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449 Cards in this Set

  • Front
  • Back
The prime function of the lung is to
alow 02 to move from the air into the venous b lood and c02 to move out
02 and c02 move between air and blod by ___,from an area of __ to __.
simple diffusion

high to low partial pressure
there are __ alveoli in the lung, each about __ diameter. If they were spheres, their area would be __ but thier volume only ____
300 million

1/3mm

85 meters sq

4 liters
the trachea divides into the __ and __, then__, then__.
right and left main bronchi

lobar bronchi

segmental bronchi
__ are the smallest airways without alveoli
terminal bronchioles
____ airways do not participate in gas exchange, but lead air to the gas exchange airways in the lung
conducting airways
the ______ consitute the ADC and is about ___ml.
conduction airways

150ml
the terminal bronchiloes divides into the _____ which have occasional alveoli
respiratory bronchioles
the respiratory bronchioles lead to the _______ which are completely lined with alveoli
alveolar ducts
the alveolar region of the lung that contributes to gas exchage is called the zone _____
repiratory
The partial pressure of a gas is found by multiplying its ____ by the ______
concentration

total pressure
water vapor pressure at sea level is __
47mm
the alveolar are __ in shape
polyhedral
The holes in alveolar walls are __
pores of Kohn
the portion of the lung distal to a terminal bronchiole forms an anatomical unit called the __
acinus
The distance from the terminal bronchiole to the most distant alveolus is only __, but the ___ zone makes up most of they zone lung.
a few mm

respiratory zone (2.5-3.0 liters during rest
The forward velocity of the gas becomes ____ beyond the terminal bronchioles
small
____ is the dominant mechanism of ventilation in the respiratory zone
diffusion of gas within the airways
inhaled dust settles in the _____ because...
region of the terminal bronchioles

because the velocity of the gas falls rapidly
gas movement in the alveolar zone is chiefly by __
diffusion
volume of the alveolar region,
2.5-3.0 liters
ADC volume
150ml approx
in the lung periphery, the ___ travel together down the center of the lobules
arteries and bronchi
The diameter of a capillary segment is about ___
10 um
A mean PA pressure of about __ is required for a flow of 6-lpm
20 cm water (15mmHg)
level of equilibration of 02 and c02 between alveolar gas and capillary blood
virtually complete
the additional blood system of the lung?
bronchial circulation, which supports the conducting airways down to about the terminal bronchioles

the lung can function OK without it (LUNG transplant)
the whole of the right heart output goes to the
lungs
thickness of blood gas barrier?
less than 0.3um
time blood spends in the capillaries
3/4 of a second
relatively large forces develop that tend to collapse alveoli because?
the surface tension of the liquid lining the alveoli (lowered by surfactant)
large particles are filtered out in the ____
nose
smaller particles that deposit in the conduction airways are removed by the...
moving staircase of mucous

secreted by mucous glands and goblet cells in the bronchial walls
the alveoli have __ cilia?
NO
particles that deposit in the alveoli are removed by...mphatics
engulfed by large macrophages, then removed by lymphatics
volumes that cannot be measured with a spirometer
total lung capacity
FRC
residual volume
total lung capacity is
vital capacity + residual volume
vital capacity is
maximal inspiration followed by maximal expiration

the exhaled volume is the VC
volume left in lung after maximal expiration is...
residual volume
volume left after normal expiration...
FRC
2 ways to measure FRC..
helium spirometry

total body plethysmography
Boyles law?
pressure x volume is constant (at constant temp)
___ and ___ can be measured with a simple spirometer
Vt, VC
body plethysmography relies on which gas law
Boyles
alveolar ventilation is...
Ve-ADC
what is the most effective way of increasing Va?
increasing Vt, because this reduces the proportion of each breath occupied by the anatomic dead space
If the alveolar ventilation is halved (and C02 production remains unchanged) the alveolar and arterial PC02 will ___
double
what is the volume of the conduction airways called>
ADC, 150ml
ADC can be measured by...
Fowlers method (nitrogen analyzer) reflects lung morphology

Bohr's method measures the volune of the lung that does not eliminate C02
___ regions ventilate better than ___ regions
lower ventilates better than upper zones
ventilation per unit volume is greatest at ________ and becomes progressively smaller towards the ____
near the bottom

top

disappears with supine positon
ventilation changes with supine
apical and basal ventilations become the same, but the posterior ventilation exceeds the anterior.

the DEPENDENT lung is best ventilated, the superior lung is best perfused
the rate of gas transfer is proportional to a diffusion constant which depends on __ and __.
properties of the tissue and the particular gas
C02 diffuses about 20x 02 because...
it has a much higher solubility but not a very different molecular weight
rate of diffusion of a gas though a tissue is ____ to the area, but is ____ to the thickness
proportional to the area

inversly proportinal to the thickness
the diffusion rate is proportinal to the _____ difference
partial pressure
diffusion rate is proportional to the ______ of the gas in the tissue but ______ to the square root of the molecular weight
proportional to solubility

inversely proportional to the square root of the molecular weight
the transfer of CO is _____ limited
diffusion limited

limited by the diffusion properties of the blood gas barrier, NOT by the amount of blood available
the transfer of nitrous oxide is ____ limited
perfusion limited

limited by the amount of blod available
O2 transfer is generally ___ limited but can be ____ limited in conditions that thicken the barrier.
normally perfusion limited

diffusion limited with disease
functions of the respiratory system [5]
gas exchange
acid-base balance
phonation
pulmonary defense
metabolism
the peripheral chemoreceptors sense the __, __ and __ levels in the arterial blood.
02, C02, H+ ions
the central chemoreceptors monitor the __ and __ levels in the CSF.
C02, H+
the cells of the pulmonary circulation can metabolize what important substance?
angiotensin 1 via ACE to AT2
The airway consists of the...[5]
nose, pharynx, larynx, trachea and lower airways
the components of the respiratory system are the...[4]
conducting airways
lungs
CNS-responsible for ventilation
chest wall
the floor of the nose is at a higher/lower level than the opening of the nostril?
higher
the anterior portion of the external nose is the
VESTIBULE, which expands above and behind into triangular spaces or FOSSAE
the posterior nares aka.____, open into the _____
choanae

pharynx
_____ is a birth defect that results in the obstruction of the airway of the obligate nose breathing newborn
choanasal atresia
the _____ choncha is in the pathway of airflow in the nose and is the one most commonly injured during nasal intubation
inferior
the respiratory mucosal tract lines the lower 2/3s of the _____ and consists of ______ and ______.
nose

ciliated epithelial cells
mucous glands
the principal arterial supple of the nasal fossae comes from the ______ through the ______ and from the ______ through the______
opthalmic arteres through the anterior and posterior ethmoid branches

internal maxillary artery through the sphenopalatine arteries
the ______ is sometimes ligated for the treatment of persistant epistaxis
internal maxillary artery
the ethmoid veins open into the ___ and the nasal veins drain in to the _____
ethmoid-superior sagital sinus

nasal-opthalmic veins into the cavernous sinuses

infections of the nose can result in meningitis because of the communicatino between the intercraninal and intranasal circulation
the lymphatic drainage from the cavaties of the nose is via the...
deep cervical lymph nodes adjacent to the IJV.
the sensory nerves from the upper resp tract come from the _____ and _____
opthlamic nerve (V)
maxillary nerve (V)
almost no particle greater than ____ in size is allowed to enter the trachea.
6mm
the ____ is part of both the resp and ailementary tract
pharynx
the upper border of the pharynx is _____ and extends to the level of ____.
base of the skull

