Management Of Arf And Chronic Pulm Disease App1

Front 1

Vital Capacity 60-70 ml/kg so 70kg patient

Back 1

4700 cc

Front 2

Inspiratory reserve volume IRV (70kg)

Back 2

3000 CC

Front 3

Expiratory Reserve Volume ERV (70kg)

Back 3

1200 CC

Front 4

Residual Volume 70 kg

Back 4

1200 cc

Front 5

FRC - functional residual capacity RV+ERV

Back 5

2400 cc

Front 6

Risk factors for Post-op pulmonary complications

Back 6

older than 65, 40 pack yr smoking hx, COPD/Asthma, thoracic/abd surg, Productive cough, exercise intolerance, GA>3hrs.

Front 7

Respiratory Failure

Back 7

Lungs cannot maintain adequate arterial oxygenation. - co2 elimination can be normal or abnormal.

Front 8

Type 1 Resp Fx for Type 2 Resp Fx

Back 8

Type 1 - Hypoxemic - PaO2- less than 60 w/ FiO2>50- PNA, Pulm edema, Pulm injury

Type 2- Hypercapnic-Hypoxemia - PaCO2> 50; pH depends on metabolic compensation. - Chronic Lung problems. OD, NM weakness, Polycythemia, Cor Pulmonale.

Front 9

Determine chronic vs acute resp failure

Back 9

Look at pH if normal - chronic

if pH low - Acute

Front 10

Acute Resp Fx what to look at to determine Hypoventilation or VQ mismatch

Back 10

Look at shunt-

A-a Gradient normal then hypoventilation

A-a Gradient greater than 5 than think shunting.

Front 11

Pulmonary Edema Cardiogenic

Back 11

Increase in Hydrostatic or decrease in capillary oncotic pressure.

LV failure, severe mitral stenosis, LA obstruction, Aortic valve disorder

GOAL: DECREASE PULMONARY CAPILLARY PRESSURE by increase LV function (inotropes) or decrease pulmonary blood flow (vasodilators), Diuretics (correct hypovolemia

Front 12

Pulmonary Edema Non-Cardiogenic

Back 12

Fluids moves to pulmonary capillaires to interstitial space then to alveoli

Albumin Leak

Front 13

**How to know difference between Cardiogenic and Non-Cardiogenic Pulmonary Edema

Back 13

Pulmonary Artery Occlusion Pressure (PAOP)

if less than 18mmHg= likely increase hydrostatic pressure (cardiogenic)

Protein - decrease protein = cardiogenic

increase in protein= non-cardiogenic

less than 18 PAOP and Protein= Non-cardiogenic

Over 18 and no protein = Cardiogenic

Front 14

Post-Obstructive Pulmonary Edema type 1

Back 14

Type 1 - follows sudden sever upper airway obstruction (post ex laryngospasm, croup, epiglottis) due to vigorous ins. effort - highly neg intrathoracic pressure, increased venous return, decrease CO, and fluid transudation into alveolar space

Front 15

Post-obstructive pulmonary edema type 2

Back 15

Develops after surgical relief of chronic upper airway obstruction - tonsillectomy or removal of upper airway tumor

sudden relief of longstanding PEEP. Lung/volumes and pressure return to normal but permeability and interstitial funds does not resolve as quickly.

Front 16

Pulm edema stages

Back 16

1- interstitial pulm edema and decreased compliance

2. intersitium overwhelmed and fluid enter alveoli

3.alveoli mostly fluid and pulm shunting

4.alveolis overwhelmed and Froth

Front 17

Pulm edema and healthy lungs

Back 17

PPC must exceed 25 mm Hg before lymphatic reserve exhausted. -- rarely acute fall in oncontic usually hydrostatic pressure.

Front 18

Direct vs Indirect Lung injury

Back 18

Direct - PNA, gastric fluid aspiration, Pulm contusion, fat emboli, near-drowning, inhalational injury, O2 toxicity

Indirect- SEPSIS, trauma w/shock, transfusion, CPB, overdose, pancreatitis

Front 19

ARDS and first 24 hours

Back 19

ARDS develop in first 24 hours after trauma good prognosis

Front 20

Mendelsons syndrome

Back 20

Gastric volume >25ml

Gastric pH < 2.5

Epithelial injury

Tx suction and PEEP

Front 21

ARDS and trauma risk**

Back 21

Fat embolus usually appear 1-3 days after trauma and a long bone fracture or pelvic fracture

see Petachiae, mental confusion, thrombocytopenia, and resp fx

Front 22

Acute lung injury vs Acute resp distress syndrome diagnosing ***8

Back 22

Identifiable cause - know why it happen

Acute onset

PaO2/FiO2 ratio< 300 in ALI

PaO2/FiO2 ratio< 200 in ARDS

Diffuse bilateral opacities on x-ray

PaOP less than18 or no evidence of LA HTN

Front 23

Usually cause of death with ARDS

Back 23

Multi-Organ System Fx

Front 24

ARDS and Pulm fibrosis

Back 24

Patients who need prolonged ventilatory support and FiO2> 50% can develop pulmonary fibrosis- leading to decreased surfactant and increased epithelial cells. typically delayed onset

Front 25

ARDS signs and symptoms

Back 25

Dyspnea, Hypoxemia, initial PaCO2 low(breathing fast), Pulm HTN, diffuse infiltrates, PaO2/FiO2 less than 200, Resp. fx.

