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113 Cards in this Set

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What is Restrictive Pulmonary Disease?
any condition that interferes with normal lung expansion during inspiration
restrictive diseases can alter what 3things?
1.ventilation

2.V/Q mismatching

3.diffusion
Reduced TLC eventually leads to decrease in what 2 things?
FEV1 and FVC
In restrictive lung disease, is the FEV1/FVC ratio decreased?
No. can be normal or elevated
Name 4 characteristics of restrictive lung disease.
1.Decreased TLC

2.Altered elastic properties of the lung (stiff lung)

3.pulmonary HTN secondary to destruction of pulmonary vasculature

4.cor pulmonale
Lungs are surrounded by what?
thoracic cage
Thoracic cage consists of what 4 things?
1.parietal pleura
2.skeletal structures
3.skeletal muscles
4.abdominal wall/ abdominal contents
What thoracic cage component influences position and movement of diaphragm?
abdominal wall/ abdominal contents
Respiratory pump apparatus consists of what 4things?
1.Rib cage
2.intercostals
3.diaphragm
4.respiratory accessory muscles
Optimal respiratory pumping requires structural integrity and synchronized contraction what 2 things?
the intercostals & diaphragm
name some Causes of respiratory pump dysfunction. (4)
1.skeletal abnormalities
2.external mass (obesity, pregnancy)
3.neuromuscular disorders
4.pleural disease that restricts lung movement
Acute intrinsic restrictive lung disease is also known as?
pulmonary edema
Name some disease processes that can lead to ACUTE INTRINSIC restrictive lung disease. (8)
1.Acute respiratory distress syndrome
2.Aspiration
3.Neurogenic problems
4.Opioid overdose
5.High altitude
6.Reexpansion of collapsed lung
7.Upper airway obstruction (negative pressure pulmonary edema)
8.CHF
Name some disease processes that can lead to CHRONIC INTRINSIC restrictive lung disease. (6)
1.Sarcoidosis
2.Hypersensitivity pneumonitis
3.Eosinophilic granuloma
4.Alveolar proteinosis
5.Lymphangiomyomatosis
6.Drug-induced pulmonary fibrosis
Name some disease processes that can lead to CHRONIC EXTRINSIC restrictive lung disease. (12)
1.Obesity
2.Ascites
3.Pregnancy
4.Deformities of costovertebral skeletal structures (Kyphoscoliosis, Ankylosing spondylitis)
5.Deformities of the sternum
6.Flail chest
7.Neuromuscular disorders
8.Spinal cord transection
9.Guillain-Barre syndrome
10.Myasthenia gravis
11.Eaton-Lambert syndrome
12.Muscular dystrophies
Disorders of the pleura and mediastinum that can lead to restrictive lung disease. (4)
1.Pleural effusion
2.Pneumothorax
3.Mediastinal mass
4.Pneumomediastinum
What are the clinical manifestations of restrictive lung disease? (7)
1.Decreased vital capacity
2.Expiratory flow rates remain normal
3.FEV1/FVC is preserved
4.Increased work of breathing (dyspnea)
5.Rapid, shallow breathing pattern (Leads to increases in PaCO2)
6.Hypercarbia & arterial hypoxemia (cause vasoconstrictive pulmonary HTN & cor pulmonale)
7.Recurring atelectasis or pneumonia
Which lung volumes/capacities are decreased with restrictive lung diseases? (4)
1.TLC
2.FRC
3.RV
4.VC
What are 2 underlying causes of ACUTE INTRINSIC restrictive lung disease?
1.increased pulmonary capillary pressure
- or -
2.increased pulmonary capillary permeability
what do chest radiographs typically show in ACUTE INTRINSIC restrictive lung disease?
bilateral symmetrical opacities (butterfly pattern)
Manifestations of cardiogenic pulmonary edema. (5)
1.Extreme dyspnea
2.Tachypnea
3.Systemic HTN
4.Tachycardia
5.Diaphoresis
what 4 things will manifest with Capillary Permeability Pulmonary Edema?
1.air bronchograms on CXRs
2.High concentrations of protein in edema fluid
3.secretory products related to an inflammatory process
4.Diffuse alveolar damage (ARDS)
What's the underlying cause of ARDS?
1.Diffuse pulmonary endothelial injury
2.Pulmonary edema secondary to marked increases in pulmonary capillary permeability to water, solutes, and macromolecules (including proteins)
ARDS is often associated with what 3 things?
1.sepsis
2.multi-system organ failure
3.high mortality rate
What is posttraumatic multiple organ system failure?
hyperdynamic, hypermetabolic state similar to sepsis
who is usually effected by posttraumatic multiple organ system failure?
critically ill or injured patients
WHat happens to the following systems in posttraumatic multiple organ system failure?
a.Lungs
b.GI
c.CV
d.CNS
a.Lungs = usually first to fail, followed by liver & kidneys
b.GI = mucosa fails
c.CV = ventricular wall motion abnormalities; paradoxical increases in CO
d.CNS = dysfunction may reflect catabolic byproducts
What's the mortality rate of posttraumatic multiple organ system failure?
nearly 100% if 3 or more organ systems affected
describe sequence of effects that lead to Aspiration Pneumonitis. (4)
1.Aspirated gastric acid 2.destruction of surfactant-producing cells & damage to pulmonary capillary endothelium
3.Atelectasis
4.Intravascular fluid leaks into lungs (permeability pulmonary edema)
What other lung disorder does aspiration pneumonitis presentation similar to?
ARDS
What are the clinical manifestations of aspiration pneumonitis? and which one is the most consistent? (4)
1.Arterial hypoxemia (most consistent clinical manifestation)
2.tachypnea
3.bronchospasm
4.pulmonary vascular vasoconstriction with pulmonary HTN
Regarding chest films for aspiration pneumonitis:

