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449 Cards in this Set
- Front
- Back
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The prime function of the lung is to
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alow 02 to move from the air into the venous b lood and c02 to move out
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02 and c02 move between air and blod by ___,from an area of __ to __.
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simple diffusion
high to low partial pressure |
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there are __ alveoli in the lung, each about __ diameter. If they were spheres, their area would be __ but thier volume only ____
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300 million
1/3mm 85 meters sq 4 liters |
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the trachea divides into the __ and __, then__, then__.
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right and left main bronchi
lobar bronchi segmental bronchi |
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__ are the smallest airways without alveoli
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terminal bronchioles
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____ airways do not participate in gas exchange, but lead air to the gas exchange airways in the lung
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conducting airways
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the ______ consitute the ADC and is about ___ml.
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conduction airways
150ml |
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the terminal bronchiloes divides into the _____ which have occasional alveoli
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respiratory bronchioles
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the respiratory bronchioles lead to the _______ which are completely lined with alveoli
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alveolar ducts
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the alveolar region of the lung that contributes to gas exchage is called the zone _____
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repiratory
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The partial pressure of a gas is found by multiplying its ____ by the ______
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concentration
total pressure |
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water vapor pressure at sea level is __
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47mm
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the alveolar are __ in shape
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polyhedral
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The holes in alveolar walls are __
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pores of Kohn
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the portion of the lung distal to a terminal bronchiole forms an anatomical unit called the __
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acinus
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The distance from the terminal bronchiole to the most distant alveolus is only __, but the ___ zone makes up most of they zone lung.
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a few mm
respiratory zone (2.5-3.0 liters during rest |
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The forward velocity of the gas becomes ____ beyond the terminal bronchioles
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small
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____ is the dominant mechanism of ventilation in the respiratory zone
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diffusion of gas within the airways
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inhaled dust settles in the _____ because...
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region of the terminal bronchioles
because the velocity of the gas falls rapidly |
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gas movement in the alveolar zone is chiefly by __
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diffusion
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volume of the alveolar region,
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2.5-3.0 liters
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ADC volume
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150ml approx
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in the lung periphery, the ___ travel together down the center of the lobules
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arteries and bronchi
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The diameter of a capillary segment is about ___
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10 um
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A mean PA pressure of about __ is required for a flow of 6-lpm
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20 cm water (15mmHg)
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level of equilibration of 02 and c02 between alveolar gas and capillary blood
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virtually complete
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the additional blood system of the lung?
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bronchial circulation, which supports the conducting airways down to about the terminal bronchioles
the lung can function OK without it (LUNG transplant) |
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the whole of the right heart output goes to the
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lungs
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thickness of blood gas barrier?
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less than 0.3um
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time blood spends in the capillaries
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3/4 of a second
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relatively large forces develop that tend to collapse alveoli because?
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the surface tension of the liquid lining the alveoli (lowered by surfactant)
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large particles are filtered out in the ____
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nose
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smaller particles that deposit in the conduction airways are removed by the...
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moving staircase of mucous
secreted by mucous glands and goblet cells in the bronchial walls |
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the alveoli have __ cilia?
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NO
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particles that deposit in the alveoli are removed by...mphatics
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engulfed by large macrophages, then removed by lymphatics
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volumes that cannot be measured with a spirometer
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total lung capacity
FRC residual volume |
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total lung capacity is
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vital capacity + residual volume
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vital capacity is
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maximal inspiration followed by maximal expiration
the exhaled volume is the VC |
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volume left in lung after maximal expiration is...
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residual volume
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volume left after normal expiration...
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FRC
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2 ways to measure FRC..
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helium spirometry
total body plethysmography |
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Boyles law?
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pressure x volume is constant (at constant temp)
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___ and ___ can be measured with a simple spirometer
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Vt, VC
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body plethysmography relies on which gas law
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Boyles
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alveolar ventilation is...
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Ve-ADC
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what is the most effective way of increasing Va?
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increasing Vt, because this reduces the proportion of each breath occupied by the anatomic dead space
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If the alveolar ventilation is halved (and C02 production remains unchanged) the alveolar and arterial PC02 will ___
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double
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what is the volume of the conduction airways called>
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ADC, 150ml
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ADC can be measured by...
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Fowlers method (nitrogen analyzer) reflects lung morphology
Bohr's method measures the volune of the lung that does not eliminate C02 |
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___ regions ventilate better than ___ regions
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lower ventilates better than upper zones
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ventilation per unit volume is greatest at ________ and becomes progressively smaller towards the ____
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near the bottom
top disappears with supine positon |
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ventilation changes with supine
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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 |
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the rate of gas transfer is proportional to a diffusion constant which depends on __ and __.