C6

at this level foreign bodies are frequently lodged
the nasopharynx extends from the __ to the __.
nares to the end of the soft palate
the oropharynx is bound superiorly by the __ and anteriorly by the __ which extend inferiorly to the ___.
soft palate

tonsillar pillars

tip of the epiglottis
the laryngopharynx extends from the __ to the _____.
tip of the epiglottis

level of C6
the major tonsils are the ____ which like in the ____
palatine

tonsilar fossa
the ___ tonsils extend across the tongue from the base of each palatine tonsil
lingual
the _____ tonsils lie on the lateral wallser of the nasopharynx
adenoid or pharyngeal
the tonsils create the ____ ring.
Waldeyer's RING-first line of defense against bacterial invasion
blood supple to the entire mouth and pharyngeal region is from the...
branches of the external carotid artery
venous drainage from the entire mouth and pharyngeal region is via the...
facial vein and EJV.
The nerve supply to the inner mouth is from..
CN 7, 9, 10
the lypmhatic drainage for the entire mouth and pharyngeal region is via...
cervical lymph nodes under and anterior to the SCM (lumps in neck with sore throat)
the adult larynx extends from __ to __ and is a protective structure that prevents__
C3 to C6

prevents aspiration during swallowing, vocalization evolved secondarily
the larynx consists of __ bone(s), __ peices of cartiladge, ligaments, muscles and membranes
1

9
the ___ bone is the chief support for the larynx.
hyoid
the ___ and ___ make up the principal part of the framework of the larynx.
thyroid cartilage
crichoid cartilage
the ____ cartilage lies closest to the root of the tongue and is vertical to the opening of the larynx
epiglottic
the epiglottis is attached to the body of the thyroid by the __ abd to the base of the tongue by the__.
throepiglottic ligament just above the vocal cords

glossoepiglottic folds
______'s level corresponds to the beginning of the trachea and the esophagus.
cricoid cartilage
the arytenoid cartilages articulate on the ____ aspect of the ___, which is slanted forward
superior posterior aspect of the cricoid cartilage
the paired arytenoid cartilages are attached to the __ ends of the __.
posterior ends of the vocal cords.
the paired corniculate (median) and cuneiform (more lateral) cartilages are embedded in the ___.
aryepiglottic folds
the ____ ligament suspends the larynx from the hyoid bone.
thyrohyoid ligament
the ____ or ____ membrane lies between the cricoid and the thyroid cartilages.
conus elasticus or cricothyroid
the cavity of the larynx is divided into 3 compartments by the __ and the __.
false vocal cords

true VC's
the supraglottic area extends from the ___ to the ___
false cords to the tip of the epiglottis
on each side of the supraglottic area is the _____
pharyngeal sinus aka pyriform sinus

food/foreign bodies can become lodged here
the second component of the larynx is _______, located between the false cords and the true cords
laryngeal ventricles
the third area of the larynx is from below the true cords to the beginning of the trachea is know as the _____
infraglottic region
the space between the true cords is the..
rima glottis
the true VC are ____ folds attatched anteriorly to the ___ and posteriorly to the ____.
anteriorly to the thyroid cartilage

posteriorly to the arytenoids
the laryngeal inlet is closed by the ___ and opened by the ___
aryepiglottic muscle

thyroepiglottic muscle
the glottic slit is dialated by the ___ and closed by the ____
posterior cricoarytenid muscle

interarytenoid muscle assisted by the lateral cricoarytenoid muscle
the ____ lengthen the true VC's and the ___ shorten them
cricothyroid muscle

thryoarytenoid muscle

both sets of muscles are important for determining pitch.
___ and ___ muscles are important for determining pitch.
cricothyroid muscle

thryoarytenoid muscle
what are the 9 cartilages of the larynx?
1 eppiglotic
2 thyroid
3 cricoid
4,5 arytenoids
6,7 corniculates
8,9 cuneiforms
both the superior and inferior laryngeal nerves are branches of the ____
Vagus
the superior laryngeal nerve arises from the ___ of the ____ and divides into __ and __.
ganglion nodosum of the vagus

internal and external
the external superior laryngela nerve gives a branch to the ___ muscle of the ___ and also to the ____ muscle.
inferior constrictor muscle of the pharynx

cricothyroid muscle

these change the position of the cricoid and thyroid cartilages and increase the tension of the VC's

if paralyzed, the voice is rough, weak and easily fatigued
the internal branch of the superior laryngeal nerve enters the larynx and then the thyrohyoid membrane and is distributed to the __ and the __.
mucus membranes of the larynx and epiglottis
the _____ provides sensation from the laryngeal side of the epiglottis down to the true VC.
internal branch of the superior laryngeal nerve
the ___ provides sensation to the tongue side of the epiglottis.
glossopharyngeal
the ____ innervates the interarytenoid muscles which are important in phonation.
internal branch of the superior laryngeal nerve
the inferior aka [recurrent] has 2 branches. the left descends with the ___ and the loops around the ___ to come back up to the neck.

the the right travels with the ___ to the ____ (loops around) and then back up to the neck.
vagus, aorta

vagus, SCA
the ____ supplies sensation to the larynx below the level of the VC's and innervates all the muscles of the larynx except the ___ and ___..
recurrent laryngeal

cricothyroid and part of the interarytenoid muscles
the blood supple to the larynx is provided by the ___ and __.
superior thyroid artery (branch of external carotid)

interior thyroid artery (branch of thyrocervical trunk, which arises from the subclavian artery)
the trachea is lined by ____ and extends from the ___ to the ___.
ciliated columnar epithelium

inferior larynx to the carina
in adults the distance from the incisors to the larynx is ___ as is that from the larynx to the __.
13 cm

carina
distance from incisors to carina in adult?
26cm
the carina is at the level of ____. This corresponds to the ___ which is at the articulation of the _____.
t4-t5

angle of louis on the sternum

2nd rib
if a patient flexes the neck, the trachea moves _______ as a result, the ETT moves ____.
upward

downward
extubation is possible with neck flexion/extension?
extension
the blood supple to the trachea is through the _____, which comes from the _____.
inferior thyroid artery

thryocervical branch of the SCA
the trachea is innervated by the
vagus
the right mainstem bronchus is ___ and ___ than the left
shorter and wider
the hole aka______ on the non-beveled edge of the ETT allows delivery of gas to the ___ is the tip of the tube is on the carina
murphy eye

left mainstem bronchus
the right mainstem bronchus ends ___ from the carina before giving rise to the _____
1.5 cm

right upper lobe bronchus
the left mainstem bronchus is ___ in length
5cm
the lingular branch is ____
a the lower half of the left upper lobe bronchus
the ____ ventilate the bronchopulmonary segments of the lungs
segmental bronchi
the alveolar ducts lead to ____
atria, each atria has 2 to 5 alveoli
dual blood supple of the lung?
bronchial, pulmonary
the bronchial arteries [__ on right, __ on left]

arise from the __
one on right, 2 on left

descending aorta
(2-3% of CO)
the bronchial and pulmonary vessels meet and anastamose at the __
junction of the terminal and respiratory bronchioles
the bronchioles without cartilagenous support are the
terminal
the right lung has ___ BPS's and the left has ___

segments that contain the word basal are located adjacent to the_____
right has 10
left has 8

diapraghm
the nerve supple to the bronchi and the lungs arises chiefly from the ____
sympathetic nerves


vagus nerve (sensation and parasympathetic)
all conduits to the lung pass through the
hilum
RIGHT LUNG

LOBES, SEGMENTS
upper
-apical
-anterior
-posterior

middle
-medial
-lateral

lower
-superior
-anterior basal
-posterior basal
-lateral basl
-medial basal
left lung


LOBES, SEGMENTS
UPPER
-apical posterior
-anterior
-superior lingular
-inferior lingular

lower
-superior
-anteromedial basal
-posterior basal
-lateral basal
the hilum is the connectino of the ____ to the ___ of each lung
mediastinum

pedicle
material in pleural space

serous fluid
pleural effusion
material in pleural space

lymph
empyema or pylothorax
material in pleural space

organized blood clot
fibrothorax

peeled from the surface of the lung during a decortication
the left lung is ___ % of the TLC, the right is ___ &
left-45
right 55
the _____ is the region between the 2 pleural sacs
medistinum
compliance is
the change is volume divided by the change in pressure

