Postoperative Respiratory Care — MCQs
Type 3 respiratory failure occurs due to ?
Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:
Patient of pneumonia on ventilator with wt. 50 kg. RR 14/min, bicarbonate - 18, pH 7.3, pCO2 48 mmHg, pO2 110 mmHg, PEEP 12 cm H2O, tidal volume 420 mL, SpO2 - 100% with FiO2 90%. What is next step in management?
Post-operative pulmonary thromboembolism is seen in all, except:
Which of the following is not a risk factor for postoperative pulmonary complication?
In the immediate post operative period the common cause of respiratory insufficiency could be because of the following, except -
In a post operative intensive care unit, five patients developed post-operative wound infection on the same day. Which of the following is the best method to prevent cross infection among patients in the same ward?
Postoperative nausea and vomiting are uncommon with
A postoperative patient with pH 7.25, MAP (mean arterial pressure) 60 mm Hg is treated with?
All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
Postoperative Respiratory Care Indian Medical PG Practice Questions and MCQs
Question 1: Type 3 respiratory failure occurs due to ?
- A. Post-operative atelectasis (Correct Answer)
- B. Kyphoscoliosis
- C. Flail chest
- D. Pulmonary fibrosis
Explanation: ***Post-operative atelectasis*** - **Type 3 respiratory failure**, also known as **perioperative respiratory failure**, is characterized by hypoxemia occurring typically after surgery. - **Atelectasis**, the collapse of lung tissue, is a common cause of hypoxemia in the post-operative period due to shallow breathing, pain, and anesthesia affecting lung volumes. *Kyphoscoliosis* - This condition leads to a **restrictive lung disease** due to chest wall deformity, causing chronic respiratory failure. [1] - It more typically results in **Type 2 respiratory failure** (hypercapnic) due to impaired ventilation over time. [1] *Flail chest* - Flail chest is a severe chest wall injury causing paradoxical movement, leading to **acute respiratory failure**. - It is often associated with **Type 1 (hypoxemic)** or **Type 2 (hypercapnic)** respiratory failure due to trauma-induced lung injury and impaired mechanics. *Pulmonary fibrosis* - This is a progressive interstitial lung disease causing **restrictive ventilatory defect** and impaired gas exchange. - It leads to chronic **Type 1 respiratory failure** (hypoxemic) as the lung tissue becomes stiff and scarred.
Question 2: Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:
- A. Extended ramping
- B. Avoid cricoid pressure (Correct Answer)
- C. Rapid sequence induction
- D. Avoid preoxygenation
Explanation: ***Avoid cricoid pressure*** - While **cricoid pressure** (Sellick's maneuver) is used to prevent **aspiration** by compressing the esophagus, its effectiveness in **obese patients** is highly debated and often hindered by excess neck tissue. - In obese patients, cricoid pressure can actually worsen the view during laryngoscopy, making intubation more difficult and potentially causing airway trauma. *Extended ramping* - **Ramping** the patient, where the head and shoulders are elevated, is crucial in **obese patients** to align the **oral, pharyngeal, and laryngeal axes**. - This position improves the view during laryngoscopy and facilitates successful intubation by effectively displacing excess tissue. *Rapid sequence induction* - **Rapid sequence induction (RSI)** is often indicated in **obese patients** undergoing emergency surgery due to their increased risk of **gastric reflux** and **pulmonary aspiration**. - RSI involves administering a sedative and a paralytic agent in rapid succession, followed immediately by intubation, to minimize the time the airway is unprotected. *Avoid preoxygenation* - **Preoxygenation** is essential in **obese patients** to maximize their **oxygen reserves** before intubation. - Obese patients have reduced **functional residual capacity (FRC)** and increased **oxygen consumption**, making them desaturate rapidly during apnea, so preoxygenation significantly prolongs safe apnea time.
Question 3: Patient of pneumonia on ventilator with wt. 50 kg. RR 14/min, bicarbonate - 18, pH 7.3, pCO2 48 mmHg, pO2 110 mmHg, PEEP 12 cm H2O, tidal volume 420 mL, SpO2 - 100% with FiO2 90%. What is next step in management?
- A. Increase PEEP
- B. Increase tidal volume
- C. Decrease fio2 (Correct Answer)
- D. Decrease RR
Explanation: **Decrease FiO2** - The patient has an **SpO2 of 100% with a FiO2 of 90%**, indicating **hyperoxia** induced by excessive oxygen delivery. - Decreasing FiO2 is the appropriate next step to prevent **oxygen toxicity** (e.g., absorption atelectasis, free radical damage) while maintaining adequate oxygenation. *Increase PEEP* - The patient's **PaO2 of 110 mmHg** is already well within the normal to high range, suggesting that oxygenation is adequate. - Increasing PEEP would be considered if the patient had **refractory hypoxemia**, not hyperoxia. *Increase tidal volume* - The current tidal volume of **420 mL for a 50 kg patient (8.4 mL/kg)** is already at the higher end of lung-protective ventilation (typically 6-8 mL/kg). - Increasing tidal volume further could lead to **ventilator-induced lung injury** (VILI) due to volutrauma, especially in a patient with pneumonia. *Decrease RR* - The patient has a **pCO2 of 48 mmHg** and a **pH of 7.3**, indicating **respiratory acidosis** (hypoventilation). - Decreasing the respiratory rate would further exacerbate the acidosis by reducing minute ventilation and increasing pCO2, which is inappropriate.
