106 Questions
What are the primary functions of the upper airway?
All of the above
What determines whether airflow is laminar or turbulent?
Reynold's number
At which level of the airways do they lose all cartilage?
Bronchioles
What is the effect of increasing division of airways on airflow resistance?
Resistance decreases
Which type of alveolar cell is responsible for gas exchange?
Type 1 squamous epithelial
What should a functional assessment of the respiratory system include?
Evaluation of respiratory mechanics, gas exchange, and cardiopulmonary interaction
What is the typical duration for airway hyperreactivity to resolve after an upper respiratory infection?
6+ weeks
When providing anesthesia care for a patient with an upper airway infection, what strategies might reduce the risk of adverse airway events?
all of the above
Which of the following medications is NOT typically used to treat asthma?
Antibiotics
What is the primary method used to assess the severity of COPD?
Pulmonary function tests (PFTs)
What is the sum of ERV and RV in a lung?
FRC
Which of the following lung volumes is not a part of vital capacity?
Residual volume
What is the minimum VO2 max required for a post-thoracotomy patient to have a lower risk of poor outcomes?
15 mL/kg/min
What is the most common cause of upper respiratory infections in children?
Viral or bacterial nasopharyngitis
What is the percentage of upper respiratory infections caused by viral or bacterial nasopharyngitis?
95%
What is the primary mechanism underlying desaturation in obese patients during anesthesia?
Decreased functional residual capacity
What is the primary indicator of pulmonary hypertension?
Mean PAP >25 mmHg or PAOP >15 mmHg
Which of the following is NOT a risk factor for obstructive sleep apnea?
Smoking
What is the primary benefit of applying PEEP during anesthesia in morbidly obese patients?
Reducing atelectasis
What percentage of patients with pulmonary hypertension experience dyspnea?
98%
What is the primary indicator of severe pulmonary hypertension?
Pre-syncopal or syncopal episodes
What is the primary diagnostic test for identifying valvular disorders, right ventricular function abnormalities, and left ventricular failure in pulmonary hypertensive patients?
Echocardiogram
What is the primary benefit of smoking cessation in terms of wound healing?
Lowered levels of toxic substance
What is the primary implication of Schamroth's sign?
Underlying systemic disorders such as chronic hypoxia
What is the recommended time frame for smoking cessation before surgery?
3-4 weeks
What is the primary mechanism by which smoking cessation improves mitochondrial function?
Decreased cyanide levels
What organs tend to obstruct the upper airway when the patient is under the influence of anesthesia?
Tongue and soft palate
What is airflow directly proportional to, and inversely proportional to?
Directly proportional to the pressure gradient and inversely proportional to the resistance
Laminar flow resistance primarily reflects what property of gas?
Viscosity
Turbulent flow reflects what property of gas?
Density
What type of airflow potentiates the trapping of inhaled particulate matter?
Turbulent airflow
Where does the trachea terminate?
At the carina, bifurcating into the right and left primary bronchi
What is unique about the right mainstem bronchus?
It is shorter and wider than the left mainstem bronchus
Which generations of airways are used for conducting air?
1-16th
What is the definition of an acinus in the context of the respiratory system?
A type of lung tissue containing air sacs made up with up to 2000 alveoli
What is the function of Type II alveolar cells?
To produce surfactant
What are the key features of a lung exam?
Inspection, palpation, percussion, and auscultation
What is the definition of total lung capacity?
The maximum amount of air that can be exhaled from the lungs after a maximal inhalation.
What is the Inspiratory Reserve Volume (IRV)?
The largest amount of air that can be inhaled after normal inhalation.
Which three lung volumes are included in vital capacity?
Expiratory reserve volume, tidal volume, and inspiratory reserve volume
What lung volumes cannot be determined by spirometry?
FRC, TLC, and RV
What is the most useful test of gas exchange capacity?
Diffusing capacity for carbon monoxide
What does DLCO (diffusion capacity of the lungs for carbon monoxide) correlate with?
The total functioning surface area of the alveolar-capillary interface
Why is the DLCO test useful in respiratory assessment?
CO has high affinity for Hgb so it follows the same path as oxygen to bind with hemoglobin
6 minute walk test correlates with VO2 max
True
The ability to climb 5 flights of stairs is approximately VO2 max > 20
True
What are the common symptoms of an Upper Respiratory Infection (URI)?
cough, sneezing, rhinorrhea
Bacterial URIs produce more serious symptoms
True
Diagnosis of URIs are usually based on cultures and labs tests
False
Children with URIs are at an increased risk of which respiratory complications?
