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103 Cards in this Set

  • Front
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list the 4 lung volumes, their definition, and average adult values (ml).
1. tidal volume (TV)= each
normal breath = 500ml
2. inspiratory reserve
volume (IRV) = max addtl
volume insired above TV =
3,000ml
3. expiratory reserve volume
(ERV)= max addtl volume
expired below TV = 1,100ml
4. residual volume (RV)=
volume remaining after
max exhalation = 1,200ml
list the 2 lung capacities, their definition, and average adult values (ml).
1. total lung capacity (TLC)
= TV+IRV+ERV+RV = 5,800ml

2. functional residual
capacity (FRC) = ERV+RV =
2,300ml
what does COPD stand for?
chronic obstructive pulmonary disease
what are the 3 pathologic conditions associated w/ COPD?
1.chronic bronchitis
2.emphysema
3.mucous plugging
name 3 airway specific characteristics associated with chronic bronchitis.
1.obstruction of small
airways
2.hypersecretion of mucus
3.bronchi inflammation
name 4 airway specific characteristics associated with emphysema.
1.destruction of lung
parenchyma; loss of lung
elasticity/recoil
2.obstruction of expiratory
flow; increased airway
resistance
3.collapse of small airways
during exhalation
4.enlargement of air spaces
from air trapping
(bullae) which compress
adjacent lung tissue
what's the most common cause of resp failure?
COPD
is COPD a reversible or irreversible obtructive lung disease?
irreversible
what's the #1 cause of COPD?
cigarette smoking > 10 yrs
what's diagnostic criteria for chronic bronchitis?
productive cough due to hyersecretion of mucus > 3 months during > 2 successive yrs
what's prognosis of chronic bronchitis pt's after having 1st episode of acute resp failure?
death w/in 5 yrs
what are "blue bloaters"?
pt's suffering from chronic bronchitis due to marked decreases in PaO2
name 5 problems associated w/ right ventricular hypertrophy due to chronic bronchitis.
1.systemic HTN
2.JVD
3.peripheral edema
4.passive hepatic congestion
5.occasionally ascites
name a problem associated w/ left ventricular hypertrophy due to chronic bronchitis.
pleural effusion
what are 3 typical physical features of "blue bloaters"?
1.overweight
2.dusky, warm extremities
3.40-55 yo
name 4 causes (other than smoking) for bronchitis.
1.air pollution
2.infection
3.familial factors (genetics)
4.allergies
what makes acute bronchitis different from chronic bronchitis?
acute bronchitis is self limiting
what is the typical cause of acute bronchitis?
viral infection w/ upper resp tract illness
in chronic bronchitis what happens to pts:
a.breathing pattern
b.PaO2
c.PaCO2
d.pulmonary vasculature
e.blood hematolgy
f.cardiac system
a.breathing pattern = moderate dyspnea
b.PaO2 = marked decrease < 65mmhg ("blue bloater")
c.PaCO2 = increased
d.pulmonary vasculature = marked cor pulmonale (from arterial hypoxemia & resp acidosis)
e.blood hematolgy = increaed HCT (from chronic arterial hypoxemia)
f.cardiac system = right ventricular hypertrophy & left ventricular failure
in emphysema what happens to pts:
a.breathing pattern
b.PaO2
c.PaCO2
d.pulmonary vasculature
e.blood hematolgy
a.breathing pattern = severe dyspnea
b.PaO2 = modest decrease ("pink puffer"
c.PaCO2 = normal to decreased
d.pulmonary vasculature = mild cor pulmonale
e.blood hematolgy = normal HCT
what's the prognosis for pulmonary emphysema?
good prognosis as long as supplemental oxygen is continued
what's are 5 PHYSICAL finds of "pink puffers"?
1.thin, emaciated
2.pursed lip breathing
3.anxious
4.prominent use of accessory
muscles
5.normal to cool extremities
what diagnostic test best evaluates the progressive nature of airflow obstruction in COPD?
forced expiratory volume in 1 second (FEV1)
what happens to FEV1 in COPD?
decreases significantly (< 40% normal)
what are the 3 causes of decreased FEV1 in COPD?
1.decreased size of
bronchial lumina
2.increased collapsibility
of bronchial walls
3.decreased elastic recoil
of lungs
What HABIT can decrease FEV1? and at what age range?
smoking (esp > 60 yo)
as COPD advances to severe what happens to breathing patterns? why?
orthopnea

