1. What is the pulmonary pressure of the right ventricle?
    5-10 cm H20
  2. What is the most common sign of a PE during surgery?
    • Decreased ETCO2
    • Cardiac arrest
  3. What is the cc/kg TV range for COPD patients?
    8-10 cc/kg
  4. What does asthma do to the airways?
    increases the resistance to air flow (Pousilles Law)
  5. Is the FRC increased or decreased in COPD?
    Increased d/t the increased RV
  6. If a patient has a URI, how long might you have to postpone the surgery?
    >4 weeks to reduce reactive airway; 6 weeks to reduce all hyperreactivity
  7. When should a surgery be cancelled for a patient with a URI?
    • fever
    • productive cough
    • and/or rhonchi
  8. What’s one way to decrease a reactive airway from an anesthesia viewpoint?
    Avoid over manipulation by using an LMA vs DL
  9. What two meds might you give to a PT preoperatively in a Pt with an active or recent URI?
    • Bronchodilator
    • Antimuscarinic (decrease secretions)
  10. What is the most common problem from an anesthesia viewpoint in a surgical Pt who has or recently had a URI?
  11. Does asthma have a productive or non-productive cough?
  12. What are the common S/S’s of asthma?
    • Wheezing
    • Retraction
    • Increased WOB
    • Non-productive cough
  13. Do asthmatics have a decreased FEV1?
  14. What kind of flow volume loop do asthmatics have?
  15. What does airflow obstruction directly correlate with in asthmatics?
    PaCo2 levels
  16. What is Theophylline used to treat asthma?
    Increases cAMP & causes bronchodilation
  17. Why give anti-inflammatory drugs to treat asthma?
    • Decrease airway inflammation
    • Reduce mast cell degranulation
    • Inhibit leukotrienes
  18. What kinds of preop tests might you consider in an asthmatic patient?
    • PFT’s (esp FEV1) if having MAJOR surgery
    • Baseline ABG
    • X-Ray
  19. What is one of the best indicators of respiratory function in an asthmatic patient?
    Ask the Pt how their breathing is?
  20. Should asthmatic patients remain on their medications & take a dose of albuterol prior to induction?
  21. Are preop tests for asthmatics necessary?
    No always (Major surgery for sure)
  22. When dealing with an asthmatic patient, what agents should you avoid to keep bronchospasm from occurring?
    • STP
    • Atracurium
    • Morphine
    • DES
  23. Can anticholinesterases precipitate bronchospasm?
    Yes, but not usually when give with anticholinergic drugs
  24. How might you adjust the I:E ratio for an asthmatic?
    Prolong the E time to allow to fully exhale
  25. Why might you do a “deep” extubation?
    To avoid bronchospasm in Stage II
  26. What do you do if you have an intraoperative bronchospasm?
    • Pull back the ETT tube (maybe tip at carina)
    • Give beta 2 agonists
    • Deepen the anesthetic
    • When is intraoperative bronchospasm a common occurance with an asthmatic?
    • Right after induction & intubation
  27. What happens with Albuterol binds to the beta 2-adrengergic receptors?
    Stimulates the production of cylic AMP wich increases the levels of cAMP which reduces Ca2+ for smooth muscle contraction
  28. Which two subclasses of diseases does COPD include?
    • Chronic bronchitis
    • Emphysema
  29. What is the mechanism of airway obstruction in chronic bronchitis?
    Decreased airway lumen d/t mucus & inflammation
  30. What is the mechanism of airway obstruction in emphysema?
    Loss of elastic recoil
  31. Is FEV1 decreased in chronic bronchitis & emphysema?
  32. Is PaO2 decreased in chronic bronchitis?
    Yes, MARKED (blue bloater) PaO2 <60 mm Hg & PaCO2 >45 mm Hg
  33. Is PaO2 decreased in emphysema?
    Yes, modest (pink puffer) PaO2>60 mm Hg
  34. Is PaCO2 increased or decreased in chronic bronchitis?
  35. Is PaCo2 increased or decreased in emphysema?
    Normal to Decreased
  36. Is Hct increased or decreased in chronic bronchitis?
  37. Is Hct increased or decreased in emphysema?
  38. Is cor pulmonale present in chronic bronchitis?
    Yes, MARKED
  39. Is cor poumonale present in emphysema?
    Yes, MILD
  40. Why do blue bloaters (chronic bronchitis) develop pulmonary HTN?
    d/t arterial hypoxemia & respiratory acidosis which evokes pulmonary vascular vasoconstriction