V/T
the difference between the inflation curve and deflation curve is called _____ and indicates ____
hysteresis

energy loss
static compliance is decreased by...[5]
fibrosis
obesity
vascular engorgement
edema
external compression


---anything that makes the lung difficult to inflate
emphysema is a disease of inflation/deflation?
deflation
static compliance change with emphysema
increased compliance...easier to inflate
compliance is ___ dependent
volume..it changes as the volume changes
dynamic compliance is
compliance while the lung is moving..it's static compliance with the added effects of airway resistance
causes for decreased dynamic compliance
obstruction
bronchospasm
fibrosis
Laplace's law
P=T/r

if surface tension {T} is constant, pressure would increase as radius (r) decreases...

this does not happen in the lung because of surfactant
surfactant composition
phospholipid
dipalnitoyl lecithin

secreed by type 2 cells
surfactant is not produced in the fetal lung until _______.

administration of ___ to the partruient can help
28-32 weeks, does not reach mature levels until 35 weeks

glucocorticoids (beclamethasone)
the ratio of ___ to ____ indicates the amuount of mature surfactant in proportion to the surfactant precursor.
L/S

lecithin to sphingomyelin

mature is dipalnitoyl lecithin
precursor is sphingomyelin
forces that oppose inflation of the lung [3]
static elastic recoil of the lung and chest wall

frictional resistance of lung tissues and chest wall

resistance to airflow
laminar flow changes to turbulent flow when the ____ # exceeds ___.
reynold's number

2000
laminar flow follows ___ law
Poiseuille's law

R=8nl/r to the 4th
doubling the radius of a tube decreases resistance ____
16 times
normally, approx ____% of the total airway resistance resides where?
in the upper airways (nasal cavity, pharynx, larynx)
the greatest resistance to flow occurs in ______ sized bronchi
medium sized bronchi, whose smooth muscle tone greatly affects airway resistance
the ______ system affects the tone of the bronchial smooth muscle.
AUTONOMIC NERVOUS SYSTEM
the ____ system as well as ___ drugs produce bronchdilation
sympathetic NS, sypmpathomimetics
parasympathomimetic drugs cause broncho------?
dilation

i.e. atropine, ipratropium
obstructive airway diseases? [3]
asthma, emphysema, bronchitis

restricts airflow through the airways
restrictive airway diseases [3]
pulmonary fibrosis
scoliosis
obesity

decreases lung compliance nd lung volumes
ADC formula?
1ml per pound
amount of gas in the lung left over after maximal expiration?
residual volume RV

1.5L
4 basic lung volumes
RV
Vt
IRV
ERV

the sum of these is the TLC
THE volume of gas expelled during a maximal forced exhalation starting at the end of a normal tidal volume
ERV
the volume of gas inhaled during a maximal forced inhalation starting at the end of a normal tidal volume
IRV
the volume of air in the lungs afer a maximal inspiratory effort
TLC
the amount of air that can be forcible exhaled after a maximal inpsiratory effort
vital capacity

approx 4.5L
the volume of gas remaining in the lungs after a normal, quiet respiration
FRC

approx 3L

SUM OF RV AND ERV
THE _____ is the volume of air inhaled into the lungs during a maximal inspiratory effort that begins at FRC
inspiratory capacity

3L
the phase of expiration that occurs as nitrogen rich alveoli at the lung apexes continue to empty after closure of the small airways in the base of the lungs.
closing volume
the closing volume increases from __% of the TLC at 20 years to __% at 70 years
30 at 20

55 at 70
why might the elderly have an intrapulmonary shunt
increased closing volumes may exceed FRC during resting lung volumes
intraalveolar pressure changes during eupnic ventilation
-1 to +1....

up to 100 if coughing

a newborn can attain -40 to -60 during the first few breaths of life
the sum of the ACD plus the alveolar dead space is the ____?

calculated with the ____ equation
physiologic dead space

Bohr

PDS=(PaC02-PEC02)/PaC02
increased alveolar dead space can be caused by..
PE..causes abrupt decreases in ETC02
rationale for increased ventilation with dependent zones
at FRC, the dependent alveoli are more compliant than the ones at the top.
factors that determine the level of 02 and C02 in the alveolus [6]
VA
FI02
FIC02
mixed venous pulmonary flow
02 consumption
C02 production
every minute, approx ___ml of 02 difusses from the alveoli to the pulmonary capillary blood, ____ ml of C02 diffuses out.

the ratio of the amount f 02 consumed to the amount of C02 produced is called the ___
02-250ml

C02-300ml

respiratory quotient (nl is 0.8)

200/250
alveolar PA02 equation
PA02=PI02-(PAC02/RQ)
the mean pulmonary transit time is ____ with the blood spending ___ in the pulmonsry capillaries.
It only takes __ for quilibration to occur
4-5 sec


0.75 sec

0.25 sec
PVR is approx ____ of SVR
1/8th
PVR is increased by [5]
norepi
serotonin
histamine
hypoxia
hypercapnea
PVR is decreased by [2]
ACH
isoproterenol
ZONE's 1/2/3
1-alveolar presssure exceeds PAP, no blood flow

2-PAP exceed alveolar pressure during systole, intermittent flow

3-PAP exceed alveolar pressure, continous flow
there is normally no zone ____ during spontaneous ventilation
zone 1, but high airway pressures during mechanical ventilation can create it.
normal V/Q?
0.8

4/5
in alveoli that are ventilated but not perfused, V/Q is...

PO2, C02?
Q=0, so V/Q=infinity (i.e. dead space)

high P02, Low C02
in alveoli that are perfused but not ventilated, V/Q is...

P02, C02?
V=0, so V/0=0( i.e. a shunt)

shunts contribute to the V/Q mismatch of the lung

low P02, high Pc02
V/Q mismatch causes..[3]

C02 findings?
PE
high airway pressure
low cardiac output


low ETC02, wide gradient between ETCO2 and PaC02
2 causes of normal anatomic shunt?
BPA
thebesian veins
pathalogic causes of shunts [3]
atelectasis
obstruction
pneumonia
changing position from upright to supine and induction of GETA cause a significant decrease in ___.

this causes...
FRC

more uniform ventilation between dependent/superior regions.

this, along with decreased CO, increased dependent perfusion, PPV, PEEP can cause a shuntlike state to occur, V/Q mismatch is incresaed
inhaled agents _____ HPV
decrease
most inhaled agents (except __) cause broncho_____
nitous

bronchodilation
GA depresses the ventilatory response to [3]
C02
metabolic acidosis
hypoxia
the ratio of total volume of RBC's to total blood volume is...
hematocrit
there is ____ of 02 per 1mmHg of P02 physically dissolved in ___ml whole blood
0.003ml of 02 in 1mmHg per 100ml whole blood

therefore with a Pa02 of 100mmHg, there is only 0.3ml of 02 per 100cc blood
each gram of Hgb can combine with ____ml 02
1.34ml

if Hgb is 10 (Hct-30) THERE IS 13.4ml per 100ml blood
nl hct

man
women
man-45
woman-39
the relationship of the P02 of the plasma and the percent Hgb saturated is represented buy the
oxyhemoglobin dissociation curve
interaction between 02 and Hgb is influenced by..[4]
pH
PC02
temperture
2.3 diphosphoglycerate
the oxyhemoglobin dissociation curve is displaced to the left by...
decreased C02
decreased temp
decreased 2,3 DPG
alkalosis

this leads to an increased affinity of the Hgb for 02 (a higher saturation for a given p02)

this favors onloading of the Hgb at the alveoli
the oxyhemoglobin dissociation curve is displaced to the right by...
increased C02
increased temp
increased 2,3,DPG
acidosis

this leads to a decreased affinity of the Hgb fort the 02 (a lower saturation for a given P02)

this favors off loading of the Hgb to the tissues

can happen with increased tissue metabolism which would increase the tissue's 02 demand
Under normal conditions the blood has a P50 of ______.

if the 02/Hgb curve shifts to the left the P50 ______

if the 02/Hgb curve shifts to the right the P50 ______
26-27 mm hg

left shift p50 decreases

right shift p50 increases
other factors (besides 02/Hgb curve related factors) that affect 02 transport are ____
CO poisoning

methemoglobinemia
CO poisoning...

treatment..
240 times the affinity for Hgb.

makes HGB unable to transport 02
100% )2
methemoglobinemia is...
Hgb with iron in it's ferric state (Fe3+) instead of its normal ferrous state (Fe2+)

in the ferric state Hgb atomms do not combine with 02

treat with methelyne blue 1-2mg/kg over 5 min
3 ways that the blood carries CO2?
dissolved 5-10%
bicarbonate ions 80-90%
chemically combined with amino acids of blood protiens 5-10%
in the presense of _____. C02 combines with ____ to form _____, which can dissociate into a ____ ion and ____.