increased airway secretions + airflow obstruction
what is asthmatic bronchitis?
combo b/t chronic bronchitis & reversible bronchospasms
in regard to physical examination findings associated w/ COPD, what happens w/:
a.airflow
b.HR
c.expiratory phase
d.breath sounds
e.wheezing?
a.airflow = expiratory
decreased

b.HR = increased

c.expiratory phase =
increased

d.breath sounds = decreased

e.wheezing? = yes;
expiratory wheezing in
supine position
what's the normal FEV1/forced vital capacity ratio?
> 80% in healthy pts
in COPD, what happens w/:
a.FEV1/FVC ratio
b.RV
c.FRC
d.TLC
a.FEV1/FVC ratio = decreased
b.RV = increased (from air trapping)
c.FRC = normal to increased
d.TLC = normal to increased
what's the advantage of increased RV & FRC?
enlarged airway diameter and increased elastic recoil
what does cxr show w/ COPD? (4 things)
Emphysema findings:
1.hyperlucency of lungs
a.arterial vascular
deficiency in lung
periphery
b.hyperinflation
2.flattened diaphragm
3.vertically oriented cardiac silhouette
4.bullae/blebs (air containing spaces)

Note: chronic bronchitis rarely shows up on cxr
what alterative diagnositic tools can be used to diagnose
emphysema?
CT
name the 2 most effective tx for COPD.
cessation of smoking
chronic administration of O2
when is chronic O2 tx recommended? (3 things)
1.PaO2?
2.Hct?
3.Pulm?
1.PaO2 < 55 mmHg
2.Hct > 55%
3.evidence of cor pulmonale
whats the PaO2 goal of supplemental O2?
PaO2 60-80 mmHg
name other drug therapies for COPD. (6 things)
1.bronchodilators
2.long-acting beta2 agonists
3.corticosteriods
4.intermittent broad antibiotics
5.annual influenza & pneumococcus vaccinations*
6.diuretics*
what other benefit besides release of bronchoconstriction does long-acting beta2 agonist provide?
decreased adhesion of bacteria (i.e. Haemophilus influenza) to airway epithelial cells
why should you take care in administering diuretics for treating cor pulmonale & right ventricle failure in COPD?
diuretic-induced chloride depletion results in hypochloremic metabolic alkalosis that
a.depresses the
ventilatory drive
b.aggravates chronic CO2
retention
what is the best method of ventilation for exacerbations of COPD?
noninvasive positive pressure nasal mask ventalation

avoiding tracheal intubation
what is lung volume reduction surgery and it's benefit?
removal of overdistended, emphysematous regions

allows normal areas to expand increasing FEV1 & potentially PaO2
in the anesth mgmt for lung volume reduction surgery, what type of airway would you use and what 2 things would you want to avoid? (3 things)
1.double-lumen endobronchial tube

2.avoid N2O (could diffuse into emphysematous bullae)

3.avoid excessive (+) airway pressure
a. inspiratory press <20
b. no PEEP
give 2 reasons why CVP monitoring is not reliable w/ COPD pts.
1.gas trapping
2.pulmonary tamponade effect from large emphysematous bullae
describe preop treatment of symptomatic COPD. (3)
1.inhaled ipratropium & beta-
agonists (these 2 have
additive effects)
2.2 wk preop systemic
corticosteriods
3.preop antibiotics for
infections
name some preop regimens for decreasing postop complications in COPD pts. (5)
1.bronchodilators
2.antibiotics
3.smoking cessation (at
least 8 wks)
4.corticosteriods
5.physical therapy (educate
pt on lung volume
expansion techniques)
what's the 2 most important SURGICAL PROCEDURE predictor of postop pulmonary complications?
1.operative site
2.surgery > 3 hrs
what operative site has greatest risk for postop pulmon problems?
abdominal and thoracic
what effect does anesthetic drugs, NMBAs, and surgical trauma have on lung volumes? (3 things)
1.decreased FRC
2.decreased VC
3.atelectasis (lasting
several days postop)
what's the most accurate assessment of postop pulmonary complications in COPD pts?
H&P (better than PFT & ABGs)
a. Hx: exercise tolerace,
chronic cough,
unexplained dyspnea
b. Physical: decreased
breath sounds,
wheezing, prlonged
expiratory phase
what's the benefit of PFTs?
management not assessing risk
name 4 intraoperative strategies for decreasing postop pulmonary conmplications in COPD pts.
1.minimally invasive surgery
(laparoscopy)
2.regional anesthesia
3.avoid long acting NMBA
4.avoid surgical procedures
> 3 hrs
name 3 postop strategies for decreasing postop pulmonary comlications in COPD pts.
1.lung volume expansion
maneuvers (IS, deep
breathing, chest physical
therapy, positive
pressure breathing
techniques)
2.maximize analgesia
3.improve FRC
what surgeries do neuraxial opioids work the best for if you're concerned about resp function postop?
intrathoracic, upper abdominal, and major vascular surgeries
name 4 postop benefits of neuraxial opioids.
1.permit tracheal extubation
2.early ambulation
3.increased FRC & PaO2 (by improving V/Q)
4.restores FEV1 to preop
level
what causes delayed depression of ventilation w/ neuraxial opioid administration?
opioids absored into subarachnoid space diffusing into 4th cerebral ventral area depressing medullary ventilatory center
who is more susceptible to delayed depression of ventilation w/ neuraxial opioids? (4)
1.elderly
2.sensitivity to opioids
3.co-adm w/ systemic opioids
4.poorly lipid soluble opioids (morphine)
name 2 criteria for maintaining mechanical ventilation postop in COPD pts.
1.FEV1/FVC ratio < 0.5
2.PaCO2 > 50 mmHg
name 5 vent settings typically seen postop in COPD pts.
1.FiO2?
2.PEEP?
3.PaCO2?
4.TV?
5.RR?
1.FiO2 at least 50% to maintain PaO2 60-100 mmHg

