Anesthesia & Respiratory Disease

Front 1

_____ maintain patency of airway?

Back 1

Pharyngeal muscles

Front 2

Sustained tonicity of _____ muscle keeps tongue away from posterior pharyngeal wall?

Back 2

genioglossus

Front 3

During inspiration, what are the actions of diaphragm, external intercostals, scalene, & serratus?

Back 3

-Diaphragm constricts & depresses floor of thorax (1.5-7cm)
-External intercostals constrict & elevate ribs
-Scalene elevates 1st 2 ribs.
-Serratus posterior superior elevates ribs up & out to expand chest.

Front 4

During inspiration, expansion of the thorax incr/decr. vol. of thoracic cavity & incr/decr. intrathoracic & intrapleural pressure?

Back 4

Increase thoracic vol. & decrease intrathoracic & intrapleural pressure

Front 5

Muscles of inspiration (5)?

Back 5

Diaphragm, external intercostals, scalene, serratus posterior superior

Front 6

Expiration active or passive in supine & sitting position?

Back 6

Sitting - active
Supine- passive

Front 7

Type 1 fibers?

Back 7

-Fatigue resistant
-Slow response, slow twtich

Front 8

Type 2 fibers?

Back 8

-Rapid response, fast twitch
-Susceptible to fatigue
-Produce strength
-Allow muscle to produce greater force

Front 9

Most important inspiratory accessory muscle during labored breathing?

Back 9

Cervical strap muscles

Front 10

Inspiratory labored breathing muscles & their function?

Back 10

Cervical strap muscles, sternocleidomastoid muscles elevate rib cage, scalene muscles prevent inward displacement of ribs

Front 11

Muscles of expiration during labored breathing?

Back 11

Internal intercostals, rectus abdominis, & transverse thoracic

Front 12

Rythmic cycling pattern of inspiration is maintained by?

Back 12

Dorsal respiratory group

Front 13

Rythmic cycling pattern of expiration is maintained by?

Back 13

Ventral respiratory group

Front 14

The automatic rhythm of ventilation can be modified by afferent information from _____ & ______ nerve fibers?

Back 14

Vagal & glossopharyngeal

Front 15

Responsible for fine tuning ventilation?

Back 15

pons

Front 16

2 areas of pons that fine tune rate & rhythm & their action?

Back 16

-Lower apneusic (excitatory)sustains inspiration
-Upper pneumotaxic (inhibitory)limit depth of inspiration

Front 17

Central chemoreceptors

Back 17

-Located in medulla
-Respond to H+ changes in CSF
-Activity is depressed by hypoxia
-Co2 has potent but indirect effects

Front 18

Peripheral chemoreceptors located?

Back 18

-Carotid & Aortic bodies

Front 19

Aortic & carotid bodies are stimulated by changes in (4)?

Back 19

PaO2, PaCO2, pH, & arterial perfusion pressure

Front 20

Peripheral chemoreceptors located?

Back 20

-Carotid & Aortic bodies

Front 21

Principle peripheral____ chemoreceptor most sensitive to _____?

Back 21

Carotid bodies are most sensitive to PaO2

Front 22

Peripheral chemoreceptors also stimulated by ____ & ____? Carotid bodies are depressed by _____ & ____?

Back 22

- stimulated by cyanide & doxapram
-depressed by anesthetics & carotid surgery

Front 23

Peripheral chemoreceptors relate info to central receptors via ?

Back 23

glossopharyngeal N.

Front 24

Deflation reflex?

Back 24

Lung receptors that shorten exhalation when lung is deflated.

Front 25

Lung receptors function?
Impulses carried by _____?

Back 25

-Inhibit inspiration during max. lung inflation
-Shorten exhalation when lung is deflated (deflation refelx).
-Vagus N.

Front 26

Left lung smaller/bigger than right & why?

Back 26

-Smaller (9 lobules)to accomodate heart.
-Right lung (10 lobules)

Front 27

Lingula?

Back 27

-Projection of upper lobe of left lung that is homologous to middle lobe
-Not a lobe but similar to right middle lobe.

Front 28

Hilum?

Back 28

Aka root of lung, point of entry for bronchi, vessles, & nerves into each lung

Front 29

Visceral pleura?
Parietal pleura?

Back 29

-Visceral covers surface of lungs
-Parietal covers surface of thoraic wall
-Pleural cavity contains pleural fluid
-Pleural fluid acts as lubricant b/w visceral & parietal

Front 30

Tracheobronchial tree is composed of ____ & ____?

