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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

Positive Pressure Ventilation

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

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

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

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

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

Introduction

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

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

Trachea Conducting Airways

Pharynx

Respiratory Airways – gas exchange with capillaries

Airway • Airway is Lips/Nose to alveoli • Upper Airway: lips/nose to vocal Cords • Lower

R heart

Airway • Airway is Lips/Nose to alveoli • Upper Airway: lips/nose to vocal Cords • Lower

vein

Airway • Airway is Lips/Nose to alveoli • Upper Airway: lips/nose to vocal Cords • Lower

pulmonary artery

L heart

Airway • Airway is Lips/Nose to alveoli • Upper Airway: lips/nose to vocal Cords • Lower

capillaries

Lower Airway

• 23 divisions follow down

1-16 conduction of ai

from L +R main bronchus

  • bronchi through to terminal bronchi

  • bronchioles

Lower Airway • 23 divisions follow down 1-16 conduction of ai from L +R main bronchus
  • 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

CXR – carina, lungs, heart

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

Physiology revision

Spirometry- basic volumes How we breathe spontaneously Compliance / elastance Deadspace and shunt

V / Q ratios

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

Physiology: Volumes

Tidal Volume, TV Functional Residual Capacity, FRC Volume in lungs at end Expiration not a fixed volume - conditions change FRC Residual Volume, RV

Volume at end of a forced expiration

Closing 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
~6000ml
Inhale
At Rest
~2500ml
~40+ supine
~60+ standing
Exhale
0 ml

Physiology: Normal Spontaneous brea

Normal breath inspiration animation, awake

Lung @ FRC= balance -2cm H 2 0

Physiology: Normal Spontaneous brea Normal breath inspiration animation, awake Lung @ FRC= balance -2cm H 0

Diaghram contracts

Physiology: Normal Spontaneous brea Normal breath inspiration animation, awake Lung @ FRC= balance -2cm H 0

Chest volume

Pleural pressure

Pressure difference from lips to alveolus drives air into lungs

ie air moves down pressure gradient to fill lungs

-5cm H 2 0

Physiology: Normal Spontaneous brea Normal breath inspiration animation, awake Lung @ FRC= balance -2cm H 0

Alveolar pressure falls -2cm H 2 0

Physiology: Normal Spontaneous brea

Normal breath expiration animation, awake

Physiology: Normal Spontaneous brea Normal breath expiration animation, awake -5cm H20 Diaghram relaxes Pleural pressure rises

-5cm H20 Diaghram relaxes

Physiology: Normal Spontaneous brea Normal breath expiration animation, awake -5cm H20 Diaghram relaxes Pleural pressure rises
Physiology: Normal Spontaneous brea Normal breath expiration animation, awake -5cm H20 Diaghram relaxes Pleural pressure rises

Pleural pressure rises

+1cm H 2 0

Air moves down pressure gradient out of lungs

Pleural / Chest volume

Alveolar pressure rises

to +1cm

H 2 0

Physiology: Compliance & Elastance

Compliance = the volume Δ for a given pressure Δ A measure of ease of expansion ΔV / ΔP Normally ~ 200ml / 1 cm H 2 O 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

Physiology: Compliance & Elastance

Chest, Lung, Thorax (= both together)

Lung Elastin fibres in lung - cause recoil = collapse Alveolar surface tension - cause recoil Alveolar surface tension reduced by surfactant

For the chest as a whole, it depends on

Lungs and Chest Wall Diseases affect separately

Physiology: Deadspace and shunt Each part of the lung has

Gas flow, V Blood 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%

Shunt

Normal ‘Shunt’

Shunt Normal ‘Shunt’ % Blood not going through ventilated alveoli or blood going through unventilated alveoli

% Blood not going through ventilated alveoli or blood going through unventilated alveoli

•Normal- 1-2% •Pulmonary eg alveolar collapse, pus, secretions •Cardiac eg ASD/VSD ‘hole in the heart’ (but mostly left to right…. due to L pressure> R pressures)

Normal ‘Shunt’

Air enters Alveolus V Pulmonary capilary Blood in contact Sa0 2 ~100% with ventilated alveolus Q
Air enters Alveolus
V
Pulmonary capilary
Blood in contact
Sa0 2 ~100%
with ventilated alveolus
Q
‘Shunted’ blood 1-2%
Venous
Arterial
‘venous admixture’

Sa0 2 75%

Increased Pulmonary Shunt

Not much air enters Alveolus

V low Alveolus filled with pus or collapsed… .. Pulmonary capilary Blood in contact with unventilated
V low
Alveolus filled with pus
or collapsed… ..
Pulmonary capilary
Blood in contact
with unventilated alveolus
Sa0 2 75%
Q normal
‘Shunted’ blood 1-2%
Venous
Arterial

V/Q = low

Sa0 2 75%

Pulmonary Hypoxic Vasoconstriction

A method of

normalising the V/Q ratio

V low Less air enters Inflammatory exudate eg pus or fluid V/Q = Q less Blood
V low
Less air enters
Inflammatory exudate
eg pus or fluid
V/Q =
Q less
Blood diverted away
from hypoxic alveoli
Venous
Arterial

towards normal

Deadspace

That part of tidal volume that does not come into contact with perfused alveoli

Deadspace volume ~ 200ml Conducting airways ie trachea

and 1-16= Anatomical deadspace

Deadspace • That part of tidal volume that does not come into contact with perfused alveoli