When HC03 leaves the cells ____ ions enter the cell to maintain neutrality, this is called the ____
carbonic anhydrase
water
carbonic acid
carbonic ion
Hydrogen

chloride

chloride shift
When the blood contains mostly HGB02, the C02 dissociation curve shifts to the _____, when the blood contains mostly deoxyhemoglobin, the C02curve shifts to the ____.
right-Bohr effect

left -haldane effect-facilitates C02 on oading at tissues
Whymust the severe metabolic acidosis that results from prolonged cardiopulmonary arrest be treated with NaHC03?
because protien receptor sensitivity and other ezymatic functions must be restored before epinephrine can be effective in resuscitation.
other buffers besides the respiratory and renal systems are

A buffer is a mixture of substances that ussually consists of a ___ and a ___.
bicarbonate
phosphate
protiens

weak acid and its conjugate base
an acute change in PaC02 of 10 mm is associated with a change in pH of ____
0.08 units
causes of metabolic acidosis
ingestion(poisoning)
infusion
lactic acidosis
decrease in excretion of acid by the kidneys
a base change of 10meq/l is assscosiated with a pH change of ____
0.15 units
resp alkalosis causes...
hypothyroidism
hypothermia
metabolic alkalosis causes...
fixed acid loss
high intake of bases
long term hypokalemia
the kidneys compensate for resp/met acidosis by...
excreting fixed acid and retaining bicarbonate
the kidneys compensate for rest/met alkalosis by...
decreasing H excretion and decreasing retention of bicarbonate
mild to moderate metabolic acidosis treatment?
hyperventilation and correction of shock
the total body bicarbonate deficit equals...

how much of dose do you give?
the base deficit (in mEq/l) that is obtained from the ABG's. The patient's bicarb level is subtracted from the normal bicarb level, the difference is multiplied by the patient's weight (in kg) and then by 0.3 (which is equal to the ECF volume and Vd of bicarb.

half, then recheck ABG's in 30 minutes
ACIDOSIS associated with renal failure treatment?
dialysis
hypoxemia treatment [3]
increase fi02
PEEP
correction of atelectasis
spinal nerves involved with the control of breathing?
C3,4,5
spontaneous respiratory rhythm is generated by the?
medularry respiratory center (found in the reticular formation of the mnedulla under the floor of the 4th ventricle)
centers that modify the output of the medullary respiratory center?[2]
apneustic center (lower pons)

pneumotaxiz center (upper pons)
the activity of the brain stem breathing centers is modulated by info rec'd from _______ and _____, as occurs in voluntary control of breathing
afferent spinal nerves
higher brain centers
stimulation of stretch receptors in the lungs cause [3]
Hering-Breuer inflation reflex
Hering-Breuer deflation reflex
paradoxic reflex of Head
what reflex may help prevent overdistension of the alveoli at high lung volumes by ihnibitino of large Vt's and may decrease the freq of inspiratory efforts by casusing a transient apenea?
Hering-Breuer inflation reflex
Reflex responsible for sighs and increased ventilation when the lings are abnormally deflated (pneumothorax)
Hering-Breuer deflation reflex
Reflex that results during partial block of the phrenic nerves such that lung inflation results in further deep inspiration instead of the apnea expected when the vagus nerve is fully functional?
paradoxic reflex of Head

involved with generating the first breath of a newborn
the ____ nerve provides afferent pathways for all of the airway's irritant receptor's except the nasal mucosa.
Vagus
PE causes ____ respirations.
rapid, shallow
pulmonary vascular congestion causes ____ respirations.
hyperpnea
the vascular receptors that cause the changes in respirations with PE/pulm vascular congestion are the....
J receptors (juxtapulmonary capillary)
elevated BP causes ____ respirations.
apnea and bronchodilation from stimulation of arterial baroreceptors
somatic pain causes ____ whereas visceal pain causes ____.
hyperpnea


apnea/decreased ventilation
Stimulation of the arterial chemoreceptors by decreased P02, increased C02 or low pH tends to_____
increase lung inflation and cause hyperpnea, bronchoconstriction and and increase in BP
what depresses the ventilatory response to
anesthesia
narcotics
COPD
increased C02 and decreased P02/pH stimulate the periphel arterial chemoreceptors, with the ____ exreting a much greater influence on medullary resp centers.
carotid has the most effect
affernt nerve from the carotid body?

afferent nerve from the aortic body?
Hering's, a branch of the glossopharyngeal


vagus\
the central chemoreceptors are/are not responsive to 02?
not responsive
which chemoreceptors are almost solely responsible for the resting ventilatory level and long-term response to and maintenance of blood C02 levels.
the central
which chemoreceptors are more important in short-tern response to C02?
peripheral
Disorder characterized by abnormal tests of expiratory flow that does not change markedly over periods of several months of observation.
COPD
COLD
condition with chronic or recurrent excess mucus secretion into the bronchial tree.
Chronic bronchitis:
chronic dilation of bronchi or bronchioles as a result of inflammatory disease or mucus obstruction.
Bronchiectasis:
condition of the lung characterized by abnormal permanent enlargement of the air spaces distal to the terminal bronchiole, accompanied by destruction of their walls and without obvious fiibrosis.
Emphysema:
collections of air within the pleura. They are not a form of emphysema. (alveolus not involved)
Blebs:
Asthma
Chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to a variety of stimuli.

Inflammation causes wheezing, breathlessness, chest tightness, and cough.

Incidence: 15 million in US. 5,000 die each year.
Asthma Under GA:
Wheezes, mucous hypersecretion, high inspiratory pressures, a blunted expiratory CO2 waveform, and hypoxemia.
Asthma with Mechanical ventilation:
air trapping and lung hyperinflation, barotrauma.
only IV induction agent with bronchodilating properties. DOC for ER cases.
ketamine
bronchospasm treatment [6]
Increase volatile agent, ketamine, propofol, lidocaine, or a combo to rapidly increase MAC
Administer 100% O2
Administer a B-2 agonist: albuterol
Severe cases warrant epi SQ or IV
IV corticosteroids
IV aminophylline (not theophylline)
Pulmonary Hypertension
PH: Mean PAP increases by 5-10 mm Hg

PA systolic pressure exceeds 30 mm Hg and
mean PAP exceeds 20 mm Hg

79% mortality rate within 5 years of diagnosis.

Primary/idiopathic (unexplained) or secondary to an associated condition.