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properties of the tissue and the particular gas
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C02 diffuses about 20x 02 because...
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it has a much higher solubility but not a very different molecular weight
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rate of diffusion of a gas though a tissue is ____ to the area, but is ____ to the thickness
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proportional to the area
inversly proportinal to the thickness |
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the diffusion rate is proportinal to the _____ difference
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partial pressure
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diffusion rate is proportional to the ______ of the gas in the tissue but ______ to the square root of the molecular weight
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proportional to solubility
inversely proportional to the square root of the molecular weight |
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the transfer of CO is _____ limited
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diffusion limited
limited by the diffusion properties of the blood gas barrier, NOT by the amount of blood available |
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the transfer of nitrous oxide is ____ limited
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perfusion limited
limited by the amount of blod available |
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O2 transfer is generally ___ limited but can be ____ limited in conditions that thicken the barrier.
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normally perfusion limited
diffusion limited with disease |
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functions of the respiratory system [5]
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gas exchange
acid-base balance phonation pulmonary defense metabolism |
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the peripheral chemoreceptors sense the __, __ and __ levels in the arterial blood.
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02, C02, H+ ions
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the central chemoreceptors monitor the __ and __ levels in the CSF.
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C02, H+
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the cells of the pulmonary circulation can metabolize what important substance?
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angiotensin 1 via ACE to AT2
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The airway consists of the...[5]
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nose, pharynx, larynx, trachea and lower airways
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the components of the respiratory system are the...[4]
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conducting airways
lungs CNS-responsible for ventilation chest wall |
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the floor of the nose is at a higher/lower level than the opening of the nostril?
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higher
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the anterior portion of the external nose is the
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VESTIBULE, which expands above and behind into triangular spaces or FOSSAE
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the posterior nares aka.____, open into the _____
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choanae
pharynx |
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_____ is a birth defect that results in the obstruction of the airway of the obligate nose breathing newborn
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choanasal atresia
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the _____ choncha is in the pathway of airflow in the nose and is the one most commonly injured during nasal intubation
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inferior
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the respiratory mucosal tract lines the lower 2/3s of the _____ and consists of ______ and ______.
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nose
ciliated epithelial cells mucous glands |
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the principal arterial supple of the nasal fossae comes from the ______ through the ______ and from the ______ through the______
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opthalmic arteres through the anterior and posterior ethmoid branches
internal maxillary artery through the sphenopalatine arteries |
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the ______ is sometimes ligated for the treatment of persistant epistaxis
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internal maxillary artery
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the ethmoid veins open into the ___ and the nasal veins drain in to the _____
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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 |
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the lymphatic drainage from the cavaties of the nose is via the...
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deep cervical lymph nodes adjacent to the IJV.
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the sensory nerves from the upper resp tract come from the _____ and _____
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opthlamic nerve (V)
maxillary nerve (V) |
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almost no particle greater than ____ in size is allowed to enter the trachea.
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6mm
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the ____ is part of both the resp and ailementary tract
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pharynx
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the upper border of the pharynx is _____ and extends to the level of ____.
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base of the skull
C6 at this level foreign bodies are frequently lodged |
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the nasopharynx extends from the __ to the __.
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nares to the end of the soft palate
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the oropharynx is bound superiorly by the __ and anteriorly by the __ which extend inferiorly to the ___.
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soft palate
tonsillar pillars tip of the epiglottis |
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the laryngopharynx extends from the __ to the _____.
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tip of the epiglottis
level of C6 |
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the major tonsils are the ____ which like in the ____
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palatine
tonsilar fossa |
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the ___ tonsils extend across the tongue from the base of each palatine tonsil
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lingual
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the _____ tonsils lie on the lateral wallser of the nasopharynx
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adenoid or pharyngeal
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the tonsils create the ____ ring.
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Waldeyer's RING-first line of defense against bacterial invasion
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blood supple to the entire mouth and pharyngeal region is from the...
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branches of the external carotid artery
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venous drainage from the entire mouth and pharyngeal region is via the...
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facial vein and EJV.
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The nerve supply to the inner mouth is from..
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CN 7, 9, 10
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the lypmhatic drainage for the entire mouth and pharyngeal region is via...
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cervical lymph nodes under and anterior to the SCM (lumps in neck with sore throat)
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the adult larynx extends from __ to __ and is a protective structure that prevents__
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C3 to C6
prevents aspiration during swallowing, vocalization evolved secondarily |
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the larynx consists of __ bone(s), __ peices of cartiladge, ligaments, muscles and membranes
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1
9 |
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the ___ bone is the chief support for the larynx.