Tidal volume = anatomical

Deadspace • That part of tidal volume that does not come into contact with perfused alveoli

Alveolar volume ~400ml

Pathological

Deadspace

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

Deadspace

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

Deadspace- Anatomical

Trachea

conduction of air

Deadspace volume

from L +R main bronchus bronchi through to terminal bronchi bronchioles

Deadspace- Anatomical Trachea conduction of air Deadspace volume from L +R main bronchus bronchi through to

respiratory bronchioles alveolar ducts alveolar sacs or ‘alveoli’

gas exchange

Alveolar volume

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

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 machine

Delivers Precise Volatile Anaesthetic Agents Carrier Gas

Other stuff

Detail of anaesthesia machine

Picture of Sevoflurane bottle

Hypnosis

Volatile or Inhalational Anaesthetic Agents

Eg Sevoflurane -A halogenated ether -with a carrier gas -ie air/N 2 0

Picture of Sevoflurane bottle Hypnosis Volatile or Inhalational Anaesthetic Agents Eg Sevoflurane -A halogenated ether -with

Intravenous- pictures

Analgesia = Pain relief

pictures

Systemic:

not limited to one part of the body

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, Fentanyl •Others Ketamine, N 2 O, 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

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- above vs blow cords

Above eg , gudel, LMA Below - Into trachea = intubation, paralysis

Anaesthesia

Airway

Equipment

images

Laryngeal Mask Airway

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

Anaesthesia ‘respiratory depression’

CO 2 and O 2 response curves of volatiles Opioids Respiratory depression

…..is

opposed by surgical stimulation

No cough – good and bad

Caused by all 3 types of drug Forced expiration: expands lungs, clears secretions Allows pt to tolerate airway tubes…eg LMA

Anaesthesia ‘respiratory depression’

Volatiles response to CO 2

V

L/min

Awake Increasing concentration of volatile 5.3 7 9
Awake
Increasing concentration of volatile
5.3
7
9

Arterial CO 2 kPa

Anaesthesia ‘respiratory depression’

Volatiles reduce minute ventilation

Unstimulated volatiles

Reduce V tidal and therefore V minute

Make you less responsive to the effects of CO 2

ie slope is more flat

= the normal increase in ventilation that occurs when CO 2 rises is reduced

Anaesthesia ‘respiratory depression’

Volatiles response to hypoxaemia

V

L/min

Awake Low concentration High concentration 5 8 13
Awake
Low concentration
High concentration
5
8
13

PaO 2 kPa

Opioids

Opioids = a drug acting on Opioid receptor

Morphine, Fentanyl Act in CNS, PNS, GI

Reduced respiratory rate, increase tidal volume, but still increase PaCO 2

Suppress cough

Opioids

Video to show opioid induced low respiratory rate

Respiratory effects of Anaesthesia

airway ‘respiratory depression’

Functional Residual Capacity, FRC

Hypoxaemia

Anaesthesia FRC

Why important?- closing Volume and O 2 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!

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

Physiology: Closing Volume

~6000ml Inhale At Rest ~2500ml Exhale 0 ml
~6000ml
Inhale
At Rest
~2500ml
Exhale
0 ml

Anaesthesia FRC

What causes these changes?

  • 1. Cephalad (to brain) movement of the diaphragm

  • 2. Loss of inspiratory muscle tone

  • 3. Reduced cross sectional rib cage area

  • 4. Gas trapping behind closed airways

Respiratory effects of Anaesthesia

airway ‘respiratory depression’ FRC Hypoxaemia

Anaesthesia Hypoxaemia

Hypoxaemia – Low blood oxygen level FRC changes- Closing Vol, collapse/atelectasis and shunt Position also effects eg legs/laparoscopy/head down - Tidal volume Hypovolaemia/vasodilation increases deadspace, V/low Q areas ….mismatch PHVC reduced by volatiles – increases V/Q mismatch No cough/ yawn ?-collapse/secretions Apnoea/Airway obstruction- no 0 2 in no CO 2 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 CO 2 and O 2 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, cough supression, PE, LVF etc

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, Analgesia, Paralysis

Summary 2

Anaesthesia effects due to drugs!

Upper airway obstruction Respiratory ‘depression’ Hypoxaemia – collapse (FRC/Closing volume) = ‘shunt’ - pulmonary blood flow - deadspace - PHVC drugs

Further reading

http://en.wikipedia.org/wiki/Respiratory_physiology

Articles and Podcast on my webpage

Pulmonary Physiology and Pathophysiology:

an integrated, case-based approach John West mostly free on google books

Writing the essay

Break the answer down into parts Lots of space Graphs and diagrams, labelled- colour? Underline important parts Headline each paragraph with a statement?

‘GA causes V/Q mismatch

Don’t just write dense text

Revision Aids

When answering question on Anaesthesia or IPPV

Lung volumes Normal airway pressures / mechanics of breathing Upper airway Lower airway Compliance/Resistance V, Q and V/Q match /mis-match (?West zones) Causes of hypoxaemia +/- hypercapnia Muscle tone (upper airway + respiration) Respiratory drive CVS effects Drug effects (Hypnosis/Analgesia/paralysis)

Other

bleeding, position, age, sleep, pathology

MCQ 1

Shunt is ??? ..

A That part of tidal volume that does not come into contact with perfused alveoli

B % Blood not going through ventilated alveoli

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