a.when will evidence of injury show up?
b.where will evidence of injury most often show up?
a. 6-12 hrs after aspiration
b. right lower lobe
When treating aspiration pneumonitis, What are the interventions? what is the most beneficial intervention?
1.If tracheal tube in place lavage with saline can be performed but may lead to exaggerated spread of the aspirate to peripheral lung tissue
2.medications (beta agonist nebulizers, antibiotics, corticosteroids, albumin)
3.Most effective treatment is delivery of supplemental oxygen and the use of PEEP
Pros and/or cons of beta agonist nebulizers on aspiration pneumonitis. Give an example of a beta agonist.
relieves bronchospasms

albuterol
pros and/or cons of antibiotic use for aspiration pneumonitis.
administered prophylactically, but no evidence that decreases the rate of infection
pros and/or cons of corticosteriod use for aspiration pneumonitis.
controversial
pros and/or cons of albumin use for aspiration pneumonitis.
may be used to treat hypoalbuminemia but may cause further extravasation
What population of patients experience neurogenic pulmonary edema?
acute brain injury (especially medulla)
Sequence of events that lead to neurogenic pulmonary edema. (4)
1.massive outpouring of SNS impulses from the injured CNS
2.generalized vasoconstriction
3.shift of blood volume into pulmonary circulation
4.Increased pulmonary capillary pressures leads to leakage of fluid into interstitial spaces and alveoli of lungs
Treatment of neurogenic pulmonary edema
1.decreasing ICP
2.support of oxygenation & ventilation
3.diuretics should not be used unless hypervolemia is present.
at what altitudes do you typically see High-Altitude Pulmonary Edema?
2500 to 5000 meter altitudes
Regarding High-Altitude Pulmonary Edema, how can the onset of symptoms be characterized?
Onset of symptoms is often gradual but typically occurs within 48 to 96 hrs.
Presumed caused of High-Altitude Pulmonary Edema?
hypoxic pulmonary vasoconstriction, which increases pulmonary vascular pressures
Treatment of High-Altitude Pulmonary Edema?
1.Administration of oxygen
2.Prompt descent from the high altitude
3.Inhaled nitric oxide may improve arterial oxygenation
Cause of Pulmonary Edema from Reexpansion of a Collapsed Lung?
increased capillary permeability due to
Rapid reexpansion of a collapsed lung
Risk of Pulmonary Edema from Reexpansion of a Collapsed Lungis related to what 3 things?
1.amount of air or liquid in pleural space
2.duration of collapse
3.rapidity of reexpansion
Treatment of Pulmonary Edema from Reexpansion of a Collapsed Lung.
--supportive
--No evidence that diuretics are useful
Cause of Negative-Pressure Pulmonary Edema?
development of highly negative intrapleural pressures caused by vigorous inspiratory efforts against an obstructed upper airway
Negative-Pressure Pulmonary Edema can lead to? (7)
1.Decreased interstitial hydrostatic pressure
2.Increases venous return
3.Increases left ventricular afterload
4.intense SNS activation (systemic HTN)
5.central pooling of blood volume
6.Pulmonary edema
7.Arterial hypoxemia
What can further promote edema formation in Negative-Pressure Pulmonary Edema ?
Arterial hypoxemia and the SNS discharge
What causes pulmonary edema in negative-pressure pulmonary edema?
increased transcapillary pressure gradients
what conditions can lead to negative-pressure pulmonary edema?
1.postextubation laryngospasm
2.epiglottitis
3.tumors
4.obesity
5.hiccups
6.obstructive sleep apnea
Treatment of negative-pressure pulmonary edema?
1.Maintenance of a patent upper airway
2.Administration of supplemental oxygen
3.Mechanical ventilation may be needed for brief period