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hyoid
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the ___ and ___ make up the principal part of the framework of the larynx.
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thyroid cartilage
crichoid cartilage |
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the ____ cartilage lies closest to the root of the tongue and is vertical to the opening of the larynx
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epiglottic
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the epiglottis is attached to the body of the thyroid by the __ abd to the base of the tongue by the__.
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throepiglottic ligament just above the vocal cords
glossoepiglottic folds |
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______'s level corresponds to the beginning of the trachea and the esophagus.
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cricoid cartilage
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the arytenoid cartilages articulate on the ____ aspect of the ___, which is slanted forward
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superior posterior aspect of the cricoid cartilage
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the paired arytenoid cartilages are attached to the __ ends of the __.
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posterior ends of the vocal cords.
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the paired corniculate (median) and cuneiform (more lateral) cartilages are embedded in the ___.
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aryepiglottic folds
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the ____ ligament suspends the larynx from the hyoid bone.
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thyrohyoid ligament
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the ____ or ____ membrane lies between the cricoid and the thyroid cartilages.
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conus elasticus or cricothyroid
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the cavity of the larynx is divided into 3 compartments by the __ and the __.
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false vocal cords
true VC's |
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the supraglottic area extends from the ___ to the ___
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false cords to the tip of the epiglottis
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on each side of the supraglottic area is the _____
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pharyngeal sinus aka pyriform sinus
food/foreign bodies can become lodged here |
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the second component of the larynx is _______, located between the false cords and the true cords
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laryngeal ventricles
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the third area of the larynx is from below the true cords to the beginning of the trachea is know as the _____
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infraglottic region
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the space between the true cords is the..
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rima glottis
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the true VC are ____ folds attatched anteriorly to the ___ and posteriorly to the ____.
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anteriorly to the thyroid cartilage
posteriorly to the arytenoids |
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the laryngeal inlet is closed by the ___ and opened by the ___
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aryepiglottic muscle
thyroepiglottic muscle |
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the glottic slit is dialated by the ___ and closed by the ____
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posterior cricoarytenid muscle
interarytenoid muscle assisted by the lateral cricoarytenoid muscle |
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the ____ lengthen the true VC's and the ___ shorten them
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cricothyroid muscle
thryoarytenoid muscle both sets of muscles are important for determining pitch. |
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___ and ___ muscles are important for determining pitch.
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cricothyroid muscle
thryoarytenoid muscle |
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what are the 9 cartilages of the larynx?
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1 eppiglotic
2 thyroid 3 cricoid 4,5 arytenoids 6,7 corniculates 8,9 cuneiforms |
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both the superior and inferior laryngeal nerves are branches of the ____
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Vagus
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the superior laryngeal nerve arises from the ___ of the ____ and divides into __ and __.
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ganglion nodosum of the vagus
internal and external |
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the external superior laryngela nerve gives a branch to the ___ muscle of the ___ and also to the ____ muscle.
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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 |
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the internal branch of the superior laryngeal nerve enters the larynx and then the thyrohyoid membrane and is distributed to the __ and the __.
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mucus membranes of the larynx and epiglottis
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the _____ provides sensation from the laryngeal side of the epiglottis down to the true VC.
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internal branch of the superior laryngeal nerve
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the ___ provides sensation to the tongue side of the epiglottis.
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glossopharyngeal
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the ____ innervates the interarytenoid muscles which are important in phonation.
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internal branch of the superior laryngeal nerve
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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 |
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the ____ supplies sensation to the larynx below the level of the VC's and innervates all the muscles of the larynx except the ___ and ___..
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recurrent laryngeal
cricothyroid and part of the interarytenoid muscles |
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the blood supple to the larynx is provided by the ___ and __.
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superior thyroid artery (branch of external carotid)
interior thyroid artery (branch of thyrocervical trunk, which arises from the subclavian artery) |
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the trachea is lined by ____ and extends from the ___ to the ___.
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ciliated columnar epithelium
inferior larynx to the carina |
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in adults the distance from the incisors to the larynx is ___ as is that from the larynx to the __.
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13 cm
carina |
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distance from incisors to carina in adult?
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26cm
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the carina is at the level of ____. This corresponds to the ___ which is at the articulation of the _____.
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t4-t5
angle of louis on the sternum 2nd rib |
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if a patient flexes the neck, the trachea moves _______ as a result, the ETT moves ____.
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upward
downward |
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extubation is possible with neck flexion/extension?
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extension
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the blood supple to the trachea is through the _____, which comes from the _____.
