Resp 117

  1. What is the common cause for ARDs?
    Respiratory failure
  2. Common features between ARDS and CHF!
    • Symptoms of anxiety, dyspnea, tachypnea
    • Reduced lung volumes and decreased compliance
    • Arterial blood gases intially show respiratory alkalosis and arterial hypoxemia
    • Chest xray shows diffuse alveolar and interstitial inflitrates
  3. Role of organ to organ interactions
    • Factors outside lung may play role in initiation & progression of ARDS & multiple organ dysfunction syndrome (MODS)
    • Treatment strategy: selective decontamination, early enteral feeding
  4. The gut-liver-lung axis may be most influential in...
    Causing the systemic inflammatory response associated with ARDS and MODS
  5. Gut-liver-lung axis
    • GI tract & liver function is often compromised in critical illness
    •   wide-spread use of antibiotics leads to overgrowth of antibiotic resistant bacteria in gut
    •   These bacteria & their toxic byproducts escape gut, taken up by reticuloendothelial (RE) cells in the liver which activate & perpetuate systemic inflammatory response & systemic organ injury
    •   Liver  is responsible for breakdown of proinflammatory mediators
  6. Exudative Phase of ARDS
    • (1-3 days)
    • Characterized by diffuse damage to alveolar and blood vessels and the influx of inflammatory cells into interstitium
    • Filled alveolar spaces with cellular debris & plasma proteins; destruction of Type I pneumocytes
  7. The exudative phase of ARDS is often difficult to differentiate from...
    Respiratory failure related to hydrostatic pulmonary edema (CHF)
  8. Patients with ARDS have...
    • Profound dyspnea
    • Tachypnea
    • Refractory hypoxemia
  9. THe exudative phase of ARDS may be...
    self limited or may progress to a fibroproliferative phase
  10. Fibroproliferative phase of ARDS
    • 3 to 7 days
    • Process of lung repair
    • Hyperplasia of alveolar Type II  pneumocytes & proliferation of fibroblasts
    • Fibroblasts form intraalveolar & interstitial fibrosis
    • Extent of fibrosis formation determines disability in those who survive
    • Lung remodeling process, degree and reversibility varies greatly
    • An intact alveolar basement membrane is necessary for normal repair
  11. The clinicals findings in ARDS!
    • Peripheral infiltrates on chest xray
    • PCWP< 18 mm Hg
    • BALF is proteinaceous and inflammatory
    • Pathologic examination shows diffuse alveolar damange, type ll pneumocyte hyperplasia with or without fibrosis
    • Ratio of PaO2/FiO2 < 200
    • air bronchograms, normal cardiac size
  12. Know about oxygen delievery and PEEP with ARDS patients!
    • Recruits additional alveoli
    • ↑FRC
    • Improved oxygenation
    • May allow for ↓FIO2 Rule and airway shear trauma
    • ↓CO
    • Use the lowest level of PEEP  that will maintain adquate oxygenation
  13. Prone positioning
    • ↑ventilation-perfusion matching
    • Patient tolerance varies due to hemodynamic instability & worsening gas exchange
  14. How much of the lung is not functioning in patents with ARDS?
    Thus, in ARDS, the lungs are effectively diminished in size to 20 to 30% of normal
  15. What are some other causes of lung cancer besides smoking?
    • Occupational and environment exposure
    • Genetic predisposition
    • Gender
    • Dietary factors
    • COPD
    • Air pollution
  16. What is the purpose of staging cancer?
    Most important prognostic variable in lung cancer, assesses extent of disease & selection of therapy
  17. What does T, M, N stand for in TNM staging?
    • Status of primary tumor (T1-T4)
    • Local & regional lymph node involvement (N0-N3)