Transient hypoxemia and laryngospasm
What effects do surgery and anesthesia have on the immune system?
They suppress the immune system.
What is the preferred airway management technique when a patient has an upper respiratory tract infection (URI)?
LMA
What is COPD?
A respiratory disease characterized by chronic inflammation of the airways that can be partially reversible
What are some common causes of Chronic Obstructive Pulmonary Disease (COPD)?
Cigarette smoking/pollutant exposure, Alpha-1 antitrypsin deficiency, chronic infections, and longstanding asthma
What differentiates asthma from COPD?
Reversible airflow obstruction
Are patients with mild well-controlled asthma at an increased perioperative risk?
False
During assessment, asthma patients should be queried about:
All of the above
In asthma patients, what can ET intubation cause?
A and B
How is the severity of COPD typically measured?
Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC)
What FEV1/FVC ratio is needed to be diagnosed with COPD?
Less than 0.7
At which FEV1/FVC ratio is moderate COPD graded?
>0.5 and <0.8
What is the FEV1/FVC ratio?
A ratio of forced expiratory volume to forced vital capacity
How does COPD affect FEV1?
It decreases FEV1 due to obstruction
How does COPD affect FRC (Functional Residual Capacity)?
It increases FRC due to reduced airflow, lost elasticity, and over expansion
What is the DLC0 in COPD?
Reduced
Is a chest x-ray useful for the routine assessment of asthma and COPD patients?
False
Is it true that pulmonary hypertension medications should be continued on the day of surgery?
True
What pulmonary changes are present in restrictive lung disease?
Decreased lung compliance and decreased functional residual capacity
What pulmonary symptoms are typically present in obstructive lung disease?
Increased lung volume due to air trapping, increased airway resistance
What are the FEV1 and FVC in restrictive lung disease?
Both FEV1 and FVC are decreased
The FEV1/FVC ratio in restrictive lung disease is increased
False
How many bronchi does the right upper lobe bronchus typically give off?
3
You can measure RV using a spirometer
False
Is obesity the most common restrictive lung disease?
True
The decreased in FRC in obese patients also decreases the tendency to desaturate during anesthesia procedures
False
What should be the goal of all interventions used during anesthesia procedures with obese patients?
Minimizing decreases in the FRC
What is the functional residual capacity (FRC)?
ERV+RV
How is the severity of Obstructive Sleep Apnea (OSA) typically measured?
Using the Apnea-Hypopnea Index (AHI)
What is the defining feature of the upper airway in obstructive sleep apnea (OSA)?
Intermittent airway obstruction
What is used preoperatively to assess OSA (obstructive sleep apnea)?
STOP-BANG questionnaire
OSA patients tolerate the respiratory depressant effects of opioids due to their tolerance of hypoxia
False
Patients with pulmonary hypertension have a high rate of perioperative morbidity and mortality
True
Moderate to severe pulmonary hypertension increases the risk of which disease?
Cor pulmonale/right-sided heart failure
Pulmonary hypertension causes a decreased sympathetic tone
False
Is opioid administration well tolerated in patients with cor pulmonale?
False
What is a common cause of pulmonary hypertension?
All of the above
In pulmonary hypertension, syncopal episodes indicate what about the disease progression?
Severe disease
What are the common signs and symptoms of pulmonary hypertension?
Dyspnea, metabolic acidosis, hypoxemia, increase PVR
What is unique about heart sounds in pulmonary hypertension?
Split S2 sound, RV heave
What type of murmur may be heard in pulmonary hypertension?
Tricuspid regurgitation murmur
What EKG changes are present in pulmonary hypertension?
Right axis deviation, RBBB, RVH, tall peaked R waves in V1-V2, peaked P waves in inferior leads
Mild pulmonary hypertension does not influence anesthetic management
True
Consulting with a patient's pulmonologist preoperatively is not necessary unless the patient has severe pulmonary hypertension
False
What is the effect of smoking on coronary blood flow?
It decreases coronary blood flow
What is the effect of smoking on macrophage function?
Decreases their ability to fight infection
What is the mechanism by which vascular relaxation occurs after the cessation of smoking?
Decreased levels of nicotine
What are some risks of pulmonary complications during surgery?
