Surgery Cf Ch 23 Acute Respiratory Insufficiency

Front 1

1. A previously healthy young man develops acute respiratory insufficient after being injured in a fall and undergoing operative repair of traumatic orthopedic injuries, what is the next step?

Back 1

a. Administration of supplemental oxygen and transfer to the ICU for closer observation and possible mechanical ventilation in the patient's condition does not improve or deteriorates
b. Diagnosis: acute respiratory insufficiency caused by acute lung injury (ALI)

Front 2

2. Physical exam with acute lung injury?

Back 2

a. Diminished breath sounds and scattered rhonchi.

Front 3

3. CXR for acute lung injury?

Back 3

a. The CXR revealed bilateral Nonne segmental infiltrates

Front 4

4. ABG for acute lung injury?

Back 4

a. Maher hypoxemia.

Front 5

5. CXR or PE?

Back 5

a. Typically presents with a relatively normal cxr.

Front 6

6. Acute lung injury by strict definition?

Back 6

a. ALI requires the respiratory insufficiency view acute in onset
b. Associated with a PaO2:FIO2 value <300
c. Bilateral infiltrates
d. Pulmonary capillary wedge pressure of <18 mm Hg.

Front 7

7. Aspiration?

Back 7

a. Spillage of gastric contents into the bronchial tree causing direct injury to the Airways
b. Can progress to a chemical burn or pneumonitis (especially when pH<3) and predisposed to bacterial pneumonia
c. When the aspirated gastric contents contain particulate matter, bronchoscopy maybe helpful in clearing the airway.
d. Half of affected patients develop subsequent pneumonia not prevented by empirical antibiotics

Front 8

8. What 3 factors increase the risk of DVT and PE occurrence?8. What 3 factors increase the risk of DVT and PE occurrence?

Back 8

1. Bed rest
2. Cancer
3. Trauma

Front 9

9. Clinical hallmarks of pulmonary embolism?

Back 9

a. Acute onset hypoxia associated with anxiety leading to tachypnea and Hypocarbia without significant CXR abnormalities

Front 10

10. Lung contusion?

Back 10

a. One trauma to the chest is a common cause of pulmonary dysfunction resulting from direct parenchymal injury and impaired chest wall function.
b. An injured chest wall leads to impaired breathing mechanics that can range from splinting secondary to a rib fracture to severe impairment of a flail chest.

Front 11

11. What is the morbidity from lung contusion attributed to?

Back 11

a. Direct parenchymal injury and bronchoalveolar hemorrhage, causing ventilation-perfusion (V/Q) mismatch leading to hypoxia.
b. This condition is worsened by chest wall injury pain, leading to atelectasis uninvolved lung.

Front 12

12. Acute respiratory distress syndrome (ARDS)?

Back 12

a. The most severe form of ALI (PaO2:FIO2 <200)
b. This condition encompasses a spectrum of lung injuries characterized by increasing hypoxia and decreased lung compliance

Front 13

13. Pathophys of ARDS

Back 13

a. Initially, injury to pulmonary endothelial cells leads to an intense inflammatory response.
b. Inhomogenous involvement in the lung occurs, with:
1. interstitial and alveolar edema
2. Loss of type II Pneumocytes
3. Surfactant depletion
4. Intra-alveolar hemorrhage
5. Hyaline membrane deposition
6. Eventual fibrosis

Front 14

14. How do the changes of ARDS manifests?

Back 14

a. Clinically as severe hypoxia, decreased lung compliance, and increases dead space ventilation.

Front 15

15. Atelectasis?

Back 15

a. The collapse of alveolar units in patients who undergo general anesthesia, which causes a reduction in functional residual capacity that is further reduced because of incisional pain.
b. Subsegmental atelectasis may progress to obstruction and inflammation leading to a larger airway obstruction and segmental collapse.
c. Most patients have only a low grade fever and mild respiratory insufficiency

Front 16

16. Cardiogenic pulmonary edema?

Back 16

a. Myocardial dysfunction most frequently resulting from ischaemia can produce left ventricular dysfunction, fluid overload, and pulmonary interstitial edema.
b. The increase in the amount of interstitial water compress the fragile bronchovascular structures, thereby increasing the V/Q mismatch and resulting in hypoxia

Front 17

17. What is indicative of a significant alveolar–arterial (A-a) gradient possibly requiring intubation and mechanical ventilation?

Back 17

a. Inability to maintain a PaO2 of 60 mm hg or an oxygen saturation of >91% with a supplemental non-Rebreathing 02 to mask.

Front 18

18. With the adequacy of ventilation generally assessed by?

Back 18

a. Observing the patient's respiratory efforts and subjective symptoms, and quantified by the measurement of PaCO2 by ABG analysis.