2.PEEP only if difficult to maintain PaO2 > 60 (take care b/c can cause more air trapping)

3.PaCO2 levels to maintain pH 7.35-7.45

4.TV 10-15 ml/kg

5.RR 6-10 breaths/min
what negative effects do smoking have r/t to surgery? (3)
1.nicotine - sympathomimetic effects on heart; transient lasting 20-30 min
2.increased carboxyhemoglobin - pulse ox overestimation of SpO2
3.mucous hypersecretion, mucociliary transport impairment, narrowing small airways
for what type of surgeries are regional anesthetics traditionally used for? (2)
1.surgeries where peritoneum will not invaded
2.surgeries on extremities
benefit of regionals compared to spinal/epidural for pulmon system?
less pulmonary complications than with spinal or epidurals
at which level is regional sensory suppression not good? why?
above T6

decreases expiratory reserve volume
in general anesthesia for COPD pts, what's the disadvantages of:
a.N2O
b.inhaled anesthetics
c.opioids
d.thiopental
e.midazolam
a.N2O = enlargement & rupture of bullae resulting in tension pneumothorax & decreased FiO2

b.inhaled anesthetics = attenuate regional hypoxic pulmonary vasoconstriction leading to right to left intrapulmonary shunting

c.opioids = prolonged

d.thiopental= prolonged

e.midazolam = prolonged
what's the overall end goal for ventilation mngmt of COPD - a. Vt & b. RR?
a. Vt = large (10-15 ml/kg)
b. RR = slow (6-10 b/min)
whats the benefit of large Vt & slow RR? (4)
1.minimizes turbulent flow
2.maintain optimal V/Q matching
3.allow time for venous return to heart
4.complete exhalation minimizing air trapping
how soon will postop VC return to preop state?
10-14 days
besides COPD, what are some less common causes of expiratory airflow obstruction? (4)
1.bronchiectasis
2.cystic fibrosis
3.bronchiolitis obliterans
4.tracheal stenosis
what expiratory obstructive resp disorder is this?

1.chronic expiratory obstructive resp condition
2.chronic productive cough
3.purulent sputum & massive hemoptysis
4.vascularized granulated tissues
5.irreversible, dilation of bronchus
6.destructive inflammation of bronchial walls
bronchiectasis
2 causes of bronchiectasis.
1.bacterial infections
2.myobacterial infections
physical feature of pt w/ bronchiectasis.
clubbing digits (not found in COPD)
can surgery be used for bronchiectasis? if so what surgeries?
yes.
surgical resection of involve lung

selective bronchial arterial embolization under radiographic control
how much sputum can be produced in pts w/ bronchoiectasis?
massive hemoptysis > 200 ml over 24 hrs
what's the anesth mgmt of bronchiectasis surgery?
double lumen endobronchial tube to prevent spillage of purulent sputum into normal areas of lungs
what is this?

most common life-shortening autosomal recessive disorder
cystic fibrosis
pathophysiology of cystic fibrosis. (4)
1.mutation on chromosome 7

2.defective chloride ion transport in epithelial cells in lungs, pancreas, liver, GI tract, reproductive organs

3.decreased transport of Na & water

4.dehydration
s/s of what?