Back 30

-columnar epithelium & glands that produce mucous & serous(clear plasma) fluid

Front 31

Trachea enters superior mediastinum & bifurcates at ?

Back 31

T4
1/2 of trachea is intrathoracic & 1/2 extrathoracic.

Front 32

How many lung generations or divisions?
No gas exchange occurs at generation ___ to ___?

Back 32

23 generations
No gas exchange at 1-16 (mainstem bronchi to terminal bronchiole)

Front 33

Gas exchange occurs starting at?

Back 33

Respiratory bronchiole (generation 17)to alveolar sac

Front 34

Angle of bifurcation & length of R. & L. bronchus?

Back 34

-R. bronchus: 25 degree angle w/ greater diameter & 2.5cm length.
-L. bronchus: 45 degree angle & 5cm length

Front 35

Bronchiole?

Back 35

-1mm in diameter
-Do not have cartilaginous support
-Highest proportion of smooth muscle
-Subdivide to become terminal bronchiole

Front 36

Last component of conductive airways?

Back 36

Terminal bronchiole

Front 37

Transitional airways include?

Back 37

Respiratory bronchiole (2-3 divisions) then becomes alveolar ducts

Front 38

Last subdivisions of respiratory airways?

Back 38

Alveolar sacs

Front 39

How many alveoli does 1 alveolar sac contain?

Back 39

17 alveoli

Front 40

Alveolar size depends on ____ & ____?

Back 40

-Gravity & lung volume
-Size varies w/ positioning (largest at apex when sitting)

Front 41

Type 1 pneumocytes?

Back 41

-Flat & form tight junctions
-Form structure of alveolar wall
-Prevent passage of lg. molecules into alveolus

Front 42

Type 2 pneumocytes?

Back 42

-Secrete surfactant
-Divide to form type 1
-Resistant to O2 toxicity
-Exist in larger # than type 1

Front 43

Role of surfactant?

Back 43

-Lower surface tension
-Allows membrane to expand to increase gas exchange

Front 44

Type 3 pneumocytes?

Back 44

-Alveolar marcophages

Front 45

Pulmonary vascular system?

Back 45

-Supplies resp. bronchioles & below
-R.CO from R. vent. via PA to lung.
-O2 blood is returned to L. heart via 4 pulm. veins
-2 pulm. arteries deliver mixed venous blood from R. vent. to pulm. capillary bed.

Front 46

Bronchial vascular system?

Back 46

-Blood from L. heart supplies O2 to conductive airways & pulm. vessels

Front 47

Compare blood flow, resistance, & pressure in pulm. vasculature & systemic vasculature?

Back 47

-Blood flow is equal
-Pulm. vascular resistance is lower than systemic
-Lower pulm. vasculature pressure than systemic
-Pulm. arteries & veins have thinner walls w/ less smooth muscle

Front 48

Transpulmonary pressure?

Back 48

P alveolar - P intapleural

Front 49

Alveolar pressure is always lower/higher than intrapleural pressure?

Back 49

higher; this gradient is what keeps lungs inflated.

Front 50

Alveolar pressure, intrapleural pressure, & transpulmonary pressure at end expiration?

Back 50

-Alveolar pressure = 0 or 760mmHg
-Intrapleural pressure = -5cm H2O
-Transpulm. pressure = 5 (sustains lung expansion)

Front 51

During inspiration, alveolar & intrapleural pressure?

Back 51

-Alveolar pressure = -3cm H2O
-Intrapleural = -8cm H2O
-Alveolar upper airway gradient is established & gas flows into alveoli

Front 52

At end inspiration, alveolar pressure & intrapleural pressure

Back 52

-Alveolar pressure = 0
-Intrapleural pressure remains -8cm H2O
-Transpulmonary = 5cm H2O(sustains lung expansion)

Front 53

Elastic recolil of lungs is due to ___ & ___?

Back 53

1. elastin fibers
2. surface tension forces
Tendency of lungs is to collapse

Front 54

Elastic properties of chest wall are due to ____ & ____ ?

Back 54

1. bony structure that resist collapse
2. intercostal muscle tone
Tendency of thoracic cavity is to expand outward

Front 55

Lung compliance is a measure of ____?

Back 55

elastic recoil

Front 56

Compliance (formula)?

Back 56

-Change in vol./change in distending pressure

Front 57

Lung compliance (formula)?