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inferior thyroid artery
thryocervical branch of the SCA |
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the trachea is innervated by the
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vagus
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the right mainstem bronchus is ___ and ___ than the left
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shorter and wider
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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
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murphy eye
left mainstem bronchus |
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the right mainstem bronchus ends ___ from the carina before giving rise to the _____
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1.5 cm
right upper lobe bronchus |
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the left mainstem bronchus is ___ in length
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5cm
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the lingular branch is ____
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a the lower half of the left upper lobe bronchus
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the ____ ventilate the bronchopulmonary segments of the lungs
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segmental bronchi
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the alveolar ducts lead to ____
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atria, each atria has 2 to 5 alveoli
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dual blood supple of the lung?
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bronchial, pulmonary
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the bronchial arteries [__ on right, __ on left]
arise from the __ |
one on right, 2 on left
descending aorta (2-3% of CO) |
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the bronchial and pulmonary vessels meet and anastamose at the __
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junction of the terminal and respiratory bronchioles
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the bronchioles without cartilagenous support are the
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terminal
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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 |
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the nerve supple to the bronchi and the lungs arises chiefly from the ____
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sympathetic nerves
vagus nerve (sensation and parasympathetic) |
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all conduits to the lung pass through the
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hilum
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RIGHT LUNG
LOBES, SEGMENTS |
upper
-apical -anterior -posterior middle -medial -lateral lower -superior -anterior basal -posterior basal -lateral basl -medial basal |
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left lung
LOBES, SEGMENTS |
UPPER
-apical posterior -anterior -superior lingular -inferior lingular lower -superior -anteromedial basal -posterior basal -lateral basal |
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the hilum is the connectino of the ____ to the ___ of each lung
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mediastinum
pedicle |
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material in pleural space
serous fluid |
pleural effusion
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material in pleural space
lymph |
empyema or pylothorax
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material in pleural space
organized blood clot |
fibrothorax
peeled from the surface of the lung during a decortication |
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the left lung is ___ % of the TLC, the right is ___ &
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left-45
right 55 |
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the _____ is the region between the 2 pleural sacs
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medistinum
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compliance is
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the change is volume divided by the change in pressure
V/T |
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the difference between the inflation curve and deflation curve is called _____ and indicates ____
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hysteresis
energy loss |
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static compliance is decreased by...[5]
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fibrosis
obesity vascular engorgement edema external compression ---anything that makes the lung difficult to inflate |
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emphysema is a disease of inflation/deflation?
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deflation
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static compliance change with emphysema
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increased compliance...easier to inflate
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compliance is ___ dependent
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volume..it changes as the volume changes
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dynamic compliance is
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compliance while the lung is moving..it's static compliance with the added effects of airway resistance
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causes for decreased dynamic compliance
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obstruction
bronchospasm fibrosis |
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Laplace's law
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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 |
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surfactant composition
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phospholipid
dipalnitoyl lecithin secreed by type 2 cells |
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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) |
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the ratio of ___ to ____ indicates the amuount of mature surfactant in proportion to the surfactant precursor.
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L/S
lecithin to sphingomyelin mature is dipalnitoyl lecithin precursor is sphingomyelin |
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forces that oppose inflation of the lung [3]
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static elastic recoil of the lung and chest wall
frictional resistance of lung tissues and chest wall resistance to airflow |
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laminar flow changes to turbulent flow when the ____ # exceeds ___.
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reynold's number
2000 |
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laminar flow follows ___ law
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Poiseuille's law
R=8nl/r to the 4th |
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doubling the radius of a tube decreases resistance ____
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16 times
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normally, approx ____% of the total airway resistance resides where?
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in the upper airways (nasal cavity, pharynx, larynx)
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the greatest resistance to flow occurs in ______ sized bronchi
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medium sized bronchi, whose smooth muscle tone greatly affects airway resistance
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the ______ system affects the tone of the bronchial smooth muscle.
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AUTONOMIC NERVOUS SYSTEM
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the ____ system as well as ___ drugs produce bronchdilation
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sympathetic NS, sypmpathomimetics
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parasympathomimetic drugs cause broncho------?
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dilation
i.e. atropine, ipratropium |
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obstructive airway diseases? [3]
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asthma, emphysema, bronchitis
restricts airflow through the airways |
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restrictive airway diseases [3]
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pulmonary fibrosis
scoliosis obesity decreases lung compliance nd lung volumes |
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ADC formula?
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1ml per pound
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amount of gas in the lung left over after maximal expiration?