Front 19

19. Pathophysiology of acute lung injury-after the inciting event which can be direct or indirect pulmonary insult?

Back 19

a. The resultant cascade of events includes both cellular and humoral components that produce an inhomogenous injury.
b. Inflammatory response involves activated PMNs that generate oxygen radicals, cytokines, lipid mediators, and nitric oxide.
c. The complement, Kinin, coagulation, and fibrinolytic systems are also involved.
d. Endothelial damage ensues with an increase in microvascular permeability leading to the accumulation of extravascular lung water.
e. This soon results in diminished lung volume and decreased lung compliance.

Front 20

20. What further hampers lung compliance in acute lung injury?

Back 20

a. The sloughing of type I Pneumocytes a decrease in surfactant production by type II Pneumocytes.
b. The process continues further aggravating interstitial edema, faveolar collapse, and long consolidation.
c. Immunopathogeneses, inflammatory cells and Fluorex? In the lungs, leading to a decrease in pulmonary compliance and an increase in the work of breathing.

Front 21

21. Update patient went on during the prodromal phase of acute lung injury?

Back 21

a. Difficulty in catching their breath, leading to tachypnea.

Front 22

22. What lab value is ventilation reflected by?

Back 22

a. PaCo2, but the patient's appearance, respiratory rate, and respiratory efforts are equally important end points.
b. Hypercapnia is not associated with anxiety or agitation; therefore, patients with an altered level of consciousness you have paCO2 (by ABG) or end tidal CO2 (by capnography) monitoring to assess ventilation.

Front 23

23. Is CPAP useful for atelectasis?

Back 23

a. Yes.

Front 24

24. 4 types of mechanical ventilation modes?

Back 24

1. Conventional ventilation (positive-pressure ventilation)
2. High-frequency ventilation
3. Liquid ventilation
4. Extracorporeal life-support

Front 25

25. Conventional ventilation (positive-pressure ventilation)?

Back 25

a. Conventional ventilation or positive pressure ventilation fills the lungs via supra-atmospheric pressure applied through the endotracheal tube to the Airways.
b. This creates a positive trans-pulmonary pressure that ensures inflation of the lungs.
c. Exhalation is positive and occurs after release of a positive pressure
d. The major settings are volume and pressure control, where the title volume delivery is based on either volume or pressure limiting settings.

Front 26

26. High-frequency ventilation?

Back 26

a. High-frequency ventilation also uses an endotracheal to facilitate exchange.
b. However, high-frequency ventilation delivers very small tidal volumes, on order of 1 mL per kilogram body weight in a very high rate, approximately 100 to 400 breaths per minute.

Front 27

27. When is high-frequency ventilation used?

Back 27

a. Although this mode has an important role in the treatment of respiratory insufficiency in neonates, and has not had the same success in adults

Front 28

28. Liquid ventilation?

Back 28

a. The theoretical advantage of liquid ventilation lies in its ability to reduce the amount of energy necessary to overcome surface tension of the gas-liquid interface of alveoli.
b. Because disease lungs have less surfactant, liquid ventilation can improve lung compliance.
c. Studies are needed to document the clinical benefits of this ventilation mode

Front 29

29. Extracorporeal life-support?

Back 29

a. Cardiopulmonary bypass or extracorporeal life-support uses a heart-lung machine to take over pulmonary and/or cardiac function.
b. If cardiac function is adequate, a venovenous circuit can be used to remove CO2 and oxygenate the blood.
c. As in the case of high-frequency ventilation, thoroughly success achieved in neonates has not been duplicated in adult populations.

Front 30

30. What is indicated for an immunocompromised individual with new Onset fever and bilateral pulmonary infiltrates?

Back 30

a. Diagnostic bronchoscopy and bronchoalveolar lavage.

Front 31

31. What is the pulmonary capillary wedge pressure approximate?

Back 31

a. The left ventricular end-diastolic pressure.

Front 32

32. A 34-year-old woman is hospitalized for septic shock caused by toxic shock syndrome. She's treated with IV nafcillin and noted to have hypoxemia. A CXR reveals diffuse infiltrates and bilateral lung fields. Which of the following most likely differentiate ARDS from cardiogenic pulmonary edema?

Back 32

a. Pulmonary artery catheter readings.
b. A low-normal pulmonary artery wedge pressure (less than 18 mmHg) supports leaky capillaries (ARDS) as the etiology, whereas a high PCWP suggests a hydrostatic mechanism, cardiogenic pulmonary edema.

Front 33

33. Complete

Back 33

33. Complete