All of the above
How do you calculate BMI?
Weight in kg / height in meters
Can chronic dyspnea of unclear etiology usually be attributed to asthma, COPD, interstitial lung disease, or cardiac dysfunction?
True
What can increase the risk of right heart failure in a pulmonary hypertension patient?
All of the above
What does FEV1 represent in respiratory assessment?
Forced Expiratory Volume at 1 second
What is FVC?
Forced Vital Capacity, the maximum volume of air that can be exhaled from the lungs
Wheezing is specific to asthma
False
What cartilage does the trachea originate from?
Cricoid cartilage
LMA is preferred in instances of high risk of broncho or laryngospasm
True
Resistance = 8 * length * viscosity / (pi*r^4)
True
Study Notes
Respiratory Assessment
- The upper airway has three main functions: conduit for inhalation and exhalation of air, warming and humidification of inspired gases, and tissue hydration and trapping of pathogens via mucous membranes.
Airway Resistance
- Airway resistance is affected by laminar flow (smooth, efficient gas exchange) and turbulent flow (chaotic, trapping inhaled particulate matter).
- Reynold's number determines whether flow is laminar or turbulent.
Trachea and Bronchi
- The trachea terminates at the carina (bifurcation).
- The right upper bronchus gives off three segmental bronchi.
Airways and Cartilage
- Airways lose all cartilage at the level of bronchioles.
Alveolar Cells and Functions
- There are three types of alveolar cells: Type 1 (squamous epithelial, for gas exchange), Type 2 (produce surfactant), and Alveolar macrophages (phagocytize foreign objects).
Functional Assessment of Respiratory System
- Functional assessment should include evaluation of three functions: respiratory mechanics, gas exchange, and cardiopulmonary interaction.
Lung Capacities and Volumes
- FRC (functional residual capacity) is the volume after normal exhalation.
- TLC (total lung capacity) is the sum of IRV, TV, and FRC.
- RV (residual volume) is the volume of air to keep lungs inflated.
- VC (vital capacity) includes inspiratory reserve volume, TV, and expiratory reserve volume.
Diffusion Capacity and CO
- Diffusion capacity for carbon monoxide (CO) is the most useful test of alveolar gas exchange.
- CO has high affinity for Hgb, following the same path as oxygen to bind with hemoglobin.
Post-Thoracotomy Patients
- Patients are at risk for poorer post-thoracotomy outcomes if their VO2 max is < 15 mL/kg/min.
- The 6-minute walk test correlates well with VO2 max.
Upper Respiratory Infection
- 95% of URIs are due to viral or bacterial nasopharyngitis.
- Symptoms include non-productive cough, sneezing, and rhinorrhea.
- Four risk factors associated with URI that increase the frequency of adverse events under anesthesia: fever, purulent rhinitis, productive cough, and rhonchi.
Asthma
- Asthma is characterized by chronic airway inflammation, variable expiratory airflow limitation, SOB, chest tightness, and cough.
- Three classes of medications an asthma patient may be taking: inhaled/oral steroids, beta2 agonists, and antibiotics.
COPD
- Five exposures likely to be associated with provoking COPD: smoking, environmental pollutants, chronic infections, longstanding asthma, and alpha1 antitrypsin deficiency.
- Measures to assess severity of COPD include spirometry and lung volumes.
Obstructive Sleep Apnea
- Risk factors for OSA: snoring, daytime sleepiness, hypertension, obesity, and family history.
- The Apnea-Hypopnea Index measures the number of apneic-hypopneic episodes per hour of sleep.
- Three airway management tasks that may be more difficult in OSA patients: mask ventilation, direct laryngoscopy, and ET placement.
Pulmonary Hypertension
- Pulmonary hypertension is defined by mean PAP >25 mmHg or PAOP >15 mmHg.
- Five events that can increase the risk of right heart failure in PH patients: hypoxia, hypercarbia, administration of vasoconstrictors, increased sympathetic tone, and increased PVR.
Tobacco Smoking
- Five complications of tobacco smoking: decreased macrophage function, impairment of coronary blood flow, vascular endothelial dysfunction, hypertension, and respiratory complications.
- Ideally, cessation of smoking should occur 3-4 weeks prior to surgery.
- Four benefits of smoking cessation: lowered CO levels, levels of toxic substances, cyanide levels, and vascular relaxation.
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