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What is the pulmonary pressure of the right ventricle?
5-10 cm H20
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What is the most common sign of a PE during surgery?
- Decreased ETCO2
- Cardiac arrest
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What is the cc/kg TV range for COPD patients?
8-10 cc/kg
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What does asthma do to the airways?
increases the resistance to air flow (Pousilles Law)
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Is the FRC increased or decreased in COPD?
Increased d/t the increased RV
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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
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When should a surgery be cancelled for a patient with a URI?
- fever
- productive cough
- and/or rhonchi
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What’s one way to decrease a reactive airway from an anesthesia viewpoint?
Avoid over manipulation by using an LMA vs DL
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What two meds might you give to a PT preoperatively in a Pt with an active or recent URI?
- Bronchodilator
- Antimuscarinic (decrease secretions)
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What is the most common problem from an anesthesia viewpoint in a surgical Pt who has or recently had a URI?
Hypoxemia
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Does asthma have a productive or non-productive cough?
Non-productive
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What are the common S/S’s of asthma?
- Wheezing
- Retraction
- Increased WOB
- Non-productive cough
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Do asthmatics have a decreased FEV1?
Yes
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What kind of flow volume loop do asthmatics have?
Obstructive
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What does airflow obstruction directly correlate with in asthmatics?
PaCo2 levels
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What is Theophylline used to treat asthma?
Increases cAMP & causes bronchodilation
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Why give anti-inflammatory drugs to treat asthma?
- Decrease airway inflammation
- Reduce mast cell degranulation
- Inhibit leukotrienes
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What kinds of preop tests might you consider in an asthmatic patient?
- PFT’s (esp FEV1) if having MAJOR surgery
- Baseline ABG
- X-Ray
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What is one of the best indicators of respiratory function in an asthmatic patient?
Ask the Pt how their breathing is?
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Should asthmatic patients remain on their medications & take a dose of albuterol prior to induction?
Yes
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Are preop tests for asthmatics necessary?
No always (Major surgery for sure)
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When dealing with an asthmatic patient, what agents should you avoid to keep bronchospasm from occurring?
- STP
- Atracurium
- Morphine
- DES
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Can anticholinesterases precipitate bronchospasm?
Yes, but not usually when give with anticholinergic drugs
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How might you adjust the I:E ratio for an asthmatic?
Prolong the E time to allow to fully exhale
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Why might you do a “deep” extubation?
To avoid bronchospasm in Stage II
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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
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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
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Which two subclasses of diseases does COPD include?
- Chronic bronchitis
- Emphysema
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What is the mechanism of airway obstruction in chronic bronchitis?
Decreased airway lumen d/t mucus & inflammation
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What is the mechanism of airway obstruction in emphysema?
Loss of elastic recoil
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Is FEV1 decreased in chronic bronchitis & emphysema?
Yes
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Is PaO2 decreased in chronic bronchitis?
Yes, MARKED (blue bloater) PaO2 <60 mm Hg & PaCO2 >45 mm Hg
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Is PaO2 decreased in emphysema?
Yes, modest (pink puffer) PaO2>60 mm Hg
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Is PaCO2 increased or decreased in chronic bronchitis?
Increased
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Is PaCo2 increased or decreased in emphysema?
Normal to Decreased
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Is Hct increased or decreased in chronic bronchitis?
Increased
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Is Hct increased or decreased in emphysema?
Normal
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Is cor pulmonale present in chronic bronchitis?
Yes, MARKED
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Is cor poumonale present in emphysema?
Yes, MILD
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Why do blue bloaters (chronic bronchitis) develop pulmonary HTN?
d/t arterial hypoxemia & respiratory acidosis which evokes pulmonary vascular vasoconstriction
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In pink puffers (emphysema), what does the loss of pulmonary capillary vascular bed lead to?
Decreased diffusing capacity
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In chronic bronchitis, is the diffusing capacity increased or decreased?
Normal
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What are the characteristics of Mild COPD?
- FEV1/FVC <70%
- FEV1 > or equal to 80% with or without cough, sputum production
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What are the characteristics of Moderate COPD?
