Pulmonary Circulation

Question 1

Main Point

Answer 1

Decreased flow through the pulmonary circulation can be caused by:

Blood clots
elevated BP in pulmonary circuit
Edema
Fibrosis
Inflammation

This leads to hypoxemia and R ventricular failure or biventricular failure

Question 2

Disorders of pulmonary circulation

Answer 2

PE

Pulmonary arterial hypertension

Pulmonary edema

ARDS

Question 3

PE Definition and Etiology

Answer 3

Endogenous or exogenous material that travels to lungs, impeding blood flow

MC emboli are from blood clots from the deep veins of upper leg and pelvis

Others: CO2, fat droplets, air bubbles, neoplastic cells

Question 4

Predisposing factors for PE

Answer 4

Stasis

Hypercoagulability (cancer, oral contraceptives, pregnancy)

Intimal injury (trauma, cath)

Question 5

PE Symptoms

Answer 5

Dyspnea

Pleuritic chest pain

cough

leg swelling/pain

hemoptysis

palpitations

wheezing

Question 6

PE Physical Exam

Answer 6

Tachypnea

Rales

Tachycardia

S4, increased P2

DVT

Diaphoresis

Fever

Wheezes

Homan’s sign

RV Heave

(In order of frequency)

Question 7

PE DDx

Answer 7

Pneumonia

Pleurisy

Musculoskeletal CP

MI

Asthma

Pneumothorax

Pleural effusion

Pulmonary Edema

Question 8

Saddle PE

Answer 8

Massive clot wedged b/w bifurcation of pulmonary artery

Hypotension

dyspnea

Life threatening

Dx urgently with echo or pulmonary angiogram

Question 9

PE Work-Up

Answer 9

**CXR* **

• may be normal or see vessel cutoff (Westermark’s sign)

EKG*

• Normal
• S1Q3T3 Pattern
• New onset A fib

Oxygenation: pulse ox or ABG* show hypoxemia

Labs: CBC, D dimer* (if normal, don’t have PE..r/o)

V/Q Scan: only if CX normal

**CT **

Gold Standard: Pulmonary Angiography

*Screening tests

Question 10

PE Criteria

Answer 10

Wells Criteria

Question 11

Definition of Pulmonary HTN

Answer 11

Pulmonary artery pressure >25mmHg

Syndrome of R ventricular failure

Question 12

Pulmonary HTN Symptoms

Answer 12

dyspnea

fatigue

syncope

raynaud’s phenomenon

angina pectoris

abdominal distention

Question 13

Pulmonary HTN PE

Answer 13

Usually normal lung exam

L parasternal lift (RV heave)

loud P2

pansystolic murmur of tricuspid regurgitation

diastolic murmur of pulmonic insufficiency

Advanced disease: signs of volume overload

Question 14

Pulmonary HTN Etiologies

Answer 14

Increased pulmonary flow

• ASD & VSD

Elevated pulmonary venous pressure

• LVF
• mitral stenosis/regurge
• L sided heart disease

Abnormalities of the pulmonary arteries or arterioles

• primary pulmonary HTN

**Reactive pulmonary vasoconstriction **

• OSA

Question 15

Primary Pulmonary HTN

Answer 15

Rare, genetic

poor prognosis

Think of in pts with scleroderma and systemic lupus in young female pts with dyspnea, fatigue, angina

Question 16

Pulmomary HTN Evaluation

Answer 16

Pulse ox or ABG

CXR (normal or enlarged central pulmonary arteries)

EKG (RVH)

PFTs

CT

V/Q

Mostly think of looking at underlying etiology

Question 17

Acute Cardiogenic Pulmonary Edema

Answer 17

Caused by exacerbation of LVF or MI

Snow ball effect of worsening LVF–>fluid in lungs–>hypoxia–>decreases CO more

Question 18

Acute Pulmonary Edema Evaluation

Answer 18

V/S

ABG

Cardiac monitor

CXR

EKG

CBC

Cardiac enzymes

Renal ftn

Question 19

Non cardiogenic pulmonary edema

AKA Adult Repsiratory Distress Syndome (ARDS)

Answer 19

Anything that can cause fluid to leak into your lungs:

Aspiration of gastric acid, water

CNS: trauma, seizures

DO: ASA, heroine

Hem alterations

Infections

Inhalation of toxins

Metabolic disorders

Trauma