Resp Final - Dr. O'leary: Disorders Of Respiratory Pump

Front 1

what are the 2 things that are involved in controlling resp rate & rhythm?

Back 1

1. chest cage
2. neurophysiologic mechanisms

Front 2

what other parts are a/w respiration?

Back 2

1. medulla
2. pons
3. brainstem
4. muscles
5. skeleton
6. chest cage
7. diaphragm
8. lungs

Front 3

what is the major muscle in respiration (equivalent to heart in keeping people alive)

Back 3

diaphragm

Front 4

what are the 4 neuromuscular (NM) ds effecting muscles of respiration?

Back 4

1. Gullain-barre syndrome
2. myasthenia gravis
3. poliomyelitis
4. amyotrophic lateral sclerosis

Front 5

Gullain-barre syndrome:
general

Back 5

- acute symmetrical, prog inflamm demyelinating polyneuropathy
- immune response to external stim (flu vaccine, hydrocarbon exposure)
- triggers destruction of myelin & failure of NT

Front 6

Gullain-barre syndrome
1. s/sx
2. incidence

Back 6

1. starts in LE; ascending paralysis --> resp failure
2. uncommon; in US, GB leading to resp failure occurs in response to flu vaccination 1/50 mill vaccines
--0.6-1.9/100,000

Front 7

Gullain-barre syndrome:
1. prognosis

Back 7

1. most people survive
2. may be some periph neuropathy as only manifestation
3. 15% cases have some residual wkns
4. end 1st year: 2/3 pt full recovery; end 2 yrs: 89%

Front 8

Gullain-barre syndrome:
MC what...?
what number of pt presenting w/ symps will have some sort of restp mm wkns?

Back 8

1. MC peripheral neuropathy
-- MC neuropathy resulting in resp failure
2. 1/3

Front 9

GB syndrome:
mortality?

Back 9

3-6% each year

Front 10

GB syndrome:
what are the 4 ways that cause resp failure?

Back 10

1. respiratory drive
2. lack upper airway protection
3. inability to maintain vent d/t paralysis
4. pulm complications -> if cant check upper airways, cant clear lungs, cough reflex ineffective --> complications --> failure

Front 11

GB syndrome:
describe how respiratory drive problems lead to resp failure

Back 11

- influenced by receptors in chest wall, diaphragm and lungs
- chemoreceptors (CO2 & O2) attempt to compensate
- leads to resp failure

Front 12

GB syndrome:
describe how lack of upper airway protection leads to resp failure

Back 12

- can't swallow/clear lungs
- mucous builds up
- resp failure

Front 13

myasthenia gravis: general

Back 13

- 2nd MC
- Abs against NMJ; ACh receptor blocked; pt has wkns
- MC presentation is in cranial nerves

Front 14

MG:
1. symps
2. classifications

Back 14

1. ocular sx (photophobia, blurred vision)
wkns inc w/ exercise & imp w/ rest
2. based on thymoma associations (develops in mediastinum)
--> Ossermans
--> Vincents

Front 15

MG:
1. myasthenia like disorders
2. tx of MG

Back 15

1. small cell lung ca, Eaton Lambert syndrome
2. cholinesterase (1* dx test: if given ChEase and symp improve = MG dx)

Front 16

MG:
monitor

Back 16

- monitored w/ spirometry, flow volume loops:
1. measures effective vol movement of air
2. continues to get worse --> may need resp support

Front 17

poliomyelitis: general

Back 17

- almost completely eradicated d/t vaccination
- viral ds effecting motor nerve cells of spinal cords
- depends on which areas attacked --> may need resp support

Front 18

Polio:
- post polio syndrome

Back 18

- pts now in 70s-80s -> survived resp wkns, not presenting w/ weak resp mm
1. return of prog symps
2. involves same mm groups involved in initial infxn
3. if resp failure then -> now resp insufficiency
4. lifetime disability -> worse w/ age, combined w/ deconditioning, obesity, sleep apnea

Front 19

amyotrophic lateral sclerosis:
general

Back 19

- degenerative ds of nervous system (Lou Gehrig)
- recent discovery: animal models that manifest symptoms
- not fully understood etiology

Front 20

amyotrophic lateral sclerosis:
cont'd

Back 20

- prog upper & lower motor neuron ds leading to muscular failure and the end pt is resp failure
- irreversible; once dx = death fo sho

Front 21

Amyotrophic lateral sclerosis:
- what is difficult about this ds?

Back 21

- difficult to prepare pt & family for progression of ds
- may need to make decision to NOT use invasive vent

Front 22

clinical features of NM ds

Back 22

- pt presents w/ altered pattern of resp rate & tidal vol
- vol that is being moved decreases
- resp rate goes up to compensate
- compensation = hypervent

Front 23

what are the 4 things a/w clinical features of NM ds?

Back 23

1. infective cough: infective PNA, bronchitis, cant clear mucous
2. restriction pattern on PFT: overall FV loop smaller, vol LOW
3. inc max insp/exp pressure-> amt of force generated
4. ABG: inc pCO2, dec pO2

Front 24

what is the MC type of diaphragmatic ds?

