Anaesthesia & Respiratory

System
Dr Rob Stephens
Consultant in Anaesthesia UCLH
Hon Senior Lecturer UCL

Thanks to Dr Roger Cordery

Positive Pressure Ventilation

Dr Rob Stephens
Consultant in Anaesthesia UCLH
Hon Senior Lecturer UCL

Thanks to Dr Roger Cordery

Anaesthesia & Respiratory
System
Dr Rob Stephens
Consultant in Anaesthesia UCLH
Hon Senior Lecturer UCL

Thanks to Dr Roger Cordery

Anaesthesia & Respiratory
System
Dr Rob Stephens
Consultant in Anaesthesia UCLH
Hon Senior Lecturer UCL

Thanks to Dr Roger Cordery

www.ucl.ac.uk/anaesthesia/people/stephens
Google UCL Stephens
talk on webpage above & supporting material
robcmstephens[at]googlemail.com

ac.ucl.uk/anaesthesia/people/stephens Google UCL Stephens .www.

.

Contents • Anatomy + Physiology revision • What is Anaesthesia?.triad • Anaesthesia effects… – – – – – airway ‘respiratory depression’ FRC Hypoxaemia after Anaesthesia • Tips on the essay • Break then Lecture 2: Positive Pressure Ventilation .

Picture of Propofol/Thio ‘Lethal injection drug production ends in the US .

intellectually interesting • Practical – understand – prevent problems • Practical – find new solutions • Practical.pass exam! .Introduction • Why learn?.

Anatomy revision • Upper Airway above the vocal cords • Lower airway – below the vocal cords – Conducting vs gas exchange.different tissue types • Muscles of respiration .

Airway • Airway is Lips/Nose to alveoli • Upper Airway: lips/nose to vocal Cords • Lower Airway: Vocal Cords down Pharynx – Trachea – Conducting Airways – Respiratory Airways – gas exchange with capillaries • R heart vein pulmonary artery L heart capillaries .

Lower Airway • 23 divisions follow down 1-16 conduction of air from L +R main bronchus bronchi through to terminal bronchi bronchioles respiratory bronchioles alveolar ducts alveolar sacs or ‘alveoli’ 17-23 gas exchange .

Anatomy • Alveolus in detail – pulmonary capillary Image to show alveolus and bronchiole .

Section to show the upper airway .

lungs. heart .CXR – carina.

Anatomy: Muscles of Respiration • • • • • Upper airway muscles upper airway tone External IntercostalsInspiration Diaghram Inspiration Internal Intercostals Forced Expiration Accessory muscles Forced Inspiration Neck • Accessory muscles Forced Expiration Abdomen .

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basic volumes How we breathe spontaneously Compliance / elastance Deadspace and shunt V / Q ratios .Physiology revision • • • • • Spirometry.

Physiology: Spirometry ~6000ml Inhale At Rest ~2500ml Exhale 0 ml .

FRC Volume in lungs at end Expiration not a fixed volume .conditions change FRC • Residual Volume. TV • Functional Residual Capacity. RV Volume at end of a forced expiration • Closing Volume.Physiology: Volumes • Tidal Volume. CV Volume in expiration when alveolar closure ‘collapse’ occurs • Others .

Physiology: Closing Capacity ~6000ml Inhale At Rest ~2500ml ~40+ supine ~60+ standing Exhale 0 ml .

Physiology: Normal Spontaneous breat Normal breath inspiration animation. awake Lung @ FRC= balance -2cm H20 Diaghram contracts Chest volume Pressure difference from lips to alveolus drives air into lungs ie air moves down pressure gradient to fill lungs Pleural pressure -5cm H20 Alveolar pressure falls -2cm H20 .

Physiology: Normal Spontaneous breat Normal breath expiration animation. awake -5cm H20 Diaghram relaxes Pleural / Chest volume  Pleural pressure rises +1cm H20 Air moves down pressure gradient out of lungs Alveolar pressure rises to +1cm H20 .

