallmark of paradoxical movemement of the chest wall at the site of the fracture is known as.
a. chestum excavatum b. flail chest c. scoliokyphosis d. pectus excavatum |
b. flail chest , Innefficient lung inflation caused by rib fracture and paradoxical breathing limits alveolar ventilation and may progress to hypoventilation, hypercapnia, and progressive alveolar collapse.
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Treatment of flail chest involves which of the following:
Choose all that apply. a epidural catheter with local anesthetic or narcotic b. intercostal nerve block c. incentive spirometry d. tracheal intubation with mechanical ventilation and PEEP if severe. e. surgical fixation if warranted f. all of the above. |
f. all of the above
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Which type of pneumothorax has no communciation with the atmosphere.
a. chylothorax b. simple pneumothorax c. hemothorax d. tension pneumothorax |
B. simple pneumothorax
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In this type of pneumothorax air in the pleural cavity exchanges with atmospheric air in the chest.
a. simple pneumothorax b. tension pneumothorax c. hemopneumothorax d. hemothorax e. communicating pneumothorax |
E. Communicating pneumothorax
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Your patient has a communicating pneumothorax. Will you pack the wound with dressing?
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NO! The dressing could get sucked into the chest cavity due to negative pressure. I would not want to explain that to the doc :)
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This type of pneumothorax develops when air accumulates under the pleural cavity. If the pressure is too great the mediastinum shifts and compression of the contralateral lung and great vessels occurs.
a. tension pneumothorax b.hemothorax c. simple pneumothorax |
a. tension pneumothorax
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Hallmark signs of this type of pneumothorax include: hypotension, hypoxemia, tachycardia, increased CVP, and increased airway pressure.
a. simple pneumo b. hemothorax c. tension pneumo |
C. tension pneumothorax .
-respiratory and cardiac disturbances ensue exhibited by a decrease in CO, decrease in BP, increase in CVP, and shunting of blood to nonventilated areas. |
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Decompression of a tension pneumothorax is done with ________g needle at __________ interspace anteriorly or ____________ interspace laterally.
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16-18 guage angiocatheter in the second or third interspace anteriorly or the fourth or fifth interspace laterally.
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An accumulation of blood in the pleural cavity is known as.
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Hemothorax
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- Treatment of a hemothorax includes replacement of blood volume if needed, and thoracostomy if the initial bleeding rate is greater than 20ml/kg/hr , if chest XR worsens, or if hypotension persists after initial blood replacement.
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The pathogenesis of pneumothorax or hemothorax includes which 3 mechanisms of injury
a. iatrogenic ( after line insertion, supraclavicular block , barotrauma, exposure to high airway pressures) b. traumatic (blunt chest trauma resulting in rib fracture or penetrating injury) c. Spontaneous (rupture of alveoli near the pleural surface of the lung after a forceful sneeze or cough, common in people with long narrow chest and emphysema |
All are possible causes of hemothorax or pneumothorax
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True or False: The blood gas partition coefficient of N20 (0.47) is 34 times greater than that of nitrogen (0.014)
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True This means that N20 can leave the blood to enter an air filled cavity 34 times more rapidly than nitrogen can leave the cavity and enter the blood.
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One study determined that N20 can double the volume of the pneumothorax in ______minutes.
a. 2 b.5 c.10 d.15 |
C. 10
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True or False: Nitrous is acceptable to use as an anesthetic gas if a chest tube is functioning.
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True.
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Which type of pneumothroax is a contraindication to the use of nitrous oxide?
a. open b.closed c.tension d.hemo |
B. Closed
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Atelectasis is characterized by a collapse of pulmonary lung tissue that prevents respiratory exchange of CO2 and O2 . It affects _______percent of patients undergoing general anesthesia.
a. 50 b.75 c.90 d. 100 |
c. 90 %
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- In low risk surgeries atelectasis postoperatively resoves spontaneously within 24-48 hours.
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Tidal volumes of ______may be more beneficial for mechanical ventilation to combat atelectasis intraoperatively.
a. 10-15ml/kg b. 5-10 ml/kg c. 6-10 ml/kg d.8-10 ml/kg |
c. 6-10 ml/kg. Was once thought that higher TV was better but realized that it caused ventilator induced lung injury.
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Lower TV does not worsen the degree of atelectasis, instead PEEP and various "open lung maneuvers" have been proposed to reduce atelectasis.