Back 24

- diaphragmatic fatigue (commonly in ICUs)

Front 25

diaphragmatic fatigue:

Back 25

- d/t underlying ds (CHF, MI)
- diaphragm is like any other mm, except stops working = stop breathing

Front 26

what happens when workload of diaphragm exceeds 30% of max capacity?

Back 26

- if this occurs on a continuous basis, the diaphragm will tire and require rest

Front 27

diaphragmatic fatigue:
1. nL, healthy, upright
2. wt gain, supine position

Back 27

1. workload is low
2. diaphragm contracting down, asked indirectly to lift more -> pt reached where can't work anymore->rest->stop-> sleep apnea

Front 28

diaphragmatic fatigue:
cross over point

Back 28

rests gets longer and longer at night -> last breath that you take, the O2 level has been utilized -> de-saturation -> O2 levels fall -> chemorecept stimulated -> hypoxic -> wake up periodically -> no nL sleep -> chronic fatigue

Front 29

fatigue d/t lack of energy

Back 29

- lack nutrition, as in cardiac pt s/p bypass
- due to FV changes that occur post-op

Front 30

fatigue d/t inefficient contraction

Back 30

- emphysema pt, advanced end stage lung ds ->
- diaphragm domed, grossly hyper inflated ->
- predisposes pt to respt failure

Front 31

max insp pressure

Back 31

- measured @ bedside
- helps determine what is causing the diaphragm fatigue

Front 32

transdiaphragmatic pressure

Back 32

- not exact, but estimate
- MC: pt tries to take breath, displaced diaphragm weak/ paralyzed, abd gets sucked up into chest
- paradox: when pt tries to take breath in, abd starts to collapse

Front 33

what are the 2 types of diaphragmatic paralysis?

which is MC?

Back 33

- unilateral (MC)
- bilateral

Front 34

unilateral paralysis
1 seen in what pop
2 CXR
3 cause
4 MCC
5 common presentation for what?

Back 34

1 pt w/ non-clearing PNA
2 CXR: elevated diaphragm
3 viral illness (non malig)
4 subdiaphragmatic abscess, hernia, etc
5 mediastinal tumors

Front 35

unilateral paralysis:
1. 30 y/o pt with chronic cough (abx/inhalers no help) - what do you do?

Back 35

- sniff test: pt in fluoroscopic setting asked to sniff in and out
- watch diaphragm for nL/abnL movement

Front 36

what do you have to prove/ rule out w/ unilateral paralaysis?

Back 36

- prove there isnt something in the mediastinum (small cell ca)
- r/o w/ CT, MRI

Front 37

What is L sided paralysis MC d/t?

Back 37

- post cardiac bypass
- bypass where heart isnt stopped
->solution used can damage phrenic nerve
-> end up w/ L diaphragm paralysis (most cases reversible)

Front 38

what procedure predisposes pt to post-op PNA?

Back 38

post op sternectomy

Front 39

bilateral paralysis

Back 39

- when pt upright, can use accessory mm
- when sleeping, need external resp support to maintain resp
- life threatening b/c pt uses accessory mm just to maintain resp

Front 40

what are ds affecting chest wall?

Back 40

1. kyphoscoliosis
2. obesity

Front 41

kyphoscoliosis

Back 41

- abnL curve of spine (rare)
- O'Leary has 2 pts w/ advanced osteoporosis -> cor-pulmonale d/t kyphoscoliosis

Front 42

how does cor pulmonale occur w/ kyphoscoliosis?"

Back 42

vol in resp cage dec -> dec SA for gas exchange -> hypoxic conditions -> inc PA pressure -> RH failure -> cor pulmonale

Front 43

what was done in the past to tx TB that resulted in advanced kyphoscoliosis?

Back 43

- crush chest cage
- make TB organism in an anaerobic environment to control it
- developed advanced kypho

Front 44

what does kyphoscoliosis do?

Back 44

- makes resp cage stiffer -> req more energy to move -> perpetuates cycle
- inc rate, dec vol during breathing
- exertional dyspnea d/t cage restriction
- V/Q mismatch
- inc pCO2, dec pO2

Front 45

Obesity

Back 45

- if pt big enough, not moving as much and lungs become restricted
- compounded w/ addn' of sleep apnea =
- PA HTN & cor pulmonale -> resp failure

Front 46

obesity causes _____ventilation

- tx of obesity?

Back 46

- hypo

- lose weight (indx for sx intervention)

Front 47

what happens in obesity that causes problems?

Back 47

- stiffer chest cage d/t extra wt
- higher resting diaphragm, gets more pushed up
- results in lower tidal vol, inc residual vol and inc dead air space

Front 48

Obesity:
. chest wall compliance is
- diaphragm is
- vent rate is
- obstructive apnea leads to

Back 48

- dec chest wall compliance
- high diaphragm
- altered vent rate
- leads to resp failure, col pulmonale