Radiographic evidence of pulmonary edema associated with negative-pressue pulmonary edema usually resolves within what period of time?
12 to 24 hours
Chronic Intrinsic Restrictive Lung Disease
is characterized by what changes? (3)
1.changes in intrinsic properties of the lungs
2.loss of pulmonary vasculature
3.Pulmonary HTN & cor pulmonale
what disease process is chronic intrinsic restrictive lung disease associated with?
pulmonary fibrosis
with Chronic Intrinsic Restrictive Lung Disease, what is common with advanced pulmonary fibrosis?
Pneumothorax
what is Sarcoidosis?
Systemic granulomatous disorder
what is an airway problem you may encounter with sarcoidosis?
Laryngeal sarcoids may interfere with the passage of adult-size endotracheal tubes
What changes with regard to lung tissue and capillary functioning in sarcoidosis?
Diffusion capacity for CO2 across alveolar capillary membranes may be decreased
what is the treatment of sarcoidosis?
Corticosteroids often used for treatment
what is Hypersensitivity Pneumonitis?
diffuse interstitial granulomatous reactions in the lungs after inhalation of dust containing fungi spores, or animal or vegetable material
what are the S&S of Hypersensitivity Pneumonitis?
1.cough 4-6 hrs after inhaling antigens
2.leukocytosis
3.eosinophilia
4.pulmonary fibrosis (repeated episodes)
Cause of Pulmonary Alveolar Proteinosis?
unknown etiology
Pulmonary Alveolar Proteinosis is characterized by what?
deposition of lipid-rich proteinaceous material in the alveoli
can Pulmonary Alveolar Proteinosis occur independently or with other disorders? if with other disorders name some.
May occur independently or in association with chemotherapy, AIDS, or inhalation of mineral dusts
what is interesting about the remission of Pulmonary Alveolar Proteinosis ?
can be spontaneous
Treatment of severe cases of Pulmonary Alveolar Proteinosis includes?
whole lung lavage to remove alveolar material and improve macrophage function
Airway management during anesthesia for lung lavage includes what?
placing a double-lumen endobronchial tube to optimize oxygenation during lavage
what is Lymphangiomyomatosis?
Restrictive & obstructive lung disease with decreases in diffusion capacity
cause of Lymphangiomyomatosis?
Proliferation of smooth muscle in abdominal and thoracic lymphatics, veins, and bronchioles
what population does Lymphangiomyomatosis occur in ?
females of reproductive age
Lymphangiomyomatosis
S&S? (4)
1.Progressive dyspnea
2.hemoptysis
3.recurrent pneumothoraces
4.ascites
when do patients with Lymphangiomyomatosis typically die?
within 4 years
Chronic Extrinsic Restrictive Lung Disease is usually due to what type of disorders?
disorders of the thoracic cage that interfere with expansion of the lungs
what are the highlights of Chronic Extrinsic Restrictive Lung Disease ? (4)
1.Lungs compression
2.Decreased lung volumes
3.Increased work of breathing
4.Compression of pulmonary vasculature commonly leading to RV dysfunction
what is the underlying cause lung dysfunction in Obesity?
Restriction of thoracic cage by extra weight on rib cage & large abdominal panniculus
what does restriction associated with obesity lead to? (3)
1.Decreased FRC
2.Little interference with lung function at rest
3.May experience significant dyspnea during exercise due to decreased compliance of the respiratory system
what is mild to moderate Kyphoscoliosis? and what clinical manafestations will you see?
scolitotic angle <60 degrees

1.minimal to mildly restrictive ventilatory defects
2.dyspnea during exercise
what is Severe Kyphoscoliosis? and what clinical manafestations will you see?
scoliotic angle >100 degrees