    • Presence of metastasis (M) 1A-4
  18. The common organs that lung cancer commonly passes to?
    • Brain
    • Bones
    • Liver
    • Adrenal glands
  19. What pulmonary function test are used to determine wheither a person can tolerate a lung recession?
    • FEV1 and DLCO
    • Above 40%
  20. What is the best treatment for non small cells cancer?
    Surgical resection offers best survivial
  21. How is small cells cancer staged?
    Limited versus extensive
  22. Limited stage for small cell lung cancer
    • Combination chemothrapy with concurrent hyperfractionated radiotherapy if prformance status is adequate
    • Prophylactic cranial radiation for those with a complete response to chemoradiotherapy
  23. Extensive stage of small cell lung cancer
    Combination chemotherapy if performance status is adequate
  24. What kind of clinicals symptons might a patient have with tumor growth in the central airways?
    • Cough
    • Hemoptysis
    • Features of large airway obstruction
    • Wheezing
    • dyspnea, dysphagia
    • esophageal compression), post-obstructive pneumonitis, hoarseness, SVC syndrome, chest pain if pleura is involved, palpitation, syncope
  25. What systems are affected by metastasize?
    • Liver
    • CNS
    • Adrenal glands
    • Bones
    • Supraclavicular lymph nodes
  26. Symptoms of Metastatic or if lung cancer spreads byond the lung!
    • Weight loss
    • Anorexia
    • Neurological symptoms
    • Localized bone pain
  27. What is associated with respiratory muscle weakness?
    Nuromuscular disease
  28. The pulmonary consequences of nuromuscular disease!
    • Hyper or hypo ventilation
    • Sleep apnea
    • Aspiration
    • Atelectasis with resulting hypoxemia
    • Pulmonary hypertension
    • Cor pulmonale
    • Respiratory failure is frequent cause of death
  29. Among the many neuromuscular problems causing pulmonary dysfunction, respiratory muscle weakness that leads to...
    • Atelectasis
    • Hypoxemia
    • Ventilatory insufficiency
  30. Symptoms of respiratory muscle weakness due to nuromuscular disease!
    • Exterional dyspnea
    • Fatigue
    • Orthopnea
    • Symptoms of cor pulmonale
  31. A decrease in FEV1 and VC greater than 20% when a patient moves from the seated to the supine position indicates...
    Diaphragmatic weakness
  32. The inability to generate normal respiratory pressures...
    Is reflected in a decreased maximal inspiratory pressure (PImax)
  33. Expiratory muscle weakness is characterized by...
    A decreased maximal expiratory pressure (PEmax)
  34. Progressive inspiratory muscle weakness leads to...
    • Hypoventilation
    • Hypercapnia
  35. Expiratory muscle weakness is associated with what problem?
    Production of cough to clear pulmonary secretions
  36. Decreased conduction of CNS impulse to peripheral muscles results in...
    Muscle weakness
  37. Guillain-Barre syndrome
    • Most common peripheral neuropathy
    • Characerized by paralysis and hyporeflexia,
    • Self-limiting disease
    • Is a demyelinating process caused by autoantibodies directed against nerve sheath
  38. Autonomic nervous system problems with guillian barre syndrome!
    • Hypotension
    • Flushing
    • Bronchorrhea
    • Dermatographia
    • Bradycardia
  39. Myasthenia Gravis
    • Intermittent muscle weakness which worsens on repetitive stimulation and improves with anticholinesterase meds (neostigmine, tensilon)
    • Abnormalities of thymus gland common
    • Muscle weakness progresses during the day with repetitive use
  40. Myasthenia Gravis typically occurs in...
    Yonger female patients
  41. The pulmonary complications of Myasthenia Gravis!
    • Upper airway obstruction
    • DOE
    • Respiratory failure
    • Decrease in TLC, VC, MIP, MEP
  42. Myasthenic crisis
    acute event – respiratory failure or loss of airway patency – intubation and PPV required stat