  41. In pink puffers (emphysema), what does the loss of pulmonary capillary vascular bed lead to?
    Decreased diffusing capacity
  42. In chronic bronchitis, is the diffusing capacity increased or decreased?
  43. What are the characteristics of Mild COPD?
    • FEV1/FVC <70%
    • FEV1 > or equal to 80% with or without cough, sputum production
  44. What are the characteristics of Moderate COPD?
    • FEV1/FVC <70%
    • FEV1 < or equal to 50%; <80% cough, sputum production
  45. What are the characteristics of Severe COPD?
    • FEV1/FVC <70%
    • FEV1 < or equal to 30%; <50% cough, sputum production
  46. What are the characteristics of Very Severe COPD?
    • FEV1/FVC <70%
    • FEV1 <30: 50% cough, sputum production AND chronic respiratory failure (PaO2 <60 & PCO2 >50)
  47. What is the diagnosis of COPD?
    Chronic productive cough & progressive exercise limitations are hallmarks of persistent expiratory airflow obstruction
  48. In COPD, are PFT’s reduced or increased?
  49. In COPD, are TLC & FRC increased or decreased
    Increased d/t increased residual volume
  50. What is the medical management of COPD?
    • Stop smoking is the greatest treatment
    • Bronchodilators (small increased FEV1)
    • Anticholinergic (decrease secretions)
    • Inhaled corticosteroids
  51. When are PFT’s useful in COPD patients?
    In thoracic procedures (NOT predictive of complications for the non-thoracic surgery PT)
  52. When should a COPD Pt be referrd to pulmonary medicine?
    • Hypoxemia on room air
    • Bicarb >33, PaCo2>50
    • Severe SOB
    • Suspected pulmonary HTN
    • Pneumonectomy (Pt’s need to be cleared)
    • Uncontrolled lung dz (need to be cleared)
    • Poor response to bronchodilator therapy (need to be cleared)
    • Should you use N20 in COPD patients?
    • No, may rupture bullae
  53. What kind of response does a COPD patient have to opiates?
    • Slow elimination thereby complicating their response to CO2 (opiates: slow RR, large TV)
    • Chronic Bronchitis has increased CO2
  54. Do COPD patients have larger TV’s?
    Yes, and may require additional time to exhale
  55. What are post-op considerations with a COPD patient?
    Lung expansion techniques, deep breathing, & IS
  56. When might a COPD Pt require mechanical ventilation post-op?
    FEV1/FVC <50% or PaCo2 level >50 mm Hg
  57. What do you titrate oxygen therapy to in COPD patients postoperatively?
    PaO2 60-100 mm Hg
  58. Do you treat the patient or the pulse Ox in a COPD Pt?
    The Patient
  59. What is the definition of respiratory failure?
    Body’s inability to adequately perform gas exchange
  60. Largest one you can to reduce airway pressure & give space for bronchs
  61. What must you assume with respiratory failure patients?
    Prolonged ventilation
  62. What is the PaO2 goal for respiratory failure patients?
    PaO2 60-100 mm Hg
  63. What are the 2 subclasses of restrictive lung DZ?
    Intrinsic & extrinsic
  64. How are intrinsic lung diseases characterized
    • Physical changes to lungs
    • Fibrosis of tissues
    • Dyspnea with rapid, shallow breathing
  65. What type of restrictive Dz is sarcoidosis
  66. What is sarcoidosis?
    Granulation of lung tissue
  67. What percentage of sarcoidosis Patient’s may be asymptomatic?
  68. What other areas can sarcoidosis affect?
    Eyes, heart, & airway
  69. What is the treatment for sarcoidosis?
    Chronic steroid use
  70. What is extrinsic restrictive lung Dz caused by?
    External compression of thorax or loss of muscle tone
  71. When is extrinsic restrictive lung Dz often seen?
    • Obesity
    • Skeletal deformities (sternum, kyphosis)
    • Spinal cord transection
  72. What are 2 types of extrinsic lung disease?
    • Guillain-Barre Syndrome
    • Muscular Dystrophy
  73. What is Guillain-Barre Syndrome?
    Autoimmune disease
  74. How is G-B syndrome characterized?
    Ascending paralysis
  75. What happens to the diaphragm and accessory muscles in G-B Syndrome?
  76. Mechanical ventilation is usually greater than how long in Pt’s with G-B Syndrome?
    >2 months
  77. What are Pt’s with G-B syndrome often predisposed to?
    Muscle weakness even after disease remission
  78. What is the cause of Muscular Dystrophy?
    Variety of causes
  79. What do Pt’s with MD have a predisposition for?
    Pulmonary dysfunction & respiratory failure
  80. What types of drugs should be avoided in Pt’s with MD?
    CNS depressants
  81. Why should CNS depressants be avoided in Pt’s with MD?
    • d/t the weak inspiratory FX & poor exhalation/cough
    • avoid exacerbating pre-existing pulmonary dysfunction
    • What kind of ECG changes do you see intraoperatively in a Pt with a PE?
    • ST-T changes
    • Right axis deviation
    • Peaked P waves
    • A-fib
    • R BBB
  82. How can a PE be identified?
    • Loss or reduced ETCO2
    • TEE
  83. How is a PE treated?
    • 100% FIO2
    • Vasopressor/ACLS
    • Heparin 5000-10,000 unit bolus
  84. What normally drives respiration?
  85. What drives respiration in COPD patients?
    O2 - when exposed to high CO2 & hypoexmia, O2 may become the drive
  86. Why might VA's be useful in COPD Pt's?
  87. What's a dowside to using GA in COPD Pt's?
    may attenuate HPV & cause more shunting
  88. How might you offset the shunting that may occur with IH in COPD Pt's?
    Increase FIO2
  89. What happens in COPD Pt's when give opioids?
    They will be prolonged causing prolonged ventilatory depression
  90. In a COPD Pt, what does a flow volume loop look like?
    The expiratory curve is concave
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