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Dr Rob Stephens
Consultant in Anaesthesia UCLH Thanks to Dr Roger Cordery
Dr Rob Stephens
Consultant in Anaesthesia UCLH Thanks to Dr Roger Cordery
Dr Rob Stephens
Consultant in Anaesthesia UCLH Thanks to Dr Roger Cordery
Dr Rob Stephens
Consultant in Anaesthesia UCLH Thanks to Dr Roger Cordery
Hon Senior Lecturer UCL
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
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
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 pulmonary artery capillaries
vein L heart
Lower Airway
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
Physiology: Normal Spontaneous breat
Normal breath inspiration animation, awake
Chest volume
Pleural pressure
Pressure
difference from
lips to alveolus -5cm H20
drives air into
lungs
Alveolar
ie air moves pressure falls
down -2cm H20
pressure gradient
to fill lungs
Physiology: Normal Spontaneous breat
Normal breath expiration animation, awake
-5cm H20
Diaghram relaxes
Pleural /
Chest volume
Pleural pressure
rises
+1cm H20 Alveolar
pressure rises
to +1cm H20
Air moves down
pressure gradient
out of lungs
Physiology: Compliance & Elastance
Compliance = the volume for a given
pressure
A measure of ease of expansion
V / P
Normally ~ 200ml / 1 cm H2O for the
chest
2 types: static & dynamic
Lung
Elastin fibres in lung - cause recoil =
collapse
Alveolar surface tension - cause recoil
Alveolar surface tension reduced by
surfactant
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
V
Air enters Alveolus
Pulmonary capilary
Blood in contact Sa02~100%
Q
with ventilated alveolus
Sa0275%
Venous Arterial
venous admixture
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%
Sa0275% Q normal
Venous Arterial
Pulmonary Hypoxic
Vasoconstriction
A method of
normalising the V/Q
ratio Less air enters V low
Inflammatory exudate
eg pus or fluid V/Q =
towards normal
Q less
Venous Arterial
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
Tidal volume deadspace
= anatomical Alveolar volume ~400ml
Pathological
Deadspace
V
Air enters Alveolus
Pulmonary capilary
Blood in contact
Q
with ventilated alveolus
Venous Arterial
Deadspace
Classic anatomical = trachea!
V
Air enters Alveolus
Blood in contact
Q
with ventilated alveolus
Venous Arterial
Deadspace- Anatomical
conduction of air
Deadspace volume
Trachea
from L +R main bronchus
bronchi through to terminal bronchi
bronchioles
respiratory bronchioles gas exchange
Alveolar volume
alveolar ducts
alveolar sacs or alveoli
Physiology: V/Q in lung
Both V and Q increase down lung
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
Eg Sevoflurane
Picture of Sevoflurane bottle
-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, Fentanyl
Others
Ketamine, N2O, gabapentin..
Analgesia = Pain relief
Regional: limited to one part of the body
images
Neuromuscular
Paralysis
Non-competitive
images
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 images
Equipment
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
CO2 and O2 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 tubeseg LMA
Anaesthesia respiratory depression
Volatiles response to CO2
Awake
5.3 7 9
Arterial CO2
kPa
Anaesthesia respiratory depression
Unstimulated volatiles
Reduce Vtidal and therefore V minute
V
L/min
Awake
Low concentration
High concentration
5 8 13
PaO2 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 PaCO2
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 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 arent done sitting!
Physiology: Closing Volume
~6000ml
Inhale
At Rest ~2500ml
Exhale
0 ml
Physiology: Closing Volume
~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 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)
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