Question 4: Post-operative pulmonary thromboembolism is seen in all, except:
- A. Obese male
- B. Pregnant female
- C. Estrogen therapy
- D. Tall and thin man (Correct Answer)
Explanation: ***Tall and thin man*** - A **tall and thin man** is generally at a lower risk for developing post-operative pulmonary thromboembolism compared to the other options. - While prolonged immobility post-surgery can increase risk for anyone, factors like **obesity**, **pregnancy**, and **estrogen therapy** significantly elevate the risk. *Obese male* - **Obesity** is a major risk factor for venous thromboembolism (VTE) due to factors like increased venous stasis and chronic inflammation. - Adipose tissue also produces prothrombotic factors, further increasing the risk of **pulmonary embolism (PE)**. *Pregnant female* - **Pregnancy** induces a hypercoagulable state to prevent excessive bleeding during childbirth, increasing the risk of VTE. - This risk is further elevated in the post-partum period and with surgical procedures like a **Cesarean section**. *Estrogen therapy* - **Estrogen therapy**, such as in oral contraceptives or hormone replacement therapy, can increase the synthesis of clotting factors and decrease natural anticoagulant proteins. - This prothrombotic effect significantly raises the risk of **deep vein thrombosis (DVT)** and subsequent **PE**.
Question 5: Which of the following is not a risk factor for postoperative pulmonary complication?
- A. Normal BMI (18.5-24.9) (Correct Answer)
- B. Age 25-40 years
- C. Upper abdominal surgery
- D. Patient with 20 pack years of smoking
Explanation: ***Patient with 20 pack years of smoking*** - This is a significant risk factor for postoperative pulmonary complications, as **chronic smoking** impairs lung function and mucociliary clearance. - Patients with a history of **20 pack-years or more** are at a substantially increased risk of developing atelectasis, pneumonia, and respiratory failure after surgery. *Normal BMI (18.5-24.9)* - A **normal BMI** is not considered a risk factor for postoperative pulmonary complications; instead, it is associated with a lower risk compared to obesity or underweight states. - Patients with a normal BMI generally have **better respiratory mechanics** and lung volumes, reducing their susceptibility to pulmonary issues. *Age 25-40 years* - This age range is generally associated with a **lower risk** of postoperative pulmonary complications compared to very young or elderly patients. - Younger adults typically have **better physiological reserves** and healthier lungs, contributing to a reduced incidence of respiratory problems post-surgery. *Upper abdominal surgery* - **Upper abdominal surgery** is a significant risk factor for postoperative pulmonary complications due to its proximity to the diaphragm. - It often leads to **diaphragmatic dysfunction**, reduced lung volumes, and increased pain, all of which predispose patients to atelectasis and pneumonia.
Question 6: In the immediate post operative period the common cause of respiratory insufficiency could be because of the following, except -
- A. Mild Hypovolemia (Correct Answer)
- B. Residual effect of muscle relaxant
- C. Overdose of narcotic analgesic
- D. Myocardial infarction
Explanation: ***Mild Hypovolemia*** - While significant **hypovolemia** can lead to systemic complications, *mild hypovolemia* itself does not directly cause *respiratory insufficiency* in the immediate postoperative period without other complicating factors. - Hypovolemia primarily affects **cardiovascular stability** and tissue perfusion, not directly the mechanics or drive of respiration unless it progresses to **shock**. *Residual effect of muscle relaxant* - **Residual neuromuscular blockade** can lead to *diaphragmatic weakness* and impaired accessory muscle function, causing insufficient ventilation and respiratory distress. - This is a common cause of *postoperative respiratory insufficiency*, especially if reversal agents are inadequate or not administered. *Overdose of narcotic analgesic* - **Narcotic overdose** depresses the *respiratory drive* in the brainstem, leading to decreased respiratory rate and depth, which can result in **hypoventilation** and *respiratory insufficiency*. - This is a significant concern in the immediate postoperative period due to pain management requirements. *Myocardial infarction* - A *myocardial infarction* can lead to **cardiogenic pulmonary edema** due to impaired cardiac function, resulting in fluid accumulation in the lungs and *respiratory insufficiency*. - Postoperative myocardial infarction is a serious complication that directly impacts respiratory function through its effect on **pulmonary hemodynamics**.
Question 7: In a post operative intensive care unit, five patients developed post-operative wound infection on the same day. Which of the following is the best method to prevent cross infection among patients in the same ward?
