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Assessment Exam 4 > Pulm HTN > Flashcards

Pulm HTN Flashcards

1
Q

How is pulmonary hypertension (PH) different from systemic hypertension?

A

Complex diagnosis and treatment

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2
Q

What is the mean pulmonary artery pressure (mPAP) threshold for defining pulmonary hypertension?

A

> 20 mmHg

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3
Q

What are some symptoms of pulmonary hypertension?

A

Accentuated S2 & S4, LE swelling

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4
Q

How is pulmonary hypertension classified based on PA wedge pressure and pulmonary vascular resistance?

A

3 hemodynamic profiles
-Isolated precapillary PH
-isolated postcapillary PH
-Combined pre and postcapillary PH

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5
Q

What is precapillary PH defined as?

A

PVR ≥3.0 wood units w/o elevated LAP or PAWP

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6
Q

What characterizes isolated postcapillary PH?

A

PAWP >15mmHg, normal PVR

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7
Q

What defines combined pre- and postcapillary PH?

A

PAWP >15mmHg, PVR >3.0 WU

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8
Q

How is high-flow PH characterized?

A

No elevation in PAWP or PVR

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9
Q

What are the three Groups of Pulmonary Hypertension?

A

Isolated precapillary, Isolated postcapillary, Combined pre- and postcapillary

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10
Q

What is required for diagnosis, classification, and treatment planning of Pulmonary Artery HTN?

A

Right heart catheterization

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11
Q

What can elevate mean pulmonary arterial pressure (mPAP)?

A

1) elevated resistance within arterial circulation 2) increased pulmonary venous pressure 3) chronically increased pulmonary blood flow 4) a combination of processes

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12
Q

How is Pulmonary Vascular Resistance (PVR) calculated?

A

(mPAP - PAWP)/COP

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13
Q

What components of lung circulation can contribute to Pulmonary Hypertension?

A

Arterial or venous abnormalities, sometimes both

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14
Q

What can TTE reveal in pulmonary hypertension?

A

RA & RV enlargement, elevated tricuspid-regurgitation velocity

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15
Q

Why is an echocardiogram commonly used in PH?

A

Estimate PASP as screening tool

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16
Q

How is the severity of PH determined after a right heart catheterization?

A

By mPAP values

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17
Q

What are the classifications based on mPAP values in PH?

A

Mild, moderate, severe

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18
Q

How much can normal pulmonary circulation accommodate in terms of COP increase without a notable change in mPAP?

A

Fourfold increase

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19
Q

What does PH stand for?

A

Pulmonary Artery HTN

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20
Q

What is the classification of PAH according to the World Health Organization?

A

Rare disease affecting 15 people per million per year

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21
Q

What is the significance of Idiopathic PAH?

A

No identifiable risk factor

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22
Q

What percentage of PAH cases are inheritable and what is the associated mutation?

A

3%, mutations in BMPR2

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23
Q

How are the remaining cases of PAH designated?

A

Associated PAH” due to drugs

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24
Q

What is the demographic shift seen in PAH patients according to current data?

A

Now more older patients and men being diagnosed

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25
Q

What is the 1-year mortality rate despite improved diagnosis and therapy for PAH?

A

Approximately 15%

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26
Q

What are the 3 main classes of pulmonary vasodilator drugs for PAH?

A

Prostanoids, Endothelin receptor antagonists (ERAs), Nitric oxide/guanylate cyclase pathway drugs

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27
Q

What leads to pathologic distortion of small pulmonary arteries in PAH?

A

Sustained vasoconstriction and remodeling processes

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28
Q

Is combination therapy often needed for the treatment of PAH?

A

Yes

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29
Q

What is the mechanism of action of prostanoids in PAH treatment?

A

Mimic prostacyclin to produce vasodilation and inhibit platelet aggregation.

30
Q

Which prostanoid in PAH treatment has been proven to reduce mortality?

A

Epoprostenol

31
Q

What is the role of Endothelin Receptor antagonists (ERAs) in PAH treatment?

A

Improve hemodynamics and exercise capacity

32
Q

How does nitric oxide produce pulmonary vasodilation?

A

Stimulating guanylate cyclase and cGMP formation in smooth muscle cells

33
Q

Why is the effect of nitric oxide transient?

A

Quickly bound by hgb and degraded by phosphodiesterase type 5

34
Q

What is a common route of administration for nitric oxide in perioperative and critical care settings?

A

Continuously inhaled

35
Q

What type of therapy has chronic treatment for PAH been directed towards?

A

PD-5 inhibitors

36
Q

What are some preoperative considerations for patients with PAH?

A

Venous embolism, elevated pressure, hypoxic vasoconstriction

37
Q

What are common presenting symptoms of PAH?

A

Fatigue, dyspnea, cough

38
Q

What are some advanced symptoms of PAH?