Physiology: Compliance & Elastance Compliance = the volume Δ for a given pressure Δ A measure of ease of expansion ΔV / ΔP Normally ~ 200ml / 1 cm H2O for the chest 2 types: static & dynamic Elastance = the pressure Δ for a given volume Δ = the opposite of compliance The tendency to recoil to its original .

cause recoil Alveolar surface tension reduced by surfactant For the chest as a whole. Lung. it depends on Lungs and Chest Wall Diseases affect separately . Thorax (= both together) Lung Elastin fibres in lung .Physiology: Compliance & Elastance Chest.cause recoil = collapse Alveolar surface tension .

V Blood flow.Physiology: Deadspace and shunt Each part of the lung has Gas flow. Q V/Q mismatching Ratio V/Q Perfect V/Q =1 Deadspace = Ratio: V Normal/ Low Q That part of tidal volume that does not come into contact with perfused alveoli Shunt = Ratio: V low/ Normal Q That % of cardiac output bypasses ventilated alveoli Normally = 1-2% .

secretions •Cardiac eg ASD/VSD ‘hole in the heart’ (but mostly left to right….Normal ‘Shunt’ Shunt % Blood not going through ventilated alveoli or blood going through unventilated alveoli •Normal. due to L pressure> R pressures) . pus.1-2% •Pulmonary eg alveolar collapse.

Normal ‘Shunt’ V Air enters Alveolus Pulmonary capilary Blood in contact with ventilated alveolus Q Sa0275% Sa02~100% ‘Shunted’ blood 1-2% Venous ‘venous admixture’ Arterial .

.Increased Pulmonary Shunt Not much air enters Alveolus V low Alveolus filled with pus or collapsed…. V/Q = low Pulmonary capilary Blood in contact with unventilated alveolus Sa0275% Q Sa0275% normal ‘Shunted’ blood 1-2% Venous Arterial .

Pulmonary Hypoxic Vasoconstriction A method of normalising the V/Q ratio Less air enters Inflammatory exudate eg pus or fluid V low V/Q = towards normal Q less Blood diverted away from hypoxic alveoli Venous Arterial .

Deadspace • That part of tidal volume that does not come into contact with perfused alveoli Deadspace volume ~ 200ml • Tidal volume = anatomical • Pathological Conducting airways ie trachea and 1-16= Anatomical deadspace Alveolar volume ~400ml .

Deadspace V Air enters Alveolus Pulmonary capilary Blood in contact with ventilated alveolus Q ‘Shunted’ blood 1-2% Venous Arterial .

Deadspace Classic anatomical = trachea! V Air enters Alveolus Pulmonary capillary low flow eg bleeding or blocked V/  Q = Hi Blood in contact with ventilated alveolus Q ‘Shunted’ blood 1-2% Venous Arterial .

Anatomical Trachea conduction of air Deadspace volume from L +R main bronchus bronchi through to terminal bronchi bronchioles respiratory bronchioles alveolar ducts alveolar sacs or ‘alveoli’ gas exchange Alveolar volume .Deadspace.

Physiology: V/Q in lung Both V and Q increase down lung Q increases more than V down lung V/Q ratios change down lung If patient supine (on back) V/Q changes front to back Another way to think about Q/V is ‘west zones’ .

Physiology: V/Q in lung .

What is Anaesthesia?
• Reversable drug induced unconsciousness
• ‘Triad’
– Hypnosis, Analgesia, Neuromuscular Paralysis
• Induction, Maintainence, Emergence, (Recovery)
• Spontaneous vs Positive Pressure Ventilation
• See podcast ‘conduct of anaesthesia’ link from my website

Anaesthesia Timeline




Preoperative
Induction: Analgesia & IV hypnotic
Maintain: Analgesia & Volatile Hypnotic
Emergence: Analgesia Only
Recovery

• Patient can be paralysed vs not=
• Needs ventilation vs spontaneously
breathing

Anaesthesia
• Hypnosis = Unconsciousness
– Gas eg Halothane, Sevoflurane
– Intravenous eg Propofol, Thiopentone

• Analgesia = Pain Relief
– Different types: ‘ladder’, systemic vs other

• Neuromuscular paralysis
– Nicotinic Acetylcholine Receptor Antagonist

Anaesthetic
Machine
• Picture of anaesthesia
Delivers Precise
machine

Volatile Anaesthetic Agents
Carrier Gas
Other stuff

Detail of anaesthesia machine .