May be acute or chronic
PH May be caused by: [6]
Pulmonary venous HTN (outflow obstruction)
Pulmonary arterial HTN (burns/sepsis)
Vasoconstriction
Viscosity
Obstruction
Reactive vascular disease
PHTN treatment
Vasodilators
Alpha-adrenergic antagonists: Doxazosin (Cardura), Prazosin (Minipress), Terazosin (Hytrin), Tamsulosin (Flomax), Alfuzosin (Uroxatral)

ACE inhibitors
PHTN Management
3. Avoid major hemodynamic changes.
4. Anticoagulants
5. Calcium antagonists
6. Nitric oxide

Avoid Ketamine (increases PVR)
avoid which IV anesthetic with PHTN
ketamine..increases PVR
Cor Pulmonale...aka
AKA (pulmonary heart disease)

PH ‡ Right ventricular hypertrophy, dilation, eventual cardiac decompensation.

3rd most common cardiac disorder (ischemic heart disease & Hypertensive heart disease)

COPD ‡ pulmonary vasoconstriction is leading cause of CP
Cor Pulmonale sx...[7]
retrosternal pain,
cough,
dyspnea on exertion,
weakness,
fatigue,
early exhaustion,
hemoptysis.
Cor Pulmonale
Treatment:
O2 for PaO2>60, SaO2>90, heart-lung transplant, decrease workload of RV, reduce PVR, prevent increases in PVR, avoid major hemodynamic changes.
Cor Pulmonale management
Volatile agents decrease PVR.

Nitrous will increase PVR in pts with PHTN

IV agents have little effect on PVR (except for Ketamine).

Goals: Oxygenate, avoid acidosis, avoid vasoconstrictors, avoid stimuli that increase sympathetic tone, avoid hypothermia.
Pulmonary Embolism facts
Impaction of a dislodged thrombus into the pulmonary vascular bed.

3rd most common cause of CV death (MI, Stroke),
>50,000/year

>90% arise from DVT’s (iliofemoral vessels)

>5 million DVT’s/year ‡10% lead to PE’s ‡ 10% of those are fatal
Other causes: air, tumor, bone, fat, catheter fragments, and amniotic fluid.

Most PE’s resolve within 8-21 days

.5-4% lead to the development of chronic PHTN

SV: pt. increases R to decrease CO2
CV: pt. can’t increase R, so CO2 rises
Virchow’s triad... (PE)
Virchow’s triad: stasis, hypercoagulability, and vessel wall injury lead to venous thrombosis

Stasis: Immobility, bed rest, anesthesia, CHF/CP, prior venous thrombosis

Hypercoagulability: Malignancy, estrogen therapy, HITT, IB disease, DIC, antithrombin III deficiency

Vessel injury: Trauma, surgery
Pulmonary Embolism sx..
Symptoms: Dyspnea, RR>20, HR>100, chest pain, cough, syncope, hemoptysis, hypoxia (anxiety, confusion), chest CT, lung scan, MRI, pulmonary angiography.
PE sx's under GA?
tachy and low C02
PE testing
Testing: Plasma D-dimer ELISA, EKG, CXR, venous ultrasound, echo, ABG, increased differences between PAO2 and PaO2.
PE anesthetic management
Anesthetic management: minimize myocardial depression, use high FiO2 (prevents pulmonary vasoconstriction), monitor PAP. PA line placement may dislodge right heart clots.
May run a catecholamine infusion
Etomidate/ketamine (remember it may increase PVR)
N20 contraindicated for venous air embolism
Narcotics are good.
Restrictive Pulmonary Disease
Any condition that interferes with normal lung expansion during inspiration.

Results in decreased lung volumes and capacities and in lung or chest wall compliance.
Restrictive Pulmonary Disease causes...
Asbestosis,
LV failure,
fibrothorax (pleural disease), Poliomyelitis,
Severe Kyphoscoliosis,
Gross obesity,
PHTN
Pulmonary edema:

occurs with...
Pulmonary edema: accumulation of excess fluid in the interstitial and air-filled spaces of the lung.
Increase in hydrostatic pressure within the pulmonary capillary system
Increase in the permeability of the alveolocapillary membrane
Decrease in intravascular colloid oncotic pressure

restrictive pulmonary disease
Other types of pulmonary edema:
Neurogenic, Uremic, High-altitude, Upper airway obstruction.
Restrictive Pulmonary Disease management
Management: O2, vasodilators, inotropes, steroids, diuretics.

MS, Nipride, Dopamine/Dobutamine

Fluid restriction and diuresis: want to achieve a “negative” fluid balance in hydrostatic pulmonary edema
Aspiration Pneumonia
Gastric contents enter the pharynx.
Gastric contents enter the lungs.

Contaminated (SBO)
Acidic (low Ph)
Particulate (french fries)
Non-particulate (diet-coke)

May occur during induction or emergence
Aspiration Pneumonia

syndromes [3]
Chemical pneumonitis (Mendelson’s syndrome)
Mechanical obstruction
Bacterial infection

Volume (>25cc), Ph (<2.5), Type of material aspirated play a significant role.
Aspiration Pneumonia sx...
Symptoms: Arterial hypoxemia is the hallmark sign. Tachypnea, dyspnea, tachycardia, HTN, late cyanosis.
Aspiration Pneumonia Prevention:
avoid GA/deep sedation. Sodium citrate, onset within 15 minutes, duration 1-3 hours. H2 blockers (zantac, pepcid, tagamet) 45-60 min. before surgery. Reglan (stimulates gastric emptying, increases lower esophageal tone, antiemetic).
Acute Respiratory Distress Syndrome
History of a preceding noxious event that served as a trigger for the subsequent development of ARDS
An interval from hours to days of relatively normal lung function after the insult
The rapid onset and progression over several hours of dyspnea, severe hypoxia, diffuse bilateral pulmonary infiltration, and stiffening and noncompliance of the lungs
ARDS sx...presentation...
Symptoms: dyspnea, hypoxia, hypovolemia, intubation & ventilation usually required

The rapid onset and progression over several hours of dyspnea, severe hypoxia, diffuse bilateral pulmonary infiltration, and stiffening and noncompliance of the lungs
ARDS facts
50-70% mortality
Risk factors:
Shock (septic, cardiogenic, hypovolemic)
Trauma
Pulmonary infection
Disease states that result in the release of inflammatory mediators (DIC, anaphylaxis, CABG, transfusion reactions)
Exposure to various agents (narcotics, barbiturates, O2)
CNS diseases
Aspiration (gastric contents, drowning)
Metabolic events (pancreatitis, uremia)
ARDS treatment
Antibiotics, oxygenation, replacement of lost intravascular fluids.
Noncytotoxic and Cytotoxic drug-Induced Pulmonary Disease
More than 100 pharmacologic agents are known to produce adverse effects on the lung parenchyma.

Usually causes chronic pneumonitis and fibrosis

Amiodarone (cordarone)

Gold (Rheumatoid arthritis treatment)
Catatonic Drug-induced Pulmonary Disease
3 syndromes (not all required for diagnosis)
Chronic penumonitis and fibrosis (most frequent, affects endothelial, interstitial, or alveolar epithelial cells). Inflammatory response ‡ proliferation of macrophages, lymphocytes, and other inflammatory cells.
Acute hypersensitivity lung disease (Bleomycin, Methotrexate). Nonproductive cough, dyspnea, chest pain. Allergic response (fever, urticaria, arthralgias, hypotension, eosinophilia).
Noncardiogenic pulmonary edema (antineoplastic agents, rare, reversable damage
Pulmonary Oxygen Toxicity
Greater than 50% O2 for > 24 hours. May be as soon as 6 hours.

D/T excessive production of oxygen free radicals

Free radicals exert their toxic effect on cell and organelle membranes; they interfere with vital cell functions, causing inactivation of enzymes and transport proteins, membrane lipid peroxidatin, and inhibition of cell growth and division. Irreversible.
5 risk factors of O2 toxicity.
Increased propensity to toxicity (bleomycin, busulfan, carmustine)
Age: Increase = decreased antioxidant defenses
Previous/current radiotherapy to the thorax
O2 therapy concurrent with chemotherapy
Combinations of chemotherapeutic agents
Pulmonary Oxygen Toxicity sx's
Symptoms: substernal CP that is prominent with inspiration, tachypnea, nonproductive cough.