Back 57

Change in lung vol./change in transpulm. pressure

Front 58

Lung compliance is affected by ? (list 4)

Back 58

1. lung volume
2. pulm. blood vol.
3. extravascular lung water
4. pathological processes

Front 59

Surface tension?

Back 59

Forces exterted on the wall of the alveoli by the gas in the alveoli & fluid filled capillaries surrounding alveoli.

Front 60

Alevoli size dynamic? T/F

Back 60

-True.
-As surfactant conc. incr. alveoli size is decr.

Front 61

Alveolar collapse is directly proportional to ____?

Back 61

surface tension

Front 62

List 4 lung volumes?

Back 62

1. Tidal vol. (TV)
2. Inspiratory reserve (IRV)
3. Expiratory reserve (ERV)
4. Residual (RV)

Front 63

Tidal volume?

Back 63

-amt. of gas inspired or expired w/ each breath
(normal breath)

Front 64

Inspiratory reserve vol.?

Back 64

Max. amt. of additional air that can be inspired from end of normal inspiration

Front 65

Expiratory reserve vol.?

Back 65

Max. vol. of additional air that can be expired from end normal expiration

Front 66

Residual vol.?

Back 66

vol. of air remaining in lung after a maximal expiration.

Front 67

Total lung capacity?

Back 67

after max. inspiration: vol. of air in lungs.
TLC= TV+IRV+ERV+RV

Front 68

Vital capacity?

Back 68

after max. inspiration: max. vol. of air that can be forcefully expelled from lungs.
VC= TV+IRV+ERV

Front 69

Functional residual capacity?

Back 69

Vol. of air remaining in lung after normal exhalation.
FRC= RV+ERV

Front 70

Inspiratory capacity (IC)?

Back 70

Max. vol. of air that can be inspired from end expiration
IC= TV+IRV

Front 71

FRC is directly proportional to ____?

Back 71

height

Front 72

Factors that decrease FRC (4)?

Back 72

1. obesity
2. supine/prone (10-15%)
3. lung disease affecting compliance
4. decrease diaphragmatic tone (GA further decr. by FRC by 5-10%)

Front 73

Closing capacity?

Back 73

-vol. at which small airways begin to close in dependent parts of lung
-normally lower than FRC & not affected by positioning

Front 74

This vol. is a function of elastic recoil affecting radial traction of small airways?

Back 74

closing capacity

Front 75

Laminar flow will convert to turbulent during?

Back 75

1. high flows
2. sharp angles(circuit)
3. changes in tube diameter

Front 76

Where does turbulent flow occur?

Back 76

-larger conducting airways
-Trachea (low resistance)
-larger bronchi to 7th gen. (incr. resistance)

Front 77

Where does laminar flow occur?

Back 77

-Smaller airways
-small bronchioles

Front 78

Areas of high & low resistance?

Back 78

Low resistance: trachea & main bronchus (b/c lg. diameter) & small bronchi due to lg. cross sectional area.
High resistance: medium size bronchi down to 7th gen.

Front 79

Reynolds # < 1,000 predicts?

Back 79

laminar flow

Front 80

Explains laminar flow through cylindrical tube?

Back 80

Poiseuille's law

Front 81

Poiseuille's law

Back 81

Airway resistance is directlly r/t air viscosity & to length of tube & inversely r/t radius in 4th power

Front 82

Doubling length airway ____ resistance?
Halving radius ____ resistance?

Back 82

-Doubles
-increase by 16th fold (16x)

Front 83

Why do small airways collapse during low lung vol. ?

Back 83

-Small airways collapse due to less radial traction increasing airway resistance
-Treat w/ PPEP (incr. lung vol. & decr. airway resistance)

Front 84

How do airways collapse due to flow?

Back 84

High intrathoracic pressure (bucking) during forced exhalation increases airway intramural pressure & results in airway collapse & incr. resistance

Front 85

Gas transport in transitional & respiratory airways is by ____?

Back 85

diffusion
Co2 is 20x more diffusible than O2

Front 86

Blood flow through capillary is direclty affected by ____ & _____?

Back 86

gravity & alveolar size

Front 87

The bigger/smaller alveoli the more resistance to blood flow?

Back 87

the bigger the more resistance

Front 88

The Pulm. capillary ____ has lg. junctions that allow passage of albumin, macrophages, & neutrophils

Back 88

endothelium

Front 89

Explains laminar flow through cylindrical tube?

Back 89

Poiseuille's law

Front 90

List in order layers of respiratory membrane (8)?