Front 26

Tx ARDS

Back 26

Primary goal preserve O2

Keep FiO2<50%

VT 6ml/kg and airway pressure less than 30

PEEP and CPAP(which can turn into PEEP at high flow)

Add PEEP to keep PaO2>60 and FiO2<50

Front 27

Issues with PEEP

Back 27

Barotrauma in increase airway pressure

decrease venous return= decrease CO

Front 28

TRALI

Back 28

Non-cardiogenic Pulm edema

usually recover 24-48 hours. tx as ARDS

Front 29

Obstructive Lung Disease

Back 29

MOST COMMON PULMONARY DISEASE

Resistance to airflow EXPIRATION = air trapping

VQ mismatch leads to decrease gas exchange

emphysema, chronic bronchitis, asthma.

Front 30

Asthma Early vs Late phase

Back 30

Early - smooth muscle contraction and mucosal edema, usually resolves in 1 hour

Late - begins 4-6 hours post exposure, more severe symptoms by eosinophils-bronchoconstriction, edema, mucus plug

small bronchi most affected (2-5mm) generation 17-19

Front 31

Asthma/Obstructive PFT's

Back 31

Decreased FEV1 and Low FEV1/FVC ratio

reversibility with tx 12% improvement good indicator... 200FEV1 absolute increase

Front 32

Asthma is it chronic

Back 32

Yes - they always have inflammation present and are hyper-reactive

Front 33

When do asthma patients have wheezing

Back 33

Auscultate - usually wheezing on expiration**

Front 34

Status Asthmaticus

Back 34

Life threatening- resp fx imminent.

progressing hours to days.

tx b2 agonists and hydrocortisone. albuterol, terbutaline, theophylline, aminophylline, mgso4, ett, volatile agents, ECMO

Front 35

Stages of COPD

Back 35

Stage 1 - mild copd - FEV1 >80%, - pt may not be aware

Stage 2- Fev1 50-80%, dyspnea on exertion- seeks attention*

Stage 3- fev1 30-50%, increase SOB, decrease exercise, repeated exacerbations impact pt lives

stage 4 - fev1 <30 or Fev1< 50 plus chronic resp fx, exacerbations life threatening

Front 36

Chronic Bronchitis vs Emphysema

Back 36

Chronic Bronchitis - Productive cough for 3 months a year for 2 consecutive years. hypertrophy of mucus glands, increase goblet cells, fibrosis in peripheral airways (blue bloaters) obstruction to expiration

Emphysema - destruction of alveolar w/airspace enlargement - no significant fibrosis (pink puffers) - alveoli and parenchyma distended/destroyed. form bullae. increase dead space.

Front 37

Chronic Bronchitis vs Emphysema

Back 37

Chronic Bronchitis - Cough w/copious secretions, increase Hct, PaCO2 elevated, increased airway resistance, and cor pulm early

Emphysema - cough w/ exertion, normal PaCO2, hyperinflation on X-ray, Cor pulm late. Diffusion impairment

Front 38

Emphysema types

Back 38

Centraiacinar - Central only

Panacinar - Everything look like broccoli

Front 39

Emphysema #1 cause

Back 39

Smoking

tx quit smoking.

Wheezing - early - mild or none....later- E then I&E, Late - no airflow. ... Flat diaphragm

PFT's - increase FRC, RV, TLC, ERV

Early FEF 25-75% first then FEV1 and FEV1/FVC ratio.

Front 40

Smoking Cessation

Back 40

12-24 hours - decreased CO and nicotine levels

48-72 hours- COHb levels normal, ciliary function improves

1-2 wk - decrease sputum production

4-6 wk - PFTs improve

6-8 wk - immune function and metabolism normal

***8-12 weeks - decreased postoperative morbidity and mortality

Front 41

Regional vs General and Obstructive Diseases

Back 41

Regional considered best choice for extremity surgery,

Avoid high spinal - COPD need intercostal for resp. also cause bronchoconstriction

Front 42

Restrictive Disease

Back 42

ALI, ARDS, Pulm Fibrosis, Silicosis, Sarcoidosis,

Extensive endothelial and epithelial destruction, inflammatory exudates, loss of surfactant, alveolar collapse, and protein leakage.

Front 43

Restrictive disease clinical picture

Back 43

Pulm HTN and Right Heart Fx.

PFT - Expiratory flow rates are normal more inspiratory issues. Decrease FEV1 and FVC...

FEV1/FVC ratio normal greater than 80.

Give small TV and lots of RR

VC < less than 15ml/kg - severe.

Front 44

Hyperoxia

Back 44

Oxygen toxicity - O2 free radicals and cytotoxic.

causes pulmonary fibrosis.

Front 45

1st sign of Hyperoxia

Back 45

**Coughing increase with deep inspiration and exposure.

burning chest pain, severe dyspnea, worsening cough, decrease VC

Front 46

Limits of Exposure to oxygen

Back 46

100%= 12 hours

80% = 24 hours

60%=36 hours

less than 50% = okay long term use.

risk for 1st tracheobronchitis (12hrs),2nd pulm interstitial edema (few days), and 3rd pulm fibrosis (weeks).