A

Angina, syncope

39
Q

What might be observed on physical exam in a patient with PAH?

A

Parasternal lift, accentuated heart sounds, JVD

40
Q

What rare complication of PAH may lead to hoarseness?

A

Compression of dilated PA on RLN

41
Q

What should a history of PH prompt further evaluation of?

A

Functional status, cardiac performance, pulmonary function tests

42
Q

What is recommended for patients with moderate or severe PH prior to moderate-high risk surgery?

A

Right heart catheterization

43
Q

What should be performed in patients with coexisting left heart disease due to potential discrepancies?

A

Left heart catheterization

44
Q

What testing is performed during right heart catheterization to determine responsiveness to vasodilator therapy?

A

Vasoreactivity testing, often with inhaled nitric oxide

45
Q

What percentage of PAH patients are nonresponsive to inhaled nitric oxide?

A

85-90%

46
Q

What may PAH patients responsive to inhaled nitric oxide also benefit from?

A

CCBs and other targeted therapy

47
Q

What is the confirmed diagnosis after right heart catheterization with mPAP 20 and PAWP 15?

A

PAH

48
Q

What is the next step after confirmed PAH diagnosis?

A

Vasodilator testing

49
Q

What is the treatment if vasodilator testing is positive?

A

CCB

50
Q

What is the management if there is no sustained response to initial therapy?

A

PAH specific therapy

51
Q

What treatment approach is recommended for low-risk PAH patients?

A

Oral meds

52
Q

What is the suggested treatment for high-risk PAH patients?

A

IV meds

53
Q

What is the appropriate approach if there is an inadequate response to initial therapy?

A

Continue therapy

54
Q

What patient factors increase the risk of morbidity and mortality in noncardiac surgery in patients with pulmonary arterial hypertension?

A

PE, CAD, chronic renal disease, NYHA/WHO FC >II, higher ASA class, RAD on ECG, Echo parameters (RVH, RVMPI 0.75), Hemodynamics (higher PAP, RVSP/SBP ratio >0.66)

55
Q

What are some operative factors that increase the risk of morbidity and mortality in noncardiac surgery in patients with pulmonary arterial hypertension?

A

Emergency surgery, Intermediate- or high-risk operations, High risk for venous embolism, Elevation in venous pressure, Reduction in lung vascular volume, Induction of severe systemic inflammatory response, Longer duration of anesthesia, Intraoperative vasopressor use

56
Q

What is the primary intraoperative goal in perioperative physiology?

A

Maintaining optimal ‘mechanical coupling’ btw right ventricle and pulmonary circulation

57
Q

Why is it important to consider any intervention that may affect RV preload, inotropy, afterload, and oxygen supply/demand relationships?

A

To promote adequate left-sided filling and systemic perfusion

58
Q

What perioperative complexities can have serious complications?

A

Transient HoTN, mechanical ventilation, modest hypercarbia, small bubbles in IV, T-burg position, Pneumoperitoneum, single-lung ventilation

59
Q

What is a hallmark of PAH?

A

Increased RV afterload

60
Q

What does increased RV afterload lead to?

A

RV dilation, increased wall stress, and RV hypertrophy

61
Q

How is the interaction between the RV and the pulmonary circulation described?

A

Pulsatile and dynamic

62
Q

What affects RV pulsatile load during surgeries?

A

Acute insults

63
Q

How can ventilator management affect RV afterload?

A

PEEP, hypoventilation, hypercarbia, acidosis, and atelectasis

64
Q

Why is the thinner-walled RV subject to greater wall tension than the LV for the same increase in end-diastolic volume?

A

Increased RV myocardial oxygen demand

65
Q

What happens to RV intramyocardial pressure compared to aortic root pressure under normal circumstances?

A

Lower than aortic root pressure

66
Q

How does PAH affect coronary flow and RV vulnerability to systemic HoTN?

A

Increased coronary flow during diastole, vulnerable to systemic HoTN

67
Q

What is the ‘lethal combination’ in the context of systemic HoTN and RV issues?

A

RV dilatation, insufficient LV filling, reduced stroke volume

68
Q

How does perioperative morbidity and mortality change in patients with PH during hip and knee replacement?

A

Substantial increase

69
Q

What effect does CO2 pneumoperitoneum have on biventricular load and pump function?

A

Acute impact

70
Q

How does the combination of pneumoperitoneum, head-down position, and increased inspiratory pressure affect right ventricular pressures and afterload?

A

Affects RV pressures and afterload

71
Q

What are the 3 features of lung collapse that are particularly relevant in thoracic surgery?

A

Transient chest pressurization, systemic hypoxia, hypoxic pulmonary vasoconstriction

72
Q

What therapy is recommended during single-lung ventilation for PAH patients?

A

Inhaled pulmonary vasodilators

Assessment Exam 4 (9 decks)

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