Hypnosis Volatile or Inhalational Anaesthetic Agents Picture of Sevoflurane bottle Eg Sevoflurane -A halogenated ether -with a carrier gas -ie air/N20 .

Intravenous.pictures .

Analgesia = Pain relief Systemic: not limited to one part of the body pictures .

Analgesia = Pain relief Systemic: not limited to one part of the body •Simple eg Paracetamol •Non Steroidal Anti-Inflammatory Drugs eg Ibuprofen •Opiods weak eg Codeine strong eg Morphine. N2O. Fentanyl •Others Ketamine.. . gabapentin….

Analgesia = Pain relief Regional: limited to one part of the body images .

Neuromuscular Paralysis Nicotinic AcetylCholine Channel @ NMJ images Non-competitive Suxamethonium Competitive All Others eg Atracurium Different properties Different length of action Paralyse Respiratory muscles Apnoea – ie no breathing Need to ‘Ventilate’ .

Respiratory effects of Anaesthesia • airway • ‘respiratory depression’ • Functional Residual Capacity. FRC • Hypoxaemia .

Respiratory effects of Anaesthesia • airway • ‘respiratory depression’ • Functional Residual Capacity. FRC • Hypoxaemia .

Anaesthesia Airway • Upper: loss of muscular tone eg oropharynx • Upper: tongue falls posteriorly ie back .

images .

above vs blow cords – Above eg .Into trachea = intubation. gudel. paralysis . LMA – Below .Anaesthesia Airway • • • • • Upper: loss of muscular tone eg oropharynx Upper: tongue falls posteriorly ie back Need to keep it open to allow airflow! “Airway obstruction’ = no airflow Keep Airway open: – Airway manoeuvres (chin lift etc) – Airway devices.

Anaesthesia Airway Equipment images .

Laryngeal Mask Airway .

• Video of LMA insertion .

Image to show how LMS sits In the airway above the vocal cords .

Respiratory effects of Anaesthesia • airway • ‘respiratory depression’ • Functional Residual Capacity. FRC • Hypoxaemia .

is opposed by surgical stimulation • No cough – good and bad – Caused by all 3 types of drug – Forced expiration: expands lungs.Anaesthesia ‘respiratory depression’ • CO2 and O2 response curves of volatiles • Opioids • Respiratory depression ….. clears secretions – Allows pt to tolerate airway tubes…eg LMA .

3 7 Arterial CO2 kPa 9 .Anaesthesia ‘respiratory depression’ Volatiles  response to CO2 Awake Increasing concentration of volatile V L/min 5.

Anaesthesia ‘respiratory depression’ Volatiles reduce minute ventilation • Unstimulated volatiles – Reduce Vtidal and therefore V minute – Make you less responsive to the effects of CO2 – ie slope is more flat = the normal increase in ventilation that occurs when CO2 rises is reduced .

Anaesthesia ‘respiratory depression’ Volatiles response to hypoxaemia V L/min Awake Low concentration High concentration 5 8 PaO2 kPa 13 .

PNS. GI • Reduced respiratory rate. but still increase PaCO2 • Suppress cough . increase tidal volume. Fentanyl • Act in CNS.Opioids • Opioids = a drug acting on Opioid receptor • Morphine.

Opioids • Video to show opioid induced low respiratory rate .

