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112 Cards in this Set

  • Front
  • Back
what is the CNS mechanism of asthma? (3)
1.allergen-induced immunological response
2.abnormal ANS regulation
3.imbalance b/t excitatory (bronchocontraction) and inhibitory (bronchodilation) neural input allowing mast cells to interact w/ ANS
what are 4 airway characteristics of asthma?
1. bronchial hyperreactivity
2. airway inflammation
3. hypertrophy of smooth muscle
4. reversible expiratory airflow obstruction
is asthma obstructive or restrictive? -and- is asthma irreversible or reversible?
expiratory obstruction of airflow; reversible
age incidence in children & adults?
children < 5; adults > 40, smokers w/ emphysema or chronic bronchitis
what endothelium and cardiac disorders associated w/ asthma?
subendothelial fibrosis & cardiac toxicity due to treatments
explain allergen-induced immunologic rxn associated w/ asthma.
1. antigen exposure
2. synthesis & secretion of
IgE antibodies
3. release of histamine,
interleukins, tumor necrosis factor,leukotrienes, prostaglandins, & platelet-activating factor from mast cells
4. airway inflammation, contraction, and hyperreactivit
5. eosinophils infiltrate airways hrs after allergen exposure
6. further release of chemical mediators
what are the 3 classic manifestations of asthma?
1. wheezing
2. coughing w/ copious yellow sputum
3. dyspnea
reason for wheezing?
turbulent airflow thru narrowed airways
during wheezing, what is an omnious sign?
it abruptly stops = complete obstruction of airways
what could single monophasic wheezing that's consistent represent?
focal airway obstruction (e.g. foreign body aspiration, neoplasm, etc.) and not asthma
can coughing be the only symptom of asthma?
what is dyspnea dependent on?
obstruction of the airflow
what other pathologic state can dyspnea mimic?
angina pectoris
what's the typcial functional exhaled volume of asthmatic patient?
< 35% normal
during severe attacks how much can FRC increase?
1-2 liters
what happens w/ TLC during asthma attack?
usually remains normal
how long can residual anomalies of PFTs persist following an attack? are symptoms present?
several days after attack; no symptoms present
are FVC increased or reduced? why?
reduced; because airways close prematurely toward end of maximal expiration
what do abg's reflect with mild asthma?
normal abgs
what do abg's reflect with moderate asthma? why?
hypocarbia & respiratory alkalosis; because of initial hyperventilation
what do abg's reflect with severe asthma? why?
hypercarbia; common cause is muscle fatigue
what happens with your v/q & o2 in severe asthma?
severe v/q mismatch and decreased o2
name 3 diagnostic tests for asthma.
cxr, ekg, & bronchodilator responsiveness
what does cxr show w/ asthma?
hyperinflation of lungs
what does ekg show w/ asthma?
right heart failure & ventricular irritability during acute attack
what is benefit of bronchodilator responsiveness test?
provides supportive evidence when asthma suspected
what does bronchodilator responsiveness test show w/ asthma?
=/> 15% increase in airflow
why would you get false (+) or false (-) w/ bronchodilator responsiveness test?
because of the episodic nature of the disease
name 10 differential dx for asthma.
1. tracheobronchitis
2. sarcoidosis
3. RA
4. CA
5. croup & other upper airway diseases
6. hx of intubation
7. hx of trauma
8. hx of surgery
9. chf
10. pulmonary edema
name 5 different types of asthma.
1. allergen-induced
2. excercise-induced
3. aspirin-induced
4. occupational
5. infectious
Which asthma type is this?
1. IgE mediated
2. most common
3. allergic rhinitis or dermatitis (may be present)
4. genetic
5. release of mediators
allergen induced asthma
what's the physiology behind exercised-induced asthma?
changes in heat & water in tracheobrachial tree during humidification of large volumes of air
what's another name for exercised-induced asthma?
"thermal induced-asthma"
who most commonly suffers from exercise-induced asthma? and why?
children & young adults b/c of high levels of physical activity
what drugs should sufferers of aspirin-induced asthma stay away from?
ASA, NSAIDS (especially tordal)
what physical feature is often seen with suffers of aspirin-induced asthma?
nasal polyps
what's the underlying cause of aspirin-induced asthma?
1. blockage of cyclooxygenase-mediated conversion of arachidonic acid to prostaglandins

2. formation of leukotrienes
how many agents have been noted for occupational asthma?
250 different agents
what are the 2 types of occupational asthma?
IgE dependent and non-IgE dependent
what's the difference b/t the 2 types of occupational asthma?
IgE dependent: longer latency periods b/t exposure & symptoms

non-IgE: brief intervals b/t exposure & symptoms
what are 3 common agents that cause occupational asthma?
what's the underlying cause of infectious asthma?
acute inflammatory disease secondary to viruses, bacteria, or mycoplasma organisms
what were the past therapies for the prevention and control of asthma?
what was the problem w/ using bronchodilators for prevention and control of asthma?
mask underlying inflammatory process by relieving symptoms but allowing continued exposure to allergens
what happens initially w/ ABGs after tx w/ bronchodilators? and what's the cause?
PaO2 initially decreases