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residual volume RV
1.5L |
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4 basic lung volumes
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RV
Vt IRV ERV the sum of these is the TLC |
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THE volume of gas expelled during a maximal forced exhalation starting at the end of a normal tidal volume
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ERV
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the volume of gas inhaled during a maximal forced inhalation starting at the end of a normal tidal volume
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IRV
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the volume of air in the lungs afer a maximal inspiratory effort
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TLC
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the amount of air that can be forcible exhaled after a maximal inpsiratory effort
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vital capacity
approx 4.5L |
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the volume of gas remaining in the lungs after a normal, quiet respiration
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FRC
approx 3L SUM OF RV AND ERV |
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THE _____ is the volume of air inhaled into the lungs during a maximal inspiratory effort that begins at FRC
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inspiratory capacity
3L |
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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.
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closing volume
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the closing volume increases from __% of the TLC at 20 years to __% at 70 years
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30 at 20
55 at 70 |
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why might the elderly have an intrapulmonary shunt
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increased closing volumes may exceed FRC during resting lung volumes
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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 |
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the sum of the ACD plus the alveolar dead space is the ____?
calculated with the ____ equation |
physiologic dead space
Bohr PDS=(PaC02-PEC02)/PaC02 |
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increased alveolar dead space can be caused by..
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PE..causes abrupt decreases in ETC02
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rationale for increased ventilation with dependent zones
|
at FRC, the dependent alveoli are more compliant than the ones at the top.
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factors that determine the level of 02 and C02 in the alveolus [6]
|
VA
FI02 FIC02 mixed venous pulmonary flow 02 consumption C02 production |
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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 |
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alveolar PA02 equation
|
PA02=PI02-(PAC02/RQ)
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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 |
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PVR is approx ____ of SVR
|
1/8th
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PVR is increased by [5]
|
norepi
serotonin histamine hypoxia hypercapnea |
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PVR is decreased by [2]
|
ACH
isoproterenol |
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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 |
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there is normally no zone ____ during spontaneous ventilation
|
zone 1, but high airway pressures during mechanical ventilation can create it.
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normal V/Q?
|
0.8
4/5 |
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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 |
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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 |
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V/Q mismatch causes..[3]
C02 findings? |
PE
high airway pressure low cardiac output low ETC02, wide gradient between ETCO2 and PaC02 |
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2 causes of normal anatomic shunt?
|
BPA
thebesian veins |
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pathalogic causes of shunts [3]
|
atelectasis
obstruction pneumonia |
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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 |
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inhaled agents _____ HPV
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decrease
|
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most inhaled agents (except __) cause broncho_____
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nitous
bronchodilation |
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GA depresses the ventilatory response to [3]
|
C02
metabolic acidosis hypoxia |
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the ratio of total volume of RBC's to total blood volume is...
|
hematocrit
|
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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 |
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each gram of Hgb can combine with ____ml 02
|
1.34ml
if Hgb is 10 (Hct-30) THERE IS 13.4ml per 100ml blood |
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nl hct
man women |
man-45
woman-39 |
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the relationship of the P02 of the plasma and the percent Hgb saturated is represented buy the
|
oxyhemoglobin dissociation curve
|
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interaction between 02 and Hgb is influenced by..[4]
|
pH
PC02 temperture 2.3 diphosphoglycerate |
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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 |
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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 |
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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 |
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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 |
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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 |
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3 ways that the blood carries CO2?
|
dissolved 5-10%
bicarbonate ions 80-90% chemically combined with amino acids of blood protiens 5-10% |
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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 |
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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 |
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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.
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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 |
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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 |
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a base change of 10meq/l is assscosiated with a pH change of ____
|
0.15 units
|
|
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resp alkalosis causes...
|
hypothyroidism
hypothermia |
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metabolic alkalosis causes...
|
fixed acid loss
high intake of bases long term hypokalemia |
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the kidneys compensate for resp/met acidosis by...
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excreting fixed acid and retaining bicarbonate
|
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the kidneys compensate for rest/met alkalosis by...
|
decreasing H excretion and decreasing retention of bicarbonate
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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 |
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ACIDOSIS associated with renal failure treatment?
|
dialysis
|
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hypoxemia treatment [3]
|
increase fi02
PEEP correction of atelectasis |
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spinal nerves involved with the control of breathing?
|
C3,4,5
|
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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)
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|
centers that modify the output of the medullary respiratory center?[2]
|
apneustic center (lower pons)
pneumotaxiz center (upper pons) |
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|
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 |
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stimulation of stretch receptors in the lungs cause [3]
|
Hering-Breuer inflation reflex
Hering-Breuer deflation reflex paradoxic reflex of Head |
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|
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
|
|
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Reflex responsible for sighs and increased ventilation when the lings are abnormally deflated (pneumothorax)
|
Hering-Breuer deflation reflex
|
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|
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 |
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|
the ____ nerve provides afferent pathways for all of the airway's irritant receptor's except the nasal mucosa.