FRC • Hypoxaemia .Respiratory effects of Anaesthesia • airway • ‘respiratory depression’ • Functional Residual Capacity.

closing Volume and O2 store Why would it change? FRC is decreased by 16-20% by Anaesthesia – Falls rapidly (seconds to minutes). – FRC remains low for 1-2 days • Weak but significant correlation with age • Less FRC reduction if patient is in the sitting position but most operations aren’t done sitting! .Anaesthesia FRC Why important?.

Physiology: Closing Volume ~6000ml Inhale At Rest ~2500ml Exhale 0 ml .

Physiology: Closing Volume ~6000ml Inhale At Rest ~2500ml Exhale 0 ml .

Gas trapping behind closed airways . Reduced cross sectional rib cage area 4.Anaesthesia FRC What causes these changes? 1. Loss of inspiratory muscle tone 3. Cephalad (to brain) movement of the diaphragm 2.

Respiratory effects of Anaesthesia • • • • airway ‘respiratory depression’ FRC Hypoxaemia .

Anaesthesia Hypoxaemia Hypoxaemia – Low blood oxygen level • FRC changes.mismatch • PHVC reduced by volatiles – increases V/Q mismatch • No cough/ yawn ?-collapse/secretions • Apnoea/Airway obstruction. – V/low Q areas ….Tidal volume • Hypovolaemia/vasodilation increases deadspace. collapse/atelectasis and shunt • Position also effects eg legs/laparoscopy/head down .Closing Vol.no 02 in no CO2 out! .

Hypoxaemia: Atelectasis Atelectasis = the lack of gas exchange within alveoli. due to alveolar collapse or fluid consolidation .

CT scan of Diaphragm during awake spontaneous breathing .

CT scan of Diaphragm during anaesthesia: Atelectasis .

After Anaesthesia • Some changes persist – – – – – Collapse/Atelectasis abnormal 1-2 days FRC abnormal 1-2 days CO2 and O2 responses normal in hours V/Q mis-smatch PHVC (reduces V/Q mismatch) • Some new changes happen – Wound pain causing hypoventilation – Drug overdose causing hypoventilation – Pneumonia. LVF etc . PE. cough supression.

Analgesia. Paralysis .Summary 1 • Airway – conducting and respiratory • Physiology • V/Q different as you go down lung • Extreme – no blood flow (Deadspace) • Extreme – no ventilation (Shunt) • Anaesthesia – Hypnosis.

deadspace .Summary 2 Anaesthesia effects due to drugs! – Upper airway obstruction – Respiratory ‘depression’ – Hypoxaemia – collapse (FRC/Closing volume) = ‘shunt’ . pulmonary blood flow .PHVC drugs .

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case-based approach John West mostly free on google books .wikipedia.org/wiki/Respiratory_physiology • Articles and Podcast on my webpage • Pulmonary Physiology and Pathophysiology: an integrated.Further reading http://en.

Writing the essay • • • • • Break the answer down into parts Lots of space Graphs and diagrams.colour? Underline important parts Headline each paragraph with a statement? – ‘GA causes V/Q mismatch • Don’t just write dense text . labelled.

pathology .hypercapnia Muscle tone (upper airway + respiration) Respiratory drive CVS effects Drug effects (Hypnosis/Analgesia/paralysis) Other bleeding. Q and V/Q match /mis-match (?West zones) Causes of hypoxaemia +/. position. sleep. age.Revision Aids • When answering question on Anaesthesia or IPPV – – – – – – – – – – – – Lung volumes Normal airway pressures / mechanics of breathing Upper airway Lower airway Compliance/Resistance V.

??? A That part of tidal volume that does not come into contact with perfused alveoli B % Blood not going through ventilated alveoli .MCQ 1 Shunt is..

MCQ 2 Pulmonary Embolus (blood clot stopping blood flowing through part of the lungs) A Is an example of a shunt B Is an example of deadspace C can cause hypoxia .

Qn3 • List as many causes of hypoxia under anaesthesia as you can .