- A. Give antibiotics to all other patients in the ward
- B. Practice proper hand washing (Correct Answer)
- C. Disinfect the ward with sodium hypochlorite
- D. Fumigate the ward
Explanation: ***Practice proper hand washing*** - **Proper hand washing** is the **single most effective measure** to prevent hospital-acquired infections, including cross-transmission of pathogens between patients in a ward. - It physically removes transient microorganisms acquired from patient contact or the environment, thus breaking the chain of infection. *Give antibiotics to all other patients in the ward* - This approach promotes **antibiotic resistance** and can disrupt the patients' normal flora, potentially leading to other infections like *Clostridioides difficile*. - Administering antibiotics prophylactically to uninfected patients is generally discouraged due to these risks and the lack of specific indication. *Disinfect the ward with sodium hypochlorite* - While **surface disinfection** is important, it is less effective than hand hygiene in preventing direct patient-to-patient transmission of pathogens carried by healthcare workers. - Frequent chemical disinfection of an entire ward with strong agents like **sodium hypochlorite** can also be harmful to equipment and may not address all modes of transmission effectively. *Fumigate the ward* - **Fumigation** is a drastic measure typically reserved for specific outbreaks or terminal disinfection, not for routine infection prevention in an occupied ICU. - It is often impractical, costly, requires patient evacuation, and may not target the primary vectors of cross-infection, such as direct contact via healthcare worker hands.
Question 8: Postoperative nausea and vomiting are uncommon with
- A. Propofol (Correct Answer)
- B. Etomidate
- C. Thiopentone
- D. All of the options
Explanation: ***Propofol*** - **Propofol** is known for its antiemetic properties, which contributes to a lower incidence of **postoperative nausea and vomiting (PONV)**. - Its mechanism involves modulating **dopaminergic activity** in the chemoreceptor trigger zone and possibly direct effects on serotonin receptors. *Etomidate* - While etomidate is a fast-acting induction agent, it does not inherently possess antiemetic properties. - Its use does not significantly reduce the risk of **PONV** compared to other induction agents, and some studies suggest it may even increase the risk slightly. *Thiopentone* - **Thiopentone**, a barbiturate, is typically associated with a higher incidence of **PONV** compared to propofol. - It does not offer any protective effect against nausea and vomiting and can contribute to these side effects in the postoperative period. *All of the options* - This option is incorrect because **etomidate** and **thiopentone** do not share the **antiemetic properties** of propofol. - Only **propofol** is specifically known to reduce the incidence of **PONV**.
Question 9: A postoperative patient with pH 7.25, MAP (mean arterial pressure) 60 mm Hg is treated with?
- A. Only normal saline
- B. fluid restriction
- C. Fluid therapy with CVP monitoring (Correct Answer)
- D. I.V. sodium bicarbonate
Explanation: ***Fluid therapy with CVP monitoring*** - The patient's **MAP of 60 mmHg** indicates **hypotension** and potential **hypovolemic shock**, while pH 7.25 suggests **acidosis**, which could be metabolic due to poor perfusion. Initial treatment should focus on **restoring circulating volume** to improve blood pressure and organ perfusion. - **Central venous pressure (CVP) monitoring** is crucial to guide fluid resuscitation. It helps assess the patient's fluid status and ensures that enough fluid is given to improve cardiac output without causing fluid overload, especially in a severely ill patient. *Only normal saline* - While normal saline is used for fluid resuscitation, simply stating "only normal saline" is insufficient because it doesn't address the **critical need for monitoring** to guide treatment. - The amount and rate of fluid administration need to be carefully controlled based on the patient's response and hemodynamic parameters. *Fluid restriction* - **Fluid restriction** would be contraindicated in this patient because the **low MAP** suggests **hypovolemia or cardiogenic shock**, requiring fluid repletion, not restriction. - Restricting fluids could further worsen hypotension and organ hypoperfusion, leading to increased acidosis and organ damage. *I.V. sodium bicarbonate* - Administering **I.V. sodium bicarbonate** to correct acidosis without addressing the underlying cause of hypotension and poor perfusion is generally not recommended. - The acidosis (pH 7.25) is likely due to **poor tissue oxygenation and lactic acid production** from inadequate blood flow; correcting this with fluids will resolve the acidosis.
Question 10: All of the following drugs increase the risk of postoperative nausea and vomiting after squint surgery in children except?
- A. Halothane
- B. Propofol (Correct Answer)
- C. Nitrous Oxide
- D. Opioids
Explanation: ***Propofol*** - Propofol is known to have **antiemetic properties** and is often used to reduce the incidence of postoperative nausea and vomiting (PONV). - Its mechanism involves modulating **GABA-A receptors** and potentially other pathways that suppress emetic responses. *Halothane* - **Inhalational anesthetics** like halothane are a significant risk factor for PONV, particularly in children and following surgeries like squint repair. - They tend to increase PONV by directly stimulating the **chemoreceptor trigger zone** and altering gut motility. *Opioids* - Opioids, commonly used for postoperative pain control, are a well-known cause of **nausea and vomiting**. - They activate **opioid receptors** in the chemoreceptor trigger zone and the gastrointestinal tract, leading to emesis and delayed gastric emptying. *Nitrous Oxide* - The use of **nitrous oxide** as part of a general anesthetic regimen has been consistently associated with an increased risk of PONV. - It is believed to contribute to PONV by increasing the risk of **bowel distension** and stimulating neurotransmitter release involved in emesis.
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