|
Vagus
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PE causes ____ respirations.
|
rapid, shallow
|
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|
pulmonary vascular congestion causes ____ respirations.
|
hyperpnea
|
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the vascular receptors that cause the changes in respirations with PE/pulm vascular congestion are the....
|
J receptors (juxtapulmonary capillary)
|
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|
elevated BP causes ____ respirations.
|
apnea and bronchodilation from stimulation of arterial baroreceptors
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somatic pain causes ____ whereas visceal pain causes ____.
|
hyperpnea
apnea/decreased ventilation |
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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
|
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|
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:
|
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|
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. |
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Asthma Under GA:
|
Wheezes, mucous hypersecretion, high inspiratory pressures, a blunted expiratory CO2 waveform, and hypoxemia.
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|
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) |
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|
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-. |
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with a high anion gap, Electroneutrality is maintained by....
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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.
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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.....
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hyperchloremic acidosis.
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High anion gap
The _____ lost is replaced by an unmeasurable anion and thus you will see a high anion gap. |
bicarbonate
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high anion gap causes...
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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 |
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Normal anion gap (hyperchloremic acidosis)
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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) |
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the most common causes of COPD are [2]
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chronic bronchitis and emphysema
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acute respiratory failure is...
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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
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the principal predisposing factor to the development of COPD is
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smoking
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in addition to smoking, emphysema may develop because...
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of a genetic predisposition to an imbalance between protease and antiprotease activities in the lungs
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THE dominant feature of the natural history of COPD is..
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progressive airflow obstruction as reflected by a decrease in FEV1
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3 causes of decreased FEV1 are...
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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 |
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_______ deficiency results in the degradation of intertitial elastin fibers
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alpha anti-trypsin
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______, 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 |
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_____ are collections of air within the pleura that are NOT a form of emphysema because they do not involve the _____
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Blebs
no acinus iunvolvement |
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COPD stages
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0-normal spirometry
1-short acting bronchodilator 2-regular dilators, occ, steroids, rehab 3-dilators,steriods, 02,rehab |
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the defense system of COPD patients is disrupted by...
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excessive mucus production
paralysis of the mucocilliary transport sustem |
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Ve in COPD
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normal or slightly elevated
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02 delivery in COPD is preserved by [3]
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increased CO
polycythemia greater extraction |
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changes with smoking [3]
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increased oxidants
increased sputum chronic hyperinflation |
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_____ is present is 2/3's of patients with severe COPD and its severity coorelates with degree of airflow obstruction
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pulsus paradoxis
from a forced expiratory pattern and positive pressure swings during expiration |
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normally inspiration ____ venous return.
increases in lung volume may negate that. |
augments
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CO increased in COPD because
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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
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whar are the four parameters of airway obstruction that have been coorelated to the heart rate response to hypoxia?
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FVC
FEV1 to FVC ratio RV to TLC ratio RV |
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renal changes with COPD
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deecreased GFR
impaired renal function decresed RBF |
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chronic pressure overload causes RV _____ where acute pressure changes cause RV_____
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hypertrophy
dilation |
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spirometry..a decrease in _____ is characteristic of airflow obstruction
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FEV1/FVC
FEV1 is ussually less than 80% of FVC in patients with COPD also increased FRC and RV |
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pink puffer??
blue bloater?? |
pink-p02>60 (emphysema)
blue-po2<60, c02>45, cor pulmonale (chronic bronchitis) |
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cyanosis relects the...
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CONCENTRATION of deoxygenated Hgb not the amount
>5gm/dl |
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PA HTN that leads to cor pulmoale is likey to develop in ___
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bronchitic patients with arterial hypoemia and hypercarbia
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arterial hypoxemia occurs in what state of emphysema?
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very late
very late PA HTN |
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preop evalulation of COPD patients focus...
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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 |
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supplemental 02 is recommended if...[3]
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p02 <60
Hct>55% cor pulmonale |
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contributing factors to COPD exacerbation...
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bronchitis
airway hyperresponiveness noxious inhalationaL AGENTS MUCUS PLUGGING pneumonitis CV dz CHF systemic inflamation |
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must assess COPD patient for...[4]
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increased effort
abnormal breath sounds altered breathing patterns productive cough |
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asthmatic bronchitis indicators
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atopy(predisposition to allergies)
CHILDhood respiratory impariment high IGe levels eosiniphilia generally more responive to treatment than smoking induced COPD |
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Acute infection is associated with epithelial desquamisation and correlated with airway hyperreactivity that my persist for _____ after the resolution of sx
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3-6 weeks
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decreases in pulmonary function as evidenced by decreased FEV1 correlates with...