By 24 hours: paresthesia, anorexia, nausea, h/a

Deliver lowest possible FiO2 to keep PaO2 > 90
Autoimmune Disorders
AKA: connective tissue diseases, collagenosis, rheumatologic diseases

Multiple organ involvement and inflammation.

Unknown causes

Sarcoidosis: Multisystemic disorder. Intense interaction of activated lymphocytes and macrophages that result in tissue injury.
Flail Chest

def,pain control, treatment
Paradoxic movement of the chest wall at the site of the fracture.

Pain control: epidural, intercostal nerve block

Treatment: IS to reduce atelectasis, may require intubation and ventilation, may require surgical intervention
Pneumothorax
Simple: no communication exists w/ atmosphere

Communicating: air in pleural cavity exchanges w/ atmospheric air, “sucking chest wound”, no pack it.

Hemothorax: accumulation of blood in the pleural

Tension: Air progressively accumulates under pressure within the pleural cavity

Mediastinal shift: decreased CO/BP, increased CVP/airway pressure

Signs: Hypotension, hypoxia, tachycardia, anxiety

16-18g, 2nd/3rd IS anteriorly or 4th/5th laterally
Atelectasis
Collapse of pulmonary tissue that prevents the respiratory exchange of CO2 and O2.

Most common causes: Airway obstruction & lack of surfactant

Results from a blockage of many small bronchi or of a major bronchus. Treat w/ IS, C & DB, CPAP.

Usually subclinical and resolves w/in 24-48 hours
Pleural Effusion
Abnormal accumulation of fluid in pleural space.
Causes:
Blockage of lymphatic drainage from pleural cavity
Cardiac failure ‡ increased pulmonary capillary pressure ‡ fluid moves into pleural cavity
Reductions in plasma colloid osmotic pressure
Infection of any other inflammatory process of the pleural membranes that alters capillary membrane permeability
Pleural Effusion treatment
Thoracostomy, thoracentesis, pleurodesis (procedure to prevent the reaccumulation of pleural fluid). Inflammation is produced w/ injection of a sclerosing agent, usually tetracycline, into the chest tube; adhesion formation and fusion of the pleural membranes result.
Skeletal Disorders
An alteration in the structure of the thorax that diminishes chest wall excursion.

Sternal deformities: Pectus Deformities, funnel chest, 1:400 children.
Kyphoscoliosis: Kyphosis & scoliosis, lateral bending and rotation
Ankylosing spondylitis: Chronic inflammatory disorder, produces fusion of spinal vertebrae and the costovertebral joints.
Thoracic Surgery
Is the likelihood of a postoperative complication so high that the surgery should not be performed?

Will postoperative pulmonary function be sufficient to allow reasonable quality of life?
Lateral Decubitus Position
Axillary roll: lateral, beneath torso, caudal to axilla to prevent compression of neurovascular bundle

Arms adducted & padded separately, Sa02 or radial artery monitoring for circulation checks

Head on pillows, aligned with body, check dependant ear (donut), eyes free of pressure/taped
Lateral Decubitus Position

zone's 1,2,3 Pa vs Pv vs PA
Zone 1: PA > Pa > Pv
(vessels closed/no flow/good air flow)

Zone 2: Pa > PA> Pv
(good blood & air flow)

Zone 3: Pa > Pv > PA
(vessels open/good blood flow, bad air flow)

Upright vs. supine position changes.
Lateral Decubitus Position
Awake lateral, SV: efficient gas exchange

Anesthetized lateral, chest closed, SV:
FRC decreases, V:P mismatch- up lung ventilated more; down lung perfused more

Anesthetized/paralyzed, CV: even more of a V:P mismatch

Anesthetized/open chest: worst V:P ratio, mediastinum shifts downward d/t loss of negative intrapleural pressure in up lung
One-lung Ventilation
Endobronchial blockers or DLT’s
Separately ventilate the lungs
Protect one lung from material in the other lung

Indications: lung resection, abscess drainage, tumors, transplants, esophageal surgery, anterior approach to thoracic spine, bronchopulmonary lavage, thoracic aortic aneurysm, PA embolism or rupture, decortication (table 25-3)

Dependent lung receives 60% of blood flow

A 40% shunt would be anticipated w/out autoregulation.

Starting OLV shunts blood causing the PaO2 to decrease from 400 ‡ 200 at Fio2 of 1.0. Blood is shunted at 27%, CO to nondependent lung is down.
HPV (hypoxic pulmonary ventilation)
Shunts blood away from hypoxic areas and directs it towards better perfused/ventilated lung tissue
HPV, drugs to avoid...[6]
Avoid drugs that inhibit HPV (NTG, nipride, dobutamine, some Ca++ antagonists, and some B2 agonists.
HPV, situations to avoid...[4]
Avoid hypothermia, hypocapnia, alkalosis, and acidosis
One-lung Ventilation Management [5]
Nitrous not generally used to allow FiO2 of 1.0

Inhaled anesthetics are the drug of choice.

Maintain 2 lung ventilation as long as possible.

May need to add PEEP to down lung or CPAP to up lung.

Increase the RR, only a slight increase in TV
Analgesia for Thoracic Surgery
Pain: causes splinting, decreased respiratory effort, hypoxemia, respiratory acidosis.

Residual pain exists in _ of thoracotomy patients after 1 year and in 1/3 of patients after 4 years.

PCA, intercostal nerve blocks, cryoanalgesia (1-3 months), intrapleural catheter infused with local anesthetic, thoracic epidurals (T6-T8)
Complications After Thoracotomy
Low CO (blood loss, herniation of the heart through a pericardial defect, right-sided heart failure, dysrhythmias)

Respiratory complications (atelectasis, pneumonia, respiratory failure, bronchopleural fistulas, pneumothorax, torsion of remaining lobes, pulmonary edema from high fluid administration), obstruction from blood, blood clots, secretions.

Thoracic duct injury (chylothorax), creamy chyle.
Mediastinal Masses...
Compress vital structures
Changes in CO
Obstruction to air flow
Atelectasis
CNS changes

Changes in airway dynamics with supine positioning can cause collapse of the airway with total obstruction to flow.

Obstructions can occur at any point in the anesthetic.

Consider wake FOB for intubation
Mediastinoscopy
Incision at suprasternal notch, single lumen tube

Complications: pneumothorax, hemorrhage from tearing major vessels (PA), arrhythmias, air embolism, bronchospasm, esophageal laceration, chylothorax

Large bore IV’s, blood available
Mediastinoscopy..more...
Mediastinoscope can place pressure on the innominate artery as it passes through the upper thorax, causing a decrease in blood flow to the right common carotid artery & right vertebral artery. Subclavian flow to the right arm will be decreased.

Pulse oximeter or A-line in right hand, NIBP on left arm.
Thoracoscopy
Lateral decubitus position.

Trocar placed at 4th-5th or 5th-6th IC space

Debridement of empyema, foreign body removal, instillation of talc or chemotherapeutic agents into the pleural space, stapling of blebs, diagnostic biopsies, evaluation of bronchopleural fistulas.

Maybe a-line/epidural/DLT…usually none of these.
Bullae
Air-filled spaces of lung tissue resulting from the destruction of alveolar tissue. A form of emphysema.

Increase in size with positive pressure.