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Abnormal accumulation of fluid in the pleural space may be caused by blockage of lymphatic drainage from the pleural cavity, cardiac failure, reductions in plasma colloid osmotic pressure, and infection or any other inflammatory process of the pleural membranes that alters capillary permeability is known as.......
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pleural effusion
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Funnel chest is known as
a. pectus carinatum b. pectus excavatum c. pineal pectus d. rectus pectus |
b. Severe cases can reduce VC and TLC
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Longitudinal protrusion of the sternum is known as
a. pectus carinatum b. pectus excavatum c. rectus pectus d. pineal pectus |
Pectus Carinatum . It is the second most common chest deformity. Patients have an increased incidence of congential heart disease and the condition has been associated with Rickets and asthma.
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Treatments for aspiration pneumonitis include 100% Fio2. T or F?
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False-want the minimum amt that will get pt adequately oxygenated. Too high Fio2 can cause mroe tissue damage.
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Antibiotics and steroids are mandatory in the treatment of aspiration pneumonitis: T or F?
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F-steroids are controversial and antibx should only be used if clinical signs of pneumonia persist for 48 hours.
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The major difference in the consensus definition of ARDS and ALI is?
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The paO2/Fio2 ratio
(ALI=PaO2/FiO2<300, ARDS=PaO2/FiO2<200), both have bilateral infiltrates on CXR |
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Risk factors associated with development of ARDS include: (choose all that apply)
A. Trauma B. sepsis C. any dz that releases inflammatory mediators D. aspiration E. anemia |
All but E
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The basis of pathophysiology of ARDS is the inflammation and damage to the alveolocapillary membrane. T or F?
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T
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ARDS pts often have microemboli as well. T or F?
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T
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The main goals of ARDS treatment include:
A. maintaining tissue oxygenation B. administering 100% FiO2 C. replacing intravascular fluids D. preserving end-organ fxn. |
A, C, D
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Which of the following drugs can be causes of ARDS?
A. Darvon B. ASA C. cholchichine D. HCTZ E. barbs |
All are correct
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When choosing vent settings for an ARDS pt, which of the followign are most important?
A. TV B. PIP C. RR D. PEEP |
B, D
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Most anesthesia vents can accomodate ARDS settings. T or F?
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F-might need to bring pts ICU vent down to OR
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Introperative anesthetic management of an ARDS pt should include:
A. aline B. PA cath C. ABG analysis D. Lactate levels E. foley |
A, C, D, E.
(can use PA cath if hemodynamically unstable or on pressors) |
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Vent modes that have preset resp rates include:
A. PCV B. IMV C. AC D. PSV |
B, C
(other 2 let pt breathe at own rate) |
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Inverse ratio ventilation (IRV) does what?
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increases I:E ratio to 1:1 or more ( 2:1, so on) to allow more time in inspiration
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Anesthetic challenges with ARDS pts include:
A. hemodynamic instability makes it difficult to titrate volatile agents B. often hypovolemic C. altered metabolism and excretion of drugs due to multisystem involvement |
All are correct
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Cytotoxic agents (chemo drugs) can cause:
A. pulm fibrosis B. chronic pneumonitis |
Both are correct
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Amiodarone can cause sever pulmonary toxicity: T or F?
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T
("drug of last resort") |
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Kyphosis and Scoliosis cause obstructive respiratory dysfunction. T/F
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FALSE. These are restrictive
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Kyphosis is a spinal deformity characterized by marked posterior curvature. T/F
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True
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Scoliosis is spinal deformity characterized by marked anterior curvature. T/F
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False. It's LATERAL curvature.
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T/F: Thoracic spinal deformity increases a pt's risk for resp alterations during sleep such as hypopnea and obstructive apnea.
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TRUE. pg 622
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statement: Spinal correction surgery (ie. for scoliosis) usually results in immediate and short-term deterioration of resp mechanics in the anesthetized pt.
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See immediate increase in chest wall elastance and flow resistance from changes in airway caliber, microatelectasis, and uneven distribution of resp mechanical properties throughout the lung.
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Alteration in pulmonary function occurs with spinal curvatures of greater than ____.
a. 60degrees b. 20deg c. 100deg d. 90deg |
a. 60 deg
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Skeletal chest wall deformity in kyphoscoliosis leads to an
increase/decrease in lung vol and pulm vascular bed. |
DECREASE of 30-65% of normal
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T/F: The main feature of lung mechanics in the pt with early-stage scoliosis are reduced lung volumes.
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True: VC, TLC, FRC, and RV are all decreased
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T/F: Late stages of scoliosis are characterized by V/Q mismatch, hypoxemia, incr PAP, hypercapnia, and incr work of breathing.