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CAD and increased overall mortality
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______ correct the hypercarbia during anesthesia
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don't
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regional anesthesia techniques that produce sensory anesthesia above T6 are...
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NOT recommend because of the potential for decreasing ERV, impairing cough effort, and creating anxiety provoking weskness
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GETA is associated with a ______ in the alveolar-arterial P02.
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an increase
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what is contraindicated with Bullae?
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Nitrous Oxide
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with COPD patients, gas exchange is very dependent on _____.
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Vt
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ideal PEEPi to PEEPe?
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PEEPe 85% or less than PEEPi
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early ambulation increases..
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FRC
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asthma definition
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chronic inflammatory disorder of the airways characterized by an increased responsiveness of the trachobronchial tree to a variety of stimuli
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cells/elements that play a role in asthma [4]
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mast cells
eosinophils neutrophils epithelial cells |
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asthma episode events [4]
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wheezing
breathlessness chest tightness cough particularly at night and early morning |
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the most important consideration with asthma is
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the identification of exacerbating factors
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extrinsic asthma (allergic) factors...
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mostly kids and young adults
infectious, environmental, psychological or physical factors atopy (heriditary, IgE mediated, clincal hypersentice state |
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intrinsic asthma (idiosyncratic)
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middle age without specific stimuli
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____ and ___ are central to the pathogenesis of asthma
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airway inflammation
nonspecific irritbility of the tracheobronchial gtree both have bronchoconstriction PERMANENT changes (remodeling) magnify the inflammatory response |
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allergic asthma is triggered by..
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antigens that provoke a T-lymphocyte-generated, IgE-mediated immune response
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the asthmatic diathesis creates airways that are [3]
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edamatous
inflamed hypersensitive to irritant stimuli degree of airway hyperrespnsiveness and bronchoconstriction parallell the extent of inflamation. |
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idiossyncratic asthma can be triggered by...[3]
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cold air
instrumentation climate changes URI |
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the increased bronchomotor tone associated with a viral infection may persist for up to ____
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5 weeks
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non-asthmatic children with an URI are _____times more likely to experience an adverse event perioperatively and are more prone to postop desaturation
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2 TO 7 TIMES
ENHANCED parasympathetic tone can contribute to the airflow obstruction |
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_____ forms of asthma are more prevalent in the perioperative period
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non-allergic mechanisms
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exercise induced asthma
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less than 1 hr
easily reversed with B2-adrenergic receptor antagonists |
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ASA induced asthma
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cyclooxygenases promotes an increase in leukotriene levels via the arachnidonic pathway
clinically associated with nasal polyps |
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Clinical hallmarks of asthma in the awake patient [8]
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wheezing
dyspnea cough taqchpnea chest tightness prolonged espiratory phase fatigue accesory muscle use |
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status asthmaticus
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persistant severe obstructin lasting for days or weeks
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chronic asthma may lead to [4]
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irreversible lung destruction
loss of lung elasticity PH lung hyperinflation |
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manifestations of asthma in the anesthetized patient [4]
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wheezing
mucus hypersecretion blunted C02 expiratory waveform hypoxemia |
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causes of wheezing other than asthma [6]
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pneumothorax
ETT obstruction endobronchial intubation anaphylaxis pulmonary edema pulmonary aspiration |
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patients with increased airway resistance have what spironmetry changes
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decreases FEV1 and FEV1/FRC %
RV, FRC, TLC increased |
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____% of asthmatics have a normal CXR
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75%
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sputum analysis in asthma
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eosiniphilia,,grossly prurlent
curshmann's spirals charcot-leuyden crystals |
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preop eval findings in asthma that may signal an likelihood of introperative difficulty [3]
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frequent nocturnal wakenings
recent increase in med use signs of viral infection |
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pretreatment with ______ has been advocated in asthma patients
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systemic corticosteroids
dexamethasone |
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asthmatics experience an increased parasympathetic tone, what meds can help this...
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anticholinergics
atropine, glycopyyrolate given 20-30 minutes preop |
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meds to avoid with asthma patients
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h2 blockers
cimetidine ranitadine atracurium, micacurium, esmolol, labetolol no Ketorolac with ASA-asthma |
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only induction agent with bronchodilating properites...