Compresses normal lung tissue and vasculature causing hypoxemia, polycythemia, and cor pulmonale. Bullae can rupture and cause pneumo/tension pneumos w/ cardiopulmonary collapse. Chest tubes may be needed. No N2O!
A high anion gap indicates that there is loss of _____ without a subsequent increase in ____ .
HCO3-

Cl-.
with a high anion gap, Electroneutrality is maintained by....
the increased production of anions like ketones, lactate, PO4-, and SO4-; these anions are not part of the anion-gap calculation and therefore a high anion gap results.
In patients with a normal anion gap the drop in HCO3- is compensated for by an increase in Cl- and hence is also known as.....
hyperchloremic acidosis.
High anion gap
The _____ lost is replaced by an unmeasurable anion and thus you will see a high anion gap.
bicarbonate
high anion gap causes...
MUDPILES

M- methanol/metformin
U- uremia
D-diabetic ketoacidosis
P- paraldehyde/propylene glycol
I- infection/ischemia/isonazide
L- lactate
E-thylene glycol/ethanol
S- salicyates/starvation
Normal anion gap (hyperchloremic acidosis)
Usually the HCO3- lost is replaced by a chloride anion, and thus there is a normal anion gap.
Gastrointestinal loss of HCO3- (i.e. diarrhea) (note: vomiting causes hypochloraemic alkalosis)
Renal loss of HCO3- (i.e. proximal renal tubular acidosis)
Renal dysfunction (i.e. renal failure, hypoaldosteronism, distal renal tubular acidosis)
Ingestions
Ammonium chloride and Acetazolamide.
Hyperalimentation fluids (i.e. total parenteral nutrition)
the most common causes of COPD are [2]
chronic bronchitis and emphysema
acute respiratory failure is...
a functional disturbance of physiologic mechanisms characterized by a significant reduction in a patient's partial pressure of Pa02 from his or her usual baseline or by an increase in the partial pressure of PaC02 with concomitant acidosis
the principal predisposing factor to the development of COPD is
smoking
in addition to smoking, emphysema may develop because...
of a genetic predisposition to an imbalance between protease and antiprotease activities in the lungs
THE dominant feature of the natural history of COPD is..
progressive airflow obstruction as reflected by a decrease in FEV1
3 causes of decreased FEV1 are...
a decrease in the intrinsic size of bronchial lumina

a increase in the collapsibility of bronchial walls

a decrease in the elastic recoil of the lungs
_______ deficiency results in the degradation of intertitial elastin fibers
alpha anti-trypsin
______, a form of empysema, are air collecting spaces greater than ___cm in diameter that result from the destruction and dilation of air spaces distal to the terminal bronchioles.

they involve the ____
Bullae

1 cm

acinus
_____ are collections of air within the pleura that are NOT a form of emphysema because they do not involve the _____
Blebs

no acinus iunvolvement
COPD stages
0-normal spirometry
1-short acting bronchodilator
2-regular dilators, occ, steroids, rehab
3-dilators,steriods, 02,rehab
the defense system of COPD patients is disrupted by...
excessive mucus production
paralysis of the mucocilliary transport sustem
Ve in COPD
normal or slightly elevated
02 delivery in COPD is preserved by [3]
increased CO
polycythemia
greater extraction
changes with smoking [3]
increased oxidants
increased sputum
chronic hyperinflation
_____ is present is 2/3's of patients with severe COPD and its severity coorelates with degree of airflow obstruction
pulsus paradoxis

from a forced expiratory pattern and positive pressure swings during expiration
normally inspiration ____ venous return.

increases in lung volume may negate that.
augments
CO increased in COPD because
mediated by an increase in catecholamines and by a redistribution of blood flow and volume from the high capacitance splanchnic regions to the lower capacitance cardiac, cerbral and muscle regions
whar are the four parameters of airway obstruction that have been coorelated to the heart rate response to hypoxia?
FVC
FEV1 to FVC ratio
RV to TLC ratio
RV
renal changes with COPD
deecreased GFR
impaired renal function
decresed RBF
chronic pressure overload causes RV _____ where acute pressure changes cause RV_____
hypertrophy

dilation
spirometry..a decrease in _____ is characteristic of airflow obstruction
FEV1/FVC

FEV1 is ussually less than 80% of FVC in patients with COPD

also increased FRC and RV
pink puffer??

blue bloater??
pink-p02>60 (emphysema)

blue-po2<60, c02>45, cor pulmonale (chronic bronchitis)
cyanosis relects the...
CONCENTRATION of deoxygenated Hgb not the amount

>5gm/dl
PA HTN that leads to cor pulmoale is likey to develop in ___
bronchitic patients with arterial hypoemia and hypercarbia
arterial hypoxemia occurs in what state of emphysema?
very late

very late PA HTN
preop evalulation of COPD patients focus...
determine the severity of the dz an identify treatments

reduce inflammation
improve secretion clearance
treat underlying infection
increase airway caliber

no preop pulm function test establishes an absolute contraindication
supplemental 02 is recommended if...[3]
p02 <60
Hct>55%
cor pulmonale
contributing factors to COPD exacerbation...
bronchitis
airway hyperresponiveness
noxious inhalationaL AGENTS
MUCUS PLUGGING
pneumonitis
CV dz
CHF
systemic inflamation
must assess COPD patient for...[4]
increased effort
abnormal breath sounds
altered breathing patterns
productive cough
asthmatic bronchitis indicators
atopy(predisposition to allergies)
CHILDhood respiratory impariment
high IGe levels
eosiniphilia

generally more responive to treatment than smoking induced COPD
Acute infection is associated with epithelial desquamisation and correlated with airway hyperreactivity that my persist for _____ after the resolution of sx
3-6 weeks
decreases in pulmonary function as evidenced by decreased FEV1 correlates with...
CAD and increased overall mortality
______ correct the hypercarbia during anesthesia
don't
regional anesthesia techniques that produce sensory anesthesia above T6 are...
NOT recommend because of the potential for decreasing ERV, impairing cough effort, and creating anxiety provoking weskness
GETA is associated with a ______ in the alveolar-arterial P02.
an increase
what is contraindicated with Bullae?
Nitrous Oxide
with COPD patients, gas exchange is very dependent on _____.
Vt
ideal PEEPi to PEEPe?
PEEPe 85% or less than PEEPi
early ambulation increases..
FRC
asthma definition
chronic inflammatory disorder of the airways characterized by an increased responsiveness of the trachobronchial tree to a variety of stimuli
cells/elements that play a role in asthma [4]
mast cells
eosinophils
neutrophils
epithelial cells
asthma episode events [4]
wheezing
breathlessness
chest tightness
cough

particularly at night and early morning
the most important consideration with asthma is
the identification of exacerbating factors
extrinsic asthma (allergic) factors...
mostly kids and young adults

infectious, environmental, psychological or physical factors

atopy (heriditary, IgE mediated, clincal hypersentice state
intrinsic asthma (idiosyncratic)
middle age without specific stimuli
____ and ___ are central to the pathogenesis of asthma
airway inflammation

nonspecific irritbility of the tracheobronchial gtree

both have bronchoconstriction

PERMANENT changes (remodeling) magnify the inflammatory response
allergic asthma is triggered by..
antigens that provoke a T-lymphocyte-generated, IgE-mediated immune response
the asthmatic diathesis creates airways that are [3]
edamatous
inflamed
hypersensitive to irritant stimuli

degree of airway hyperrespnsiveness and bronchoconstriction parallell the extent of inflamation.
idiossyncratic asthma can be triggered by...[3]
cold air
instrumentation
climate changes
URI
the increased bronchomotor tone associated with a viral infection may persist for up to ____
5 weeks
non-asthmatic children with an URI are _____times more likely to experience an adverse event perioperatively and are more prone to postop desaturation
2 TO 7 TIMES

ENHANCED parasympathetic tone can contribute to the airflow obstruction
_____ forms of asthma are more prevalent in the perioperative period
non-allergic mechanisms
exercise induced asthma
less than 1 hr

easily reversed with B2-adrenergic receptor antagonists
ASA induced asthma
cyclooxygenases promotes an increase in leukotriene levels via the arachnidonic pathway

clinically associated with nasal polyps
Clinical hallmarks of asthma in the awake patient [8]
wheezing
dyspnea
cough
taqchpnea
chest tightness
prolonged espiratory phase
fatigue
accesory muscle use
status asthmaticus
persistant severe obstructin lasting for days or weeks
chronic asthma may lead to [4]
irreversible lung destruction
loss of lung elasticity
PH
lung hyperinflation
manifestations of asthma in the anesthetized patient [4]
wheezing
mucus hypersecretion
blunted C02 expiratory waveform
hypoxemia
causes of wheezing other than asthma [6]
pneumothorax
ETT obstruction
endobronchial intubation
anaphylaxis
pulmonary edema
pulmonary aspiration
patients with increased airway resistance have what spironmetry changes
decreases FEV1 and FEV1/FRC %