1.chronic alveolar hypoventilation
2.arterial hypoxemia
3.secondary erythrocytosis
4.pulmonary HTN & cor pulmonale
Kyphoscoliosis
Respiratory failure is most likely in patients associated with what 2 things?
1.vital capacity < 45% of the predicted value
2.scoliotic angle of more than 110 degrees
what can CNS depressant drugs do to
kyphoscoliosis patients?
Increases the risk for developing pneumonia and hypoventilation
cause of Flail Chest?
Multiple rib fractures
what is Flail Chest?
Paradoxical inward movement of the unstable portion of the thoracic cage as the remainder of the thoracic cage moves outward during inspiration; The same portion of the chest then moves outward with exhalation
Flail Chest manifestations? (4)
1.Diminished tidal volumes
2.Progressive arterial hypoxemia
3.Alveolar hypoventilation
4.Increased PaCO2
Flail chest Treatment:
positive-pressure ventilation until stabilization of rib fractures accomplished
what is the underlying cause of neuromuscular disorder restrictive lung disease?
interference with the transfer of CNS output to skeletal muscles necessary for inspiration & expiration
what is neuromuscular disorder restrictive lung disease characterized by?
Expiratory muscle weakness prevents generation of normal respiratory pressures
or forceful coughs
what is the underlying cause of pneumonia and/or resp failure in neuromuscular disorder restrictive lung disease?
retained secretions after administration of depressant drugs
Pts with neuromuscular disorder restrictive lung disease depend on what to maintain ventilation?
wakefulness
what happens during sleeping in pts with neuromuscular disorder restrictive lung disease ? (3)
1.arterial hypoxemia 2.hypercapnia
3.cor pulmonale
Common neuromuscular disorders associated with restrictive lung disease.
1.Diaphragmatic Paralysis
2.Spinal Cord Transection
3.Guillan-Barre Syndrome
4.Myasthenia Gravis
5.Muscular Dystrophy
Pleural Effusion
Signs & symptoms? (6)
1.Dyspnea (usually severe)
2.ipsilateral chest pain
3.Arterial hypoxemia
4.Hypotension
5.Hypercarbia
6.Tachycardia (most common physical finding)
Treatment of pneumothorax? (3)
1.Chest tube placement or 2.Observation if pneumothorax is small & pt 3.Supplemental oxygen
what are Mediastinal Tumors
associated with?
Superior vena cava syndrome
what is Superior vena cava syndrome? and what does it lead to? (4)
obstruction of venous drainage in upper thorax

1.Dilation of collateral veins in thorax & neck
2.Edema & cyanosis of the face, neck, & upper chest
3.Edema of the conjuctiva
4.Increased ICP
what causes Acute Mediastinitis?
results from bacterial contamination following esophageal rupture
Pneumomediastinum causes? (2)
1.may follow tracheostomy & alveolar rupture
2.may also occur spontaneously
what are Bronchogenic Cysts?
fluid or air filled cysts lined with respiratory epithelium
what are the symptoms of bronchogenic cysts?
may be asymptomatic or lead to airway obstruction
where are bronchogenic cysts usually located?
adjacent to the tracheobronchial tree
PAT for restrictive lung disease patients should include what 6 things do you want to focus on?
1.severity of lung disease
2.treating reversible components
3.pulmonary fxn studies, ABGs if hx of dypsnea
4.CXRs
5.CT scans
6.flexible fiberoptic bronchoscopy
what reversible componentes of restrictive lung disease may be treated prior to surgery? (5)
1.pulmonary infections
2.improvement of sputum clearance
3.cardiac dysfunction
4.improve breathing strength w/ exercises
5.respiratory therpy training
what are CTs beneficial for preope in restrictive lung disease pts?
1.diagnosis of mediastinal tumors
2.evaluation of degree of tracheobronchial compression
what is an alternative for evaluating airway obstruction in restrictive lung disease pts?
flexible fiberoptic bronchoscopy
Anesthesia Management of restrictive lung disease pts should include? (4)
1.Minimize ventilation depression
2.Avoid nitrous oxide in patients with known or suspected pneumothorax
3.Regional anesthesia could be considered for dermatome levels below T10
4.May require increased peak pressures to inflate poorly compliant lungs
Diagnostic Techniques for restrictive lung disease. (4)
1.Fiberoptic bronchoscopy
2.Percutaneous needle biopsies
3.Pleuroscopy
4.mediastinoscopy
what is the fiberoptic bronchoscopy good for?
visualizing airways and obtaining biopsies
what is a pleuroscopy?
- fiberoptic scope introduced into the pleural space through the intercostal space
what type of anesthesia does a mediastinoscopy require?
general
what is a mediastinoscopy?
- performed through small transverse incisions just above suprasternal notch
- blunt dissections of the pretracheal fascia & biopsy of paratracheal lymph nodes to the level of the carina
Mediastinoscopy Complications include? (5)
1.Pneumothorax
2.Mediastinal hemorrhage
3.Venous air embolism
4.Injury to recurrent laryngeal nerve (hoarseness & vocal cord paralysis)
5.
Transient loss of distal pulses in right arm during mediastinoscopy warrants what monioring modification?
monitor BPs in the left arm during the procedure