  43. Guillian Barre syndrome can be weaned from mechanical ventilation when...
    • VC greater than 18 mm/kg
    • Transdiphragmatic pressure greater than 31 cm H2O
    • PImax greater than 30 cm H2O
  44. How is paralyzed diaphgram diagnosed?
    • Phrenic nerve arises form spinal cord at C3-C5
    • Damage or interruption of this nerve leads to paralysis of ipsilateral hemidiaphragm
    • Bilateral interruption is seen in high cervical cord injury and results in complete diaphragmatic paralysis
  45. Patients with unilateral diaphragmatic paralysis..
    May have a 15 to 20% reduction in VC and TLC in the upright position and a further reduction while supine
  46. Diaphragmatic paralysis is diagnosed...
    • Most often with chest radiograph
    • paralyzed side is displaced upward; fluoroscopy – effected side paradoxically rises during “sniff”
  47. Amyotropic lateral sclerosis
    • Progressive degeneration of upper & lower motor neurons
    • Onset at mid-to late life with male predominance
    • Poor prognosis – 80% die within 5 years of onset
    • Monitor FVC, MIP, MEP – assesses ability to clear secretions, maintain gas exchange
    • MEP> 40cm needed to generate cough
  48. What are the hallmark signs of diaphragmatic paralisis?
    • Patients adopt rapid, shallow breathing, using accessory inspiratory muscles
    • Abdominal paradox or paradoxical breathing is hallmark of significant diaphragmatic weakness – results in orthopnea
  49. Where does a spinal cord injury occur to affect the diaphragm?
    • Middle to low cervical cord lesions (C3-8)
    • The diaphgram receives its innervation from C3-5
  50. What are the breathing patterns of a patient who has had a stroke?
    • Apnea
    • Hyperpnea
    • Cheyne strokes respirations
  51. What are the complications of flail chest?
    • Atelectasis
    • V/Q mismatch
    • Decreased compliance
    • Hypoxemia
  52. Sleep apnea
    Repeated episodes of complete cessation of airflow for 10 seconds or longer
  53. Hypopnea
    • Significant decrease in breathing without complete cessation of airflow
    • 30% airflow decrease and 4% oxygen desaturation
  54. What causes obstructive sleep apnea?
    • Small or unstable pharyngeal airway caused by:
    • Upper body obesity
    • Tonsilar hypertrophy
    • Skeletal factors such as small or recessed chin
  55. What are some symptoms of OSA?
    • Habitual snoring
    • Sensations of nocturnal choking, gasping, snorting
    • Witnessed by bed partner
    • Fatigue, EDS, irritability
    • Morning headaches, depression
    • Nocturnal reflux, nocturia, chronic nasal obstruction
  56. What are some problems with CPAP?
    • Feelings of claustrophobia
    • Nasal congestion
    • Rhinorrhea
    • Skin irritation
    • Nasal dryness
  57. Auto CPAP or smart PAP
    Adjusts pressure when abnormal upper airway function is detected
  58. UPPP or palatal surgery
    • Portions of soft palate, uvula, additional excess tissue are removed 
    • Less than 50% success rate
    • Not currently recommended
    • Performed with a standard cold knife technique and or laser
  59. Central sleep apnea
    • Associated with CHF & stroke
    • Patients have periodic breathing – waxing & waning of respiratory drive
    • Cheyne-Stokes is a severe type of periodic breathing
  60. What is the association between sleep apnea and systemic hypertension?
    Repetitive upper airway closure & opening increases sympathetic tone
  61. Increased sympathetic tone is caused by...
    • Episodes of hypoxemia & hypercapnia
    • arousals & microarousals also increase sympathetic response
  62. Apnea-hypopnea index (AHI) or the respiratory distrubance index (RDI)
    • Number of apnea / hypopnea events per hour of sleep
    • AHI >30 = severe sleep apnea
    • AHI = 15-30 moderate
    • AHI = 5-15 mild
    • AHI < 5 = normal
  63. The use of alcohol with sleep apnea?
    • Decreases the arousal threshold and can increase the duration of apnea
    • Reduce upper airway muscle tone, causing the airway to be more compliant and more prone to complete or partial closure
Card Set
Resp 117
Test 3