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True. Shunt developes from hypoventilation of some alveoli d/t low TV.
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All of the following are associated CV abnormalities assoc with Scoliosis EXCEPT which ONE.
a. LVH b. mitral valve prolapse c. increase PVR d. PAH (pulm art htn) |
all true execpt
a. LVH |
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Which of the following inhalation agents should not be used in a pt with scoliosis?
a. Sevo b. Des c. Iso d. N2O |
D. N2O may increase PVR and these pts are already at risk for increased PVR, PAH, and cor pulmonale
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Which one of the following is the most commonly occuring abnormality with Ankylosing Spondylitis?
a. mitral regurg b. pulmonary apical firbrosis c. cor pulmonale d. a-fib |
B
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In Ankylosing Spondylitis, which of the following are true (more than 1)
a. restricted thoracic cage b. slightly increased RV, FRC c. norm abg values d. norm pulm compliance e. norm diffusion capacity |
All are true
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Why would a person with Ankylosing Spondylitis have a hoarse/weak voice?
a. cricoarytenoid involvement b. CN IX involvement c. these people tend to smoke d. they shouldn't |
A.
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What benefits a patient with brochogenic carcinoma most?
1. radiation 2. Chemotherapy 3. Resection of affected lung tissue |
3. Resection of affected lung tissue
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What 2 questions should you ask yourself when doing a preop on a patient in need of pulmonary resection?
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1. Does the risk of potential postop complications preclude performing the surgery
2. Will postop functioning be sufficient to allow for reasonable quality of life |
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How much does spirometry parameters (FEV1 and FVC) decline following a lobectomy? pneumonectomy?
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lobectomy = 10% decline
pneumonectomy = 33% |
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What are risk factors that you might see in a cancer patient scheduled for lung resection?
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smoking, air pollution, and industrial chemical exposure
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What are the 4 "M's" the lung cancer patient should be assessed for?
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Mass effects
Metabolic effects Metastases Medications |
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The CXR for a patient with COPD shows?
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hyperinflation
Increased AP diameter Increased vascular markings Increased pulmonary vascular resistance |
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Increased pulmonary vascular resistance from compression of the vascular bed increases the patients risk for?
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Right ventricular failure
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Why should you be concerned with metabolic changes in the lung cancer patient?
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Some tumors secrete endocrine-like substances like adrenocorticotripic hormone, ADH, serotonin, parathyroid hormones, insulin
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Which of the following are factors that characterize low-risk patients for Postop complications?
1. FEV1 >2L or 80% predicted 2. PPO FEV1 <40% of predicted normal value 3. VO2max > 20 ml/kg/min 4. Ability to climb 5 flights of stairs. |
1,3,4
2 false should be- PPO FEV1 at least 80% of predicted normal value |
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What facters characterize high risk patients for post-op complications?
1. FEV1 <2L or <40% of predicted 2. Oxygen desaturation of >4% during exercise 3. Inability to climb 1 flight of stairs 4. VO2max <10ml/kg/min |
All high-risk factors
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What information from the CXR may be important when considering a difficult airway in thoracic surgery?
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1. locations of masses
2. compression of mediastinal structures 3. tracheal shift 4. invasion of the airway |
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What changes could you see on EKG with pulmonary disease?
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1. low voltage QRS
2. poor R wave progression 3. RVH |
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What type of preanesthetic assessment should you perform on all patients prior to thoracic surgery?
1. DLVO 2. assess exercise tolerance 3. VO2 max 4. estimate PPO FEV1% 5. postoverpative analgesia 6. discontiuation of smoking |
2, 4, 5, 6
1 and 3 are for patients with a PPO FEV1 <40% |
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What additional preanesthetic assessments whould you perform on a patient with cancer prior to thoracic surgery?
1. ABG 2. Mass effects 3. Metabolic effects 4. Metastases 5. Medications |
2,3,4, and 5 are the "4 M's"
1 is for a patient with COPD |
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Choose additional assessments for a patient with COPD and thoracic surgery?
1. Physiotherapy 2. VO2 Max 3. ABG 4. 4 M's 5. Bronchodilators |
1, 3, and 5
2. is for pt. with PPO FEV1 <40% 4. if for cancer patients |
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What additional preanesthesia assessments for a patient with increased renal risk?
1. ABG 2. Creatinine 3. BUN 4. VO2 Max |
2 and 3
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All of the following are indicators of postoperative complications in thoracic surgery except?