1.dehydration
2.GI: pancreatic insuffiency; meconium ileus at birth; DM; obstrutctive hepatobiliary tract disease (cirrhosis & portal HTN; malabsorption)
3.GU: obstructive azospermia
4.Resp: coughing, chronic purulent sputum, exertional dyspnea, chronic pansinusitis
cystic fibrosis
cystic fibrosis diagnosis.
sweat chloride concentration ( >80mEq/L)
what does bronchoalveolar lavage show in cystic fibrosis?
high neutrophils
name 3 cystic fibrosis treatment modules.
1.bronchodilators
a.beta2
b.anticholinergics

2.reduction of viscoelasticity of sputum
a.purified recombinant
human
deoxyribonuclease for
digestion

3.antibiotics
a.aminoglycoside
b.b-lactam (for
pseudomonas aeruginosa)
what does the anesth mgmt of cystic fibrosis include? (3)
1.vit K if hepatic fxn poor or malabsorption present
2.volatile agents w/ high O2
3.frequent sxning
what is this?

congenital impairment of ciliary activity in resp tract epithelial cells & sperm tails
primary ciliary dyskinesia
what conditions are associated w/ ciliary dyskinesia?
1. resp (4)
2. GU (3)
3. organs
4. cardiac (2)
1.resp: chronic sinusitis, secondary otitis media, productive cough, bronchiectasis
2.GU: male & female infertility; uterine displacement
3.organs: organ inversion
4.cardiac: dextrocardia (reverse ecg); inversion of great vessels
in relation to primary ciliary dyskinesia, what is the triad of kartagener syndrome?
1. chronic sinusitis
2. bronchiectasis
3. situs inversus
which population is effected by bronchiolitis obliterans?
children
cause of bronchiolitis obliterans?
respiratory syncytial virus
what major resp disorder can bronchiolitis obliterans lead to?
COPD
what disorders/situations can bronchiolitis obliterans accompany? (4)
1.viral pneumonia
2.collagen vascular disease (RA)
3.inhalation of N2O ("siol filler's diseas)
4.graft-versus-host disease after bone marrow transplant
manifestations of which expiratory obstructive resp disorder?

1.dyspnea
2.nonproductive cough
3.cardiogenic pulmonary edema
bronchiolitis obliterans
what is treatment of bronchiolitis obliterans? is it effective?
corticosteriods to suppress inflammatory rxns

not usually effective
what is an extreme example of COPD?
tracheal stenosis
causes of tracheal stenosis? (4)
1.prolonged mechanical ventilation
2.tracheostomy
3.infections
4.systemic hypotension
what's the underlying patho of tracheal stenosis?
a.tracheal mucosal ischemia
b.destruction of cartilaginous rings
c.circumferential constricting scar formation
how can you minimized occurance of tracheal stenosis?
high residual volume cuffs on ett to avoid excessive pressure on mucosa
when will tracheal stenosis become symptomatic?
when adult trachea diameter < 5 mm
manifestations of which expiratory obstructive resp disorder?

1.dyspnea prominent at rest
2.use of accessory muscles
3.ineffective cough
4.audible stridor
5.slow breathing
6.inability to increase Vt
7.decreased peak flow rates during exhalation
tracheal stenosis
treatments of tracheal stenosis? (2)
1.tracheal dilation
2.surgical resection of stenotic tracheal segment w/ primary anastomosis
during surgery w/ tracheal stenosis, what's the goal for:

a.volative agents and oxygen
b.frequency
a.volatile agents w/ maximum FiO2

b.high frequency
what is another inhalational agent not typically used that could be beneficial for tracheal stenosis operations? why?
helium 50-75%

decreases density of gases;
may improve flow thru narrowed tracheal areas
what resp disorder does this describe?

resp: chronic sinusitis, secondary otitis media, productive cough, bronchiectasis
ciliary dyskinesia
what resp disorder does this describe?

GU: male & female infertility; uterine displacement
ciliary dyskinesia
what resp disorder does this describe?

organs: organ inversion
ciliary dyskinesia
what resp disorder does this describe?

cardiac: dextrocardia (reverse ecg); inversion of great vessels
ciliary dyskinesia