Back 90

1. Alveoli
2. Surfactant
3. Alveolar epithelium
4. Alveolar basement membrane
5. Interstitial space (b/w alveolus & capillary)
6. Capillary basement membrane
7. Capillary endothelium
8. RBC

Front 91

Pulmonary lympathics?

Back 91

-originate in interstitial space
-Lymph has high protein count
-total lymph= 20ml/hr
-R. lungs drains into R. lymphatic duct
-L. lung drains into thoracic duct

Front 92

Thoracic duct drains?

Back 92

-L. throrax, LUE, L. side head & neck

Front 93

Pulm. blood flow is a tight relationship b/w (3)?

Back 93

1. Pulm. artery pressure (Pa)
2. Alveolar pressure (PA)
3. Pulm. venous pressure (Pv)

Front 94

Lung Zones?

Back 94

-Zone 1: most gravity independent (apex)
-Zone 2: from lower limit of zone 1 to upper limit zone 3
-Zone 3: most gravity dependent (bases)
*Location of zone varies w/ position.

Front 95

Zone 1?

Back 95

-No blood flow
-PA>Pa>Pv
-V/Q = 1
-PA= atm. pressure &
Pa=subatm.
-Ventilation w/o perfussion = alveolar dead space
-Alveolar pressure promotes collapse of pulm. capillaries

Front 96

Zone 3?

Back 96

-Pa>Pv>PA
-Cont. blood flow b/c intravascular pressure is higher than alveolar pressure

Front 97

Zone 2?

Back 97

-Located in middle
-Pa>PA>Pv
-Blood flow depends on diff. b/w arterial & alveolar pressure
-Flow varies w/ respiration

Front 98

Minute ventilation?

Back 98

-The sum of all exhaled gas volumes in 1 min.
-Minute ventilation = RR x Tv
-Norm = 5L/min

Front 99

Dead Space?

Back 99

-Part of Tv that does not participate in gas exchange
-Alveolar, anatomical, & physiologic dead space

Front 100

Physiologic dead space?

Back 100

-Sum of anatomic & alveolar dead space
-Norm.= 150mL (2mL/kg)

Front 101

Factors that modify anatomic dead space?

Back 101

1. tracheal intubation
2. tracheostomy
3. incr. length of circuit
Anatomic DS- oronasopharynx to terminal & resp. bronchioles

Front 102

Physiologic dead space is primarily modified by changes in _____?

Back 102

alevolar dead space

Front 103

1,2,3 rule of dead space for spont. ventilating pt.?

Back 103

1mL xlb = anatomic dead space
2mL xlb = alveolar dead space
3mL xlb = Tidal Vol.

Front 104

Why do non-dependent areas get less ventilated?

Back 104

Because intrapleural pressure is more (-) at the apex & alveoli in apices are more inflated & less compliant

Front 105

Why do dependent areas get better ventilated?

Back 105

Because less (-) intrapleural pressure at bases & alveoli are smaller therefore more compliant & have greater expansion.

Front 106

Why are alveoli at bases smaller?

Back 106

Due to lower transpulmonary pressure at the bases.

Front 107

Alveoli filling depends on (3)?

Back 107

1. inspiratory time
2. compliance
3. airway resistance

Front 108

Pulmonary perfusion?

Back 108

-Norm. 5L/min
-100mL at a time participate in gas exchange
-Systole & spont inspirations incr. pulm. blood flow

Front 109

HPV?

Back 109

-Physiologic reflex stimulated by alveolar hypoxia
-Reduces shunting & prevents hypoxemia
-Hypercapnia & acidosis also stimulate HPV
-Blunted by PIA's

Front 110

Intrapulmonary shunt?

Back 110

-Portion of CO that returns to L.heart & systemic circulation w/o being oxygenated
-Perfusion w/o ventilation

Front 111

Relative shunt?

Back 111

-V/Q ratio is low but still exists; some gas exchange
-O2 therapy may improve

Front 112

Absolute shunt?

Back 112

-V/Q ratio = 0
-Hypoxemia not reveresed w/ O2
-No gas exchange

Front 113

Venous admixture?

Back 113

-5% CO normally shunted via pleural, bronchiolar, & thebesian veins into L. ventricle
-R. to L. absolute anatomic shunt
-Amt. of mixed venous blood that would account for diff. b/w pulm. end capillary & arterial oxygen tension

Front 114

Conditions that cause relative shunting?