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ketamine
propofol is OK, NO barbiturates (histamine release) |
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treatment for bronchospasm during anesthesia
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deepen anesthesia
100% 02 B2-agonist epi iv/sq IV aminophylline Theophylinne has little efficacy for acute episode |
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strategy for mechanical ventilation of asthmatic patient [4]
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avoid hyperinflation
longer exp time reduce Ve by limiting I-time moderate permissive hypercapnea |
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emergence for asthmatic [3]
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try to avoid anticholinesterase
lidocaine atropine/glycopyrolate |
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asthmatic pregnant patient [5]
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avoid IV beta agonists
maintain maternal oxygenation minimize hypotension ephedrine if pressor needed avoid nitrous |
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prognosis of PH is largly determined by
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RV integrity
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PH CAUSES [3]
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left atrial outflow obstruction
pulmonary veno-occlusive dz hyperdynamic circulation |
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PH is characterized by [2]
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an increase in vascular tone and the growth and proliferation of pulmonary vascular smooth muscle
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first complaints with PH [2]
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dyspnea
exercise intolerance |
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anesthesia management of PH
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vasodilator agents
preventiono of increases in PH and avoidance of major hemodynamic changes ketamine increases PH, all of the others-no change or decrease |
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leading cause of cor pulmonale
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HPV caused by COPD
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sx of cor pulmonale
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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 |
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treatment of Cor Pulmonale
|
improvement of gas exchange
02 transplant volatile agents decrease PVR (N20 INCREASES PVR IN PATIENTS WITH PH) |
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anesthetic mamagement of patient with Cor pulmonale
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keep well oxygenatede
avoid acidosis avoid vsdoconstrictors (worsen hypoxemia) avoid stimuli that increases sympathetic tone avoid hypothermia |
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PE's originate from the _____ in 90% of patients. The remainder originate in the ______ veins.
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ileofemoral vessels
pelvic |
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3 factors that promote the formation of a embolus
(virchow's triad) |
stasis
venous injury hypercoagulation states |
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most PE'd resolve in...
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8 to 21 days
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emboli are most often seen in the ____ lobes, these lobes also receive ____ ventilation
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lower
the least |
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after PE, moderate _____ without _______ is often seen as both __ and __ increase.
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hypoxemia without C02 retention
physiological shunt and dead space |
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wih PE, spontanously breathing patients maintain C02 levels by ___.
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increasing RR
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with PE, the anesthetized patient has what C02 chages?
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increased C02, more rapid desaturation
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the difference between _____ and ____ are very useful indicators in PE with the anesthetized patient
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ETCO2 and PaC02
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most commom s/s of PE? [4]
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dyspnea
increased RR chest pain tachycardia |
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Massive PE ABG's
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hypoxia and hypocapea
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anesthetic management of PE
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100% Fi02
PA Cath to assist in optimizing RV function |
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first s/s seen with PE in anesthetized paitent...
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decreasing ETC02
tachcardia followed by desaturation and ABG's that indicate unexplained arterial hypoxemia |
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EKG changes with PE
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right axis deviation
right bundle branch block peaked T waves a systolic ejection murmur may be present |
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Other challenges with PE
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reperfusion edema
pulmonary steal persistant hypoxemia pericardial effusion psychiatric disorders |
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restrictive pulmonary disease definition
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any condition that interferes with the normal lung expansion during expiraion.
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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 |
|
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3 types of restrictive pulmonary diseases
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acute intrinsic
chronic intrinsic chronic extrinsic |
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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
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acute intrinsic restrictive
restrictive pulmonary diseases examples |
pulmonary edema
aspiration pneumonia ARDS |
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chronic intrinsic
restrictive pulmonary diseases are carachterized by |
characterized by pulmonary fibrosis
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chronic intrinsic
restrictive pulmonary disease examples |
ideopathic pulmonary fibrosis
radiation injury cytotoxic and noncytotoxic drug exposure, 02 toxicity, autoimmune diseases sarcoidosis |
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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 |
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pulmonary edema can be caused by [3]
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increase in hydrostatic pressure (most common)
increase in permeability decrease in intravascular colliodial oncotic pressure |
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pulmonary edema is classified as either __ or __.
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cardiogenic (high pressure, hydrostatic)
non-cardiogenic(increased permeability) |
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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)
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|
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 |
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in non-cardiogenic pulmonary edema _____ is leaked
|
protiens because the endothelium is not intact
|
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|
most common cause of non-cardiogenic pulmonary edema
|
systemic sepsis that leads to ARDS
|
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|
neurogenic pulmonary edema stems from
|
LV failure from HTN fron excessive sympathetic outflow
|
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|
uremic pulmonary edema is from
|
renal insufficiency or failure
|
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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 |
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|
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
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