RV, FRC, TLC increased
____% of asthmatics have a normal CXR
75%
sputum analysis in asthma
eosiniphilia,,grossly prurlent

curshmann's spirals
charcot-leuyden crystals
preop eval findings in asthma that may signal an likelihood of introperative difficulty [3]
frequent nocturnal wakenings
recent increase in med use
signs of viral infection
pretreatment with ______ has been advocated in asthma patients
systemic corticosteroids

dexamethasone
asthmatics experience an increased parasympathetic tone, what meds can help this...
anticholinergics

atropine, glycopyyrolate given 20-30 minutes preop
meds to avoid with asthma patients
h2 blockers

cimetidine
ranitadine


atracurium, micacurium,
esmolol, labetolol

no Ketorolac with ASA-asthma
only induction agent with bronchodilating properites...
ketamine

propofol is OK, NO barbiturates (histamine release)
treatment for bronchospasm during anesthesia
deepen anesthesia
100% 02
B2-agonist
epi iv/sq
IV aminophylline

Theophylinne has little efficacy for acute episode
strategy for mechanical ventilation of asthmatic patient [4]
avoid hyperinflation
longer exp time
reduce Ve by limiting I-time
moderate permissive hypercapnea
emergence for asthmatic [3]
try to avoid anticholinesterase
lidocaine
atropine/glycopyrolate
asthmatic pregnant patient [5]
avoid IV beta agonists
maintain maternal oxygenation
minimize hypotension
ephedrine if pressor needed
avoid nitrous
prognosis of PH is largly determined by
RV integrity
PH CAUSES [3]
left atrial outflow obstruction
pulmonary veno-occlusive dz
hyperdynamic circulation
PH is characterized by [2]
an increase in vascular tone and the growth and proliferation of pulmonary vascular smooth muscle
first complaints with PH [2]
dyspnea
exercise intolerance
anesthesia management of PH
vasodilator agents

preventiono of increases in PH and avoidance of major hemodynamic changes

ketamine increases PH, all of the others-no change or decrease
leading cause of cor pulmonale
HPV caused by COPD
sx of cor pulmonale
retrosternal pain
cough
DOE
weakness
fatigue
early exhaustion
hemoptysis

occasionally hoarseness due to compression of the recurrent larygeal nerve by the enlarged PA

elevated JVD/CVP
S3 gallop
S4
widely split S2
poss murmur from tricuspid insuficiency
acites
hepatomegaly, LE edema
treatment of Cor Pulmonale
improvement of gas exchange
02
transplant
volatile agents decrease PVR
(N20 INCREASES PVR IN PATIENTS WITH PH)
anesthetic mamagement of patient with Cor pulmonale
keep well oxygenatede
avoid acidosis
avoid vsdoconstrictors (worsen hypoxemia)
avoid stimuli that increases sympathetic tone
avoid hypothermia
PE's originate from the _____ in 90% of patients. The remainder originate in the ______ veins.
ileofemoral vessels

pelvic
3 factors that promote the formation of a embolus

(virchow's triad)
stasis
venous injury
hypercoagulation states
most PE'd resolve in...
8 to 21 days
emboli are most often seen in the ____ lobes, these lobes also receive ____ ventilation
lower

the least
after PE, moderate _____ without _______ is often seen as both __ and __ increase.
hypoxemia without C02 retention

physiological shunt and dead space
wih PE, spontanously breathing patients maintain C02 levels by ___.
increasing RR
with PE, the anesthetized patient has what C02 chages?
increased C02, more rapid desaturation
the difference between _____ and ____ are very useful indicators in PE with the anesthetized patient
ETCO2 and PaC02
most commom s/s of PE? [4]
dyspnea
increased RR
chest pain
tachycardia
Massive PE ABG's
hypoxia and hypocapea
anesthetic management of PE
100% Fi02
PA Cath to assist in optimizing RV function
first s/s seen with PE in anesthetized paitent...
decreasing ETC02
tachcardia

followed by desaturation and ABG's that indicate unexplained arterial hypoxemia
EKG changes with PE
right axis deviation
right bundle branch block
peaked T waves

a systolic ejection murmur may be present
Other challenges with PE
reperfusion edema
pulmonary steal
persistant hypoxemia
pericardial effusion
psychiatric disorders
restrictive pulmonary disease definition
any condition that interferes with the normal lung expansion during expiraion.
FEV1 ad FVC changes with restrictive pulmonary dz
both are decreased owing to a decrease in TLC or a decrease in chest wall compliance

the FEV1/FVC ratio is normal or elevated
3 types of restrictive pulmonary diseases
acute intrinsic
chronic intrinsic
chronic extrinsic
acute intrinsic restrictive pulmonary disease causes
abnormal movement of intravascular fluid into the interstitium of the lung and alveoli secondary to the increase in pulmonary vasular pressures occuring with left ventricular failure, fluid overload, or and increase in pulmonary capillary permeability
acute intrinsic restrictive
restrictive pulmonary diseases examples
pulmonary edema
aspiration pneumonia
ARDS
chronic intrinsic
restrictive pulmonary diseases are carachterized by
characterized by pulmonary fibrosis
chronic intrinsic
restrictive pulmonary disease examples
ideopathic pulmonary fibrosis
radiation injury
cytotoxic and noncytotoxic drug exposure,
02 toxicity,
autoimmune diseases sarcoidosis
chronic extrinsic
restrictive pulmonary disease are..

examples...
disorders that inhibit normal lung expansion

flail chest
pneumothorax
atelectasis
pleural effusion
acites
obesisty
pregnancy
neuro/skeletal disorder
pulmonary edema can be caused by [3]
increase in hydrostatic pressure (most common)
increase in permeability
decrease in intravascular colliodial oncotic pressure
pulmonary edema is classified as either __ or __.
cardiogenic (high pressure, hydrostatic)

non-cardiogenic(increased permeability)
When Pulm capillary pressures reach ____ the rate of fluid transudation offten exceeds lymphatic drainage capacity and alveolar flooding occurs
20-25 (10-16 is normal)
conditions that increase pulmonary cappilary hydrostatic pressure and can cause pulmonary edema
CAD
HTN
cardiomyopathies
MR
mistral stenosis
pulmonary occlusive disesae
fibrosis mediastinitis
head trauma
CVA
high altitudes
overhydration
in non-cardiogenic pulmonary edema _____ is leaked
protiens because the endothelium is not intact
most common cause of non-cardiogenic pulmonary edema
systemic sepsis that leads to ARDS
neurogenic pulmonary edema stems from
LV failure from HTN fron excessive sympathetic outflow
uremic pulmonary edema is from
renal insufficiency or failure
the detection of ____ is the the traditional hallmark of early pulmonary edema

the earliest and most often disregarded clinical sign is...
basiliar crackles

these crackles occur in the bronchiles, therefore the alveoli are already flooded


rapid and shallow breathing
Morphine's effect on pulmonary edema
veodilatory and preload reducing properties
3 aspiration syndromes
chemical pneumonitis (Mendelson's)
mechanical obstruction
bacterial infection
Characteristics of Mendelson's syndrome (chemical pneumonitis)
a triphasic sequence of

immediate resp distress combined with bronchospasm, cyanosis, tachcardia and dyspnea followed by

partial recovery and

a final phase of gradual return to fucntion
hallmark sign of aspiration pneumonia
hypoxemia