- FEV1/FVC <70%
- FEV1 < or equal to 50%; <80% cough, sputum production
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What are the characteristics of Severe COPD?
- FEV1/FVC <70%
- FEV1 < or equal to 30%; <50% cough, sputum production
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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)
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What is the diagnosis of COPD?
Chronic productive cough & progressive exercise limitations are hallmarks of persistent expiratory airflow obstruction
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In COPD, are PFT’s reduced or increased?
Reduced
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In COPD, are TLC & FRC increased or decreased
Increased d/t increased residual volume
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What is the medical management of COPD?
- Stop smoking is the greatest treatment
- Bronchodilators (small increased FEV1)
- Anticholinergic (decrease secretions)
- Inhaled corticosteroids
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When are PFT’s useful in COPD patients?
In thoracic procedures (NOT predictive of complications for the non-thoracic surgery PT)
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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
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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
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Do COPD patients have larger TV’s?
Yes, and may require additional time to exhale
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What are post-op considerations with a COPD patient?
Lung expansion techniques, deep breathing, & IS
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When might a COPD Pt require mechanical ventilation post-op?
FEV1/FVC <50% or PaCo2 level >50 mm Hg
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What do you titrate oxygen therapy to in COPD patients postoperatively?
PaO2 60-100 mm Hg
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Do you treat the patient or the pulse Ox in a COPD Pt?
The Patient
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What is the definition of respiratory failure?
Body’s inability to adequately perform gas exchange
-
Largest one you can to reduce airway pressure & give space for bronchs
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What must you assume with respiratory failure patients?
Prolonged ventilation
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What is the PaO2 goal for respiratory failure patients?
PaO2 60-100 mm Hg
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What are the 2 subclasses of restrictive lung DZ?
Intrinsic & extrinsic
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How are intrinsic lung diseases characterized
- Physical changes to lungs
- Fibrosis of tissues
- Dyspnea with rapid, shallow breathing
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What type of restrictive Dz is sarcoidosis
Intrinsic
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What is sarcoidosis?
Granulation of lung tissue
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What percentage of sarcoidosis Patient’s may be asymptomatic?
2/3
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What other areas can sarcoidosis affect?
Eyes, heart, & airway
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What is the treatment for sarcoidosis?
Chronic steroid use
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What is extrinsic restrictive lung Dz caused by?
External compression of thorax or loss of muscle tone
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When is extrinsic restrictive lung Dz often seen?
- Obesity
- Skeletal deformities (sternum, kyphosis)
- Spinal cord transection
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What are 2 types of extrinsic lung disease?
- Guillain-Barre Syndrome
- Muscular Dystrophy
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What is Guillain-Barre Syndrome?
Autoimmune disease
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How is G-B syndrome characterized?
Ascending paralysis
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What happens to the diaphragm and accessory muscles in G-B Syndrome?
Loss
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Mechanical ventilation is usually greater than how long in Pt’s with G-B Syndrome?
>2 months
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What are Pt’s with G-B syndrome often predisposed to?
Muscle weakness even after disease remission
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What is the cause of Muscular Dystrophy?
Variety of causes
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What do Pt’s with MD have a predisposition for?
Pulmonary dysfunction & respiratory failure
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What types of drugs should be avoided in Pt’s with MD?
CNS depressants
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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
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How can a PE be identified?
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How is a PE treated?
- 100% FIO2
- Vasopressor/ACLS
- Heparin 5000-10,000 unit bolus
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What normally drives respiration?
CO2
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What drives respiration in COPD patients?
O2 - when exposed to high CO2 & hypoexmia, O2 may become the drive
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Why might VA's be useful in COPD Pt's?
bronchodilation
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What's a dowside to using GA in COPD Pt's?
may attenuate HPV & cause more shunting
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How might you offset the shunting that may occur with IH in COPD Pt's?
Increase FIO2
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What happens in COPD Pt's when give opioids?
They will be prolonged causing prolonged ventilatory depression
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In a COPD Pt, what does a flow volume loop look like?
The expiratory curve is concave
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