2nd to relief of vasoconstriction in poorly ventilated areas
why is the initially drop in PaO2 w/ bronchodilator tx tolerated?
due to greatly enhanced airflow
what is the current preferred first line tx for asthma?
what caused the switch from bronchodilators to steriods for prevention and control of asthma?
asthma now recongnized as chronic inflammatory process
why do bronchodilators work for asthma?
beta-agonist causing dilation of bronchial smooth muscles
what are 2 current uses for bronchodilators?
1. prevention of exercise-induced asthma

2. relief of symptoms when anti-inflammatory therapy is insufficient
what should happen to FEV after drug treatment for asthma?
FEV should return to 50% normal
name 6 drug therapies for asthma.
1. anti-inflammatories
2. cromolyn
3. leukotriene inhibitors
4. bronchodilators
5. anticholinergics
6. methylxanthines
what drug therapy is most effective at controlling chronic symptoms of asthma?
via which route are corticosteriods typically administered?
how long does it generally take for inhaled corticosteriods to take effect?
several months after tx airway hyperresponsiveness is reduced
what drug regimen is associated w/ decreased risk of death from asthma?
regular low-dose inhaled steriods
name some drugs w/in the inhaled steriod class for tx of asthma.
are inhaled steriods water soluble or lipid soluable? and what's the advantage of this property?
highly lipophilic

allows for rapid entery into airway cells
what's the mechanism of action of inhaled steriods?
inhibts gene transcription for cytokines during asthmatic inflammation
how much of the inhaled steriod is swallowed? and is this a problem?
most (~80%)

no, b/c the drug is still systemically absorbed following the first pass effect
what are 4 side effects of inhaled corticosteriods?
1. hoarseness
2. candidiasis (elderly)
3. glossitis
4. pharyngitis
do inhaled steriods effect metabolism? or pituitary-adrenal function?
no evidence

little to no effect even at high doses
how does cromolyn work?
inhibits release of chemical mediators from mast cells
what the disadvantage of cromolyn?
not effective once bronchospasm is present
in relation to anti-inflammatory therapy: how are leukotriene inhibitors used?
with or substituted for anti-inflammatory therapy
which types of asthma do leukotrienes play a role in?
aspirin induced
excercise induced
allergen induced
how do bronchodilators work?
a. stimulate beta 2 receptors
b. increase cAMP
c. tracheobronchial smooth muscle relaxation
r/t steriod therapy: how are bronchodilators typically used?
in combination w/ steriods
which bronchodilator is most selective beta 2 agonist?
name 5 side effects of bronchodilators.
1. SNS stimualtion
2. tachycardia
3. cardiac dysrhythmias
4. intracellular shift of K
5. down regulation
how do anticholinergics work in the tx of asthma?
blocks muscarinic receptors in airway smooth muscle decreasing vagal tone
which respiratory disease process are anticholinergics more effective in ?
give an example of an anticholinergic for tx of asthma.
ipratropium (Isuprel)
give 2 examples of methylxanthines for tx of asthma.
what are the potency level effects of methylxanthines control?
modest anti-inflam

bronchodilator effects < beta 2 agonist
what measurements are important during tx w/ methylxanthines?
blood therapeutic levels
what is status asthmaticus?
un-resolved life-threatening bronchospasm
what are 4 effective tx of status asthmaticus?
1. repeated doses of inhaled beta 2 agonists

2. iv corticosteriods

3. supplemental oxygen to keep sat > 95%

4. broad-spectrum antibiotics
give 2 examples of IV corticosteriods.
what ABG parameter warrants tracheal intubation and mechanical ventilation during status asthmaticus?
PaCO2 > 50 due to resp fatigue despite aggressive treatment
are low or high peak pressure needed for intubated status asthmaticus patients? why?
high peak pressures

in order to deliver adequate TV despite bronchocontriction
what's the disadvantage of OR vents when managing status asthmaticus patients?
too much compressible volume wasted on circuit to deliver adequate TV w/ such high pressure
what's the benefit of high gas flows w/ status asthmaticus patients?
shorter inspiratory time

greater exhalation time

lower PEEP
is hypercarbia positive or negative w/ status asthmaticus patients? why?