1. FVC >50% 2. DLCO <50% predicted 3. FEV1 <2L 4. FEV1/FVC <50% |
1. FVC should be <50%
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Aspiration pneumonitis only complicates about 1 in 3000 surgeries, but in what two types of surgery is the incidence doubled?
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c-section and emergency surgery
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Only ____% of aspiration pneumonitis result in death.
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5%
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At what times during an anesthetic is aspiration most likely?
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induction, intubation or within 5 minutes of extubation
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Name the three types of aspiration syndromes.
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1.chemical pneumonitis(Mendelson syndrome)
2.mechanical obstruction 3.bacterial infection |
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The volume aspirtated correlates with the severity of pulmonary damage from aspiration but there is LESS correlation between the volume in the stomach and pulmonary damage.
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Statement
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Name 6 risk factors for aspiration. (box27-13 pg 606 Naglehout has the complete list)
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1.difficult airway management
2.head injury 3.cricoid pressure 4.opioid administration 5.Obstetrics 6.severe hypotension |
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Name the 4 stages in the pathophysiology of aspiration pneumonitis(A.P.)
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1.damage to lung parenchyma and necrosis
2.Atelectasis in minutes due to parasympathetic response that leads to airway closure and a decrease in lung compliance. 3. 1 to 2 hrs after injury there is an intense inflammatory reaction characterized by pulmonary edema and hemorrhage. 4.24 hours after initial insult secondary injuries result from fibrin deposits and necrosis of alveolar cells |
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True or False
immediately do deep suctioning or bronchoscopy after aspiration. |
False. unless a particulate was aspirated and can be retreieved suctioning causes more irritation and is NOT helpful. Suctioning mouth and pharynx can help.
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What is the hallmark sign of A.P.
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Arterial hypoxemia
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Other signs of A.P. are.....Name 5
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tachypnea
dyspnea tachycardia hypertension cyanosis |
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True of False
The majority of aspirations are very obvious. |
False. majority are asymptomatic or mildly symptamatic. Therefore unexplained hypoxemia in the otherwise healthy pt post op may frequently be a sign of silent aspiration
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What are the most common findings on chest xray of pt with aspiration
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Infiltrates in the perihilar and basilar regions along with pulmonary edema
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The most frequently encountered pattern in drug-induced pulmonary injury?
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Interstitial pneumonitis and fibrosis
mechanism of injury is a direct cytotoxic effect of a drug or its metabolites on the endothelial, interstitial, or alveolar epithelial cells. |
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On lung parenchyma, the cytotoxic effect of a drug elicits an __________ response characterized by the proliferation of macrophages, lymphocytes, and other inflammatory cells. This response leads to deposition of _____ within the alveoli, which produces interstitial _________ and _________.
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On lung parenchyma, the cytotoxic effect elicits an INFLAMMATORY response characterized by the proliferation of macrophages, lymphocytes, and other inflammatory cells. This response leads to deposition of FIBRIN within the alveoli, which produces interstitial INFLAMMATION and FIBROSIS.
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Common manifestations of interstitial pneumonitis (acute, subacute, or chronic) include dys____, dry _____, low-_____ ____, f______, and m_____.
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Common manifestations of interstitial pneumonitis (acute, subacute, or chronic) include dyspnea, dry cough, low-grade fever, fatigue, and malaise.
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Hypersensitivity lung disease has been associated with:
A. bleomycin B. Methotrexate C. L-asparaginase D. promethazine E. procarbazine |
A. bleomycin
B. Methotrexate C. L-asparaginase E. procarbazine |
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Hypersensitivity lung disease clinical manifestations include:
A. nonproductive cough B. dyspnea C. chest pain D. leg pain |
A. nonproductive cough
B. dyspnea C. chest pain |
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Suspicion of a hypersensitivity drug reaction should be followed by prompt _________ __ ___ _____.
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Suspicion of a hypersensitivity drug reaction should be followed by prompt withdrawal of the agent.
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Sarcoidosis is a __________ disorder described as an intense interaction of activated ___________ and ___________ that result in tissue ______.
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Sarcoidosis is a multisystemic disorder described as an intense interaction of activated lymphocytes and macrophages that result in tissue injury.
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Sarcoidosis most frequently involves:
A. lungs B. reticuloendothelial system C. skin D. eyes E. myocardium |
A. lungs
B. reticuloendothelial system C. skin D. eyes E. myocardium |
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T/F - Sarcoidosis is more common in whites.