Back 114

1. Mild. pulm. edema
2. Post-op atelectasis
3. COPD
(low V/Q, perfusion w/ some ventilation)

Front 115

Conditions that cause absolute shunt?

Back 115

1. Acute lobar atelectasis
2. Acute lung injury
3. Adv. pulm. edema
4. Consolidated pneumonia
(No gas exchange)

Front 116

Alveolar PO2 calculation?

Back 116

PAO2=FiO2(BP-PH2O)-PACo2/R
BP= 760mmHg at sea level
PH2O= 47mmHg
R= 0.8
PACo2 (alveolar) is same as arterial

Front 117

Causes of alveolar dead space (3)?

Back 117

1. decr. CO (most common)
2. pulm. emboli
3. PPV

Front 118

A-a gradient incr. w/ (4)?

Back 118

1. age
2. V/Q mismatch
3. R. to L. shunt
4. diffusion defects

Front 119

A-a gradient does not take into account (4)?

Back 119

1. venous admixture
2. decr. CO
3. anemia
4. incr. VO2

Front 120

A-a gradient takes in account (is dependent on)?
Normal A-a gradient?

Back 120

-Dependent on R. to L. shunt; V/Q mismatch, mixed venous O2 tension
-Norm. = <10mmHg, may variate 5-20mmHg

Front 121

Spirometry?

Back 121

-measures expiratory vol. & flow rates
-requires max. inspiratory & expiratory effort
-detects bronchial hyperreactivity in asthma (inhaled histamine)
-Used to dx obst. & restrictive lung disease
-Reversibility of obst. assessed w/ bronchiodilator

Front 122

Spirometry results?

Back 122

-Results expressed as % or absolute value
-value <80% of predicted value is abn.

Front 123

Spirometry normal values vary depending on?

Back 123

1. gender (men bigger w/ bigger lungs)
2. race
3. age
4. height (most used to define norm. values)

Front 124

Lung volume test?

Back 124

-Measures inhalation
-used to dx restrictive dz
-pt. w/ restrictive dz = decr. vol. w/ inhal.

Front 125

Forced vital capacity?

Back 125

-measures air vol. of a forceful inspiration/expiration
-decr. w/ restrictive dz
-norm. or slightly incr. w/ COPD

Front 126

Forced expiratory vol. (FEVt)?

Back 126

-compared w/ FVC
-decr. w/ restrictive (decr. vol. in & decr. vol. out) & obst. (lg. vol. in but exhale slowly)
-Normal: can exhale 75% of FVC in 1st second of FEV
-

Front 127

FEV1/FVC?

Back 127

-normal = 75%
-COPD <75%
-Normal w/ restrictive (b/c no problems exhale in 1st sec.)

Front 128

Maximum midexpiratory flow rate (FEF 25-75%)?

Back 128

-measures forced expiratory flow during middle 1/2 of FEV
-middle 1/2 of FEV falls b/w 25-75% of FEV
-Very sensitive to dx early COPD
-Normal value = 100 + or - 25% or 4.7L/sec (280ml/min)
-decr flow % indicates mid-size obst.
-normal w/ restrictive dz

Front 129

Flow volume loops?

Back 129

-Graphical representation og lung vol. expired during forced expiratory effort followed by a forced inspiratory maneuver.

Front 130

Flow volume loops in normal patients after a small amt. of gas has been exhaled, flow depends on (3)?

Back 130

1. airway compression
2. elastic recoil of lung
3. resistance upstream of that point

Front 131

Effects of anesthesia on pulm. mechanics?

Back 131

-induction decr. FRC by additional 15-20%
-decr. muscle tone decr. FRC
(cephald movement of dependent diaphragm at end expiration & chest wall moves inward)
-No change in airway resistance due to bronchiodilator effects of PIA's

Front 132

Effects of anesthesia on gas exchange?

Back 132

-Incr. physiologic dead space
-Incr. intrapulm. shunting
-Incr. venous admixture to 5-10%
-Inhibition of HPV (incr. pulm. shunt)

Front 133

Signs & symptoms of bronchospasm?

Back 133

-delayed expiratory phase by capnograph
-high peak inspiratory pressures
-wheezing

Front 134

Treatment of bronchospasm?

Back 134

-incr. PIA
-check ETT for secretions, kinks,mucous plugs
-B agonist (albuterol inh)
-IV hydrocortisone (1.5-2mg/kg)

Front 135

Differential diagnosis for bronchospasm?

Back 135

1. Pulm. edema
2. emboli
3. pneumothorax