can reduce barotrauma
when is general anesthesia required for production of bronchodilation? and what inhalational agents are beneficial?
very ill patients

halothane, enflurane, isoflurane
name 6 preop evaluation goals for anesthesia mgmt of asthma patients.
1. plan that prevents/blunts obstruction of airflow
2. h&p
3. understand: disease & effectiveness of tx
4. listen to pt's lungs
5. PFT (before & after bronchodilator therapy), ABGs, CXR
what 5 drug types may be given to an asthma patient preop? and what concerns are present?
1. opioids (watch
ventilatory effects)
2. anticholinergics (watch
for increased viscosity
of secretions)
3. H2 receptor antagonists
(watch for
bronchoconstriction due
to blocked
bronchodilating effects
of H2)
4. bronchodilators (should
be continued up to
5. corticosteriods
(supplementation may be
needed for larger
surgeries, esp w/
possibility of adrenal
suppresion by drugs used
to tx asthma)
what's the effect of ASA, NSAIDS, etc during postoperative period?
ASA, NSAIDS may produce adverse effects (asthma attack) in pts w/ asthma so use w/ caution
what's the #1 goal of induction and maintenance for asthma pts?
depress airway reflexes w/ anesthetic drugs to avoid bronchoconstriction in response to mechanical stimulation
name one factor that would precipitate bronchospasms during intubation.
inadequate depth of anesthesia to suppress airway reflexes
what is an alternative to intubating? why?
regional anesthesia

will avoid intubation & instrumentation of airway
what's the + or - benefits of propofol w/ asthma pts?
+ = bronchodilating effects

- = use only if hemodynamics are stable
what's the + or - benefits of ketamine w/ asthma pts?
+ = sympathomimetic effects for those actively wheezing

- = do not use in increased ICP, etc.
what's the + or - benefits of thiopental w/ asthma pts?
+ = doesn't cause bronchospasms

- = doesn't suppress airway reflexes enough for instrumentation which may acutally trigger bronchospasms
what is metabisulfates and their significance to asthma pts?
preservative found in generic propofol

may cause bronchospasm
which volatile gas is the most effective bronchodilator? and at what MAC?

MAC < 1.7
which 2 volatile agents are less pungent? which 2 are more pungent? and why is this important?
halothane & sevoflurane < isoflurane & desflurane

less pungent = less coughing and bronchospasms
what's the importance of lidocaine for induction in asthmatics? and when should it be given?
blunts airway relexes

1-3 minutes prior to DVL & intubation
why is albuterol so important during intubation/maintenance phase?
it's most effective at blunting airway responsiveness to intubation
which NMBA is best for asthma pts?
anyone that is less likely to cause histamine release
what is the effect of atricurium on histamine release & the airway of asthma pts?
large increases in histamine release

severe broncospasms following administration
what is the effect of sux on histamine release & the airway of asthma pts?
mild increases in histamine

there's been no evidence of increased airway resistance w/ sux
what effect can anticholinesterase drugs have on the airway of asthma pts? and what's the underlying cause?
bronchospasms of smooth muscles of airway

due to stimulation of postganglionic cholinergic receptors in airway smooth muscles
what blunts the effects of anticholinesterase drugs on the smooth muscles of the airway?
anticholinergic drugs given w/ them during reversal of NMBAs
name 5 facts for ventilatory managments during surgery on asthma pts.
1. slow inspiratory flow
(for optimal V/Q ratios)
2. allow sufficient time for
exhalation (to prevent
air trapping)
3. avoid PEEP (it can impair
adeq exhalation along w/
narrowed airways)
4. humidification (to reduce
transmucosal heat loss
that can trigger
5. maintain hydration w/
liberal IV fluids (aid in
expulsion of secretions)
what are 2 possible extubation plans for asthma pts?
1. deep extubation (b/c airway reflexes are still suppressed)

2. awake extubation (but continuous lidocaine 1-3 mg/kg/hr to minimized airway stimulation may be needed)
what's important to note regarding the admin of ASA, NSAIDS, etc in asthma pts postop?
use caution b/c adverse asthma attacks are possible
name 4 ways to manage intraop bronchospasms in asthma pts.
1. bronchospasm NOT due to
acute asthma exacerbation
will respond to deepening
of anesthesia with
volatile agents OR NMBAs
2. bronchospasm due to acute
asthma exacerbation will
respond to deepening of
anesthesia with volatile
agents but NOT NMBAs
3. beta 2 agonists, i.e.
albuterol, thru T-
connector (for
bronchospasms after
deepened anesthesia)
4. corticosteriod therapy
(for bronchospasms after
deepening of anesthesia &
does albuterol have a synergistic or additive effect w/ volatile agents?
what's the onset of therapeutic action for corticosteriod theraphy?
at least 3-4 hrs after administration
what is the conflict regarding emergency surgery and asthma pts?
conflict b/t airway protection from aspiration & production of bronchospasms w/ awake intubation
compare the use of bronchodilator therapy and regional anesthesia for EMERGENCY surgery in asthma pts.
bronchodilator therapy - insufficient time for benefit

regional anesthesia - may be best option if possible for superficial or extremity injuries