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F - Black (12:1)
White - even M to F Black - Female to male (2:1) |
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Prior to lung resection, what percentage of FEV1 indicates high risk for complications or death?
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FEV1 <40%
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FEV1 ____ of predicted or ___ indicates minimal risk; further testing is not indicated.
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FEV1 >80%; >2L
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True or False:
Advanced age alone is a contraindication for lung resection surgery. |
False: Advanced age alone should not be considered as acontraindication for lung resection surgery.
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What should be done if FEV1 or DLCO <80%?
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Postoperative lung function should be estimated.
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What does DLCO <60% indicates?
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DLCO<60% predicts increased complications.
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What are some common causes of Restrictive lung disease
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-interstitial fibrosis
-Pulmonary edema -Pleural disease -Neuromuscular disease -Skeletal abnormalities -Marked Obesity |
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What is a common cause of interstitial fibrosis
a. Fibrothorax b. Asbestosis c. Poliomyelitis d. Left ventricular failure |
b
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What is a common cause of Pleural disease (restrictive)
a. asbestosis b. fibrothorax c. poliomyelitis d. kyphoscoliosis |
b
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Neuromuscular disease is a common cause of restrictive lung disease. What is an example of a neuromuscular disease?
a. asbestosis b. fibrothorax c. poliomyelitis d. kyphoscoliosis |
c
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Skeletal abnormalities are a common cause of restrictive lung disease. What is an example of a skeletal abnormality.
a. asbestosis b. fibrothorax c. poliomyelitis d. kyphoscoliosis |
d
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A type of pulmonary edema that is initiated by some type of left-sided heart incompetence or failure
a. neurogenic b. cardiogenic c. uremic d. high-altitude |
b
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Type of pulmonary edema that begins with a massive outpouring of sympathetic nervous system stimulation triggered by CNS insult
a. neurogenic b. cardiogenic c. uremic d. high-altitude |
a
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Type of pulmonary edema caused by overhydration and expansion of the circulating blood volume that leads to increases in pulm. cap. pressures.
a. neurogenic b. cardiogenic c. uremic d. high-altitude |
c
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Type of pulmonary edema that can occur in the absence of left ventricular failure whenever an individual overexerts berfore acclimating to a high altitude.
a. neurogenic b. cardiogenic c. uremic d. high-altitude |
d
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DLCO <40% indicates_______
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High risk.
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True or False: If preop or predicted postop FEV1 or DLCO are <40% of predicted normal, exercise testing should be perfomed.
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True.
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Inability to climb one flight of stairs, V02max <10mL/kg/min or desaturation>4% during exercise is indicative of______
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High risk for complications/mortality.
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How is PPO FEV1 calculated?
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It is calculated by multiplying the current FEV1 by the fraction of functioning lung or the fraction of lung segments that will remain after surgery.
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What is diffusion capacity?
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A test of the lung's ability to allow transport of gas across the alveolar-capillary membrane.
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State the 5-pronged aggressive preoperative respiratory preparation regimen:
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1. Require the patient to stop smoking (to terminate the stimulus for brochoconstriction and secretions)
2. Dilate the airways (Drugs) 3.Loosen secretions (Hydration) 4. Remove secretions (postural drainage, chest PT, coughing) 5. Increase patient's participation (Educate, motivate, cough, IS, exercise, weight loss) |
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What is the purpose of monitoring during thoracic surgery?
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It is the quick recognition of sudden and severe changes in ventilation and hemodynamics that can accompany positioning, one lung ventilation (OLV), and surgical manipulation of the airway and thoracic structures.
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What instantly identifies acute hypotension with surgical manipulation during thoracic surgery?
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Arterial blood pressure monitoring.
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True or False: Central venous pressure (CVP) monitoring is required for routine thoracotomies.
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False-It is not required, but may be indicated if the patient's volume status is unclear or if large fluid shifts are anticipated.
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The CVP line (if required) can be inserted through:
A. External jugular veins B. Internal jugular veins C. Brachial veins D. Subclavain veins |
A, B, D,
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If a subclavian puncture is planned, the insertion site should be contralateral/ipsilateral side as the planned thoracotomy.
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Ipsilateral (same side)
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Pulmonary artery pressure monitoring IS/IS NOT helpful in predicting postoperative complications.
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It is not, but may be useful in preventing fluid overload.
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More than ___% of pulmonary artery catheters float into the right lung.
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90%.
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During right thoracotomy with PA catheter monitoring, the catheter will likely be where?
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-In the nondependent, collapsed lung giving a false low reading for cardiac output.
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