Pulmonary Circulation Flashcards
What is high pressure pulmonary edema?
Cardiogenic pulmonary edema
-Elevated LVEDP causes elevated hydrostatic pressures which result in increased edema formation
PE: JVD, S3, Hepatosplenomegaly, edema, cool extremities, thready pulse
CXR: vascular engorgement, peripheral infiltrates, cephalization, kerley B lines, pleural effusions are common
Causes-LV systolic or diastolic dysfunction, mitral valve disease, hyperkalemia with normal cardiac function
What are the treatments of high pressure pulmonary edema?
- oxygen, noninvasive mask ventilation
- decrease preload
- nitrates, diuretics, venodilators - decrease afterload
- ACE inhibitors, hydralazine - Increase contractility
- dobutamine, milrinone
What is low pressure pulmonary edema?
Acute respiratory distress syndrome (ARDS) or acute lung injury
-increased permeability (leaky capillaries) causes increased edema
Follows any of a number of insults
-most commonly sepsis, trauma, pancreatitis
Edema has protein concentration approaching serum
PE: lack signs of elevated filling pressures, if sepsis is the underlying cause then typically warm extremities, bounding pulses and wide pulse pressure
-refractory hypoxemia is early problem then hypercapnia becomes the problem
CXR: diffuse four quadrant fluffy infiltrates. pleural effusions and cardiomegaly are rare
What does the swan ganz catheter do?
gives you left atrial and what would be left ventricle end diastolic pressure
In high pressure pulmonary edema are the extremities warm or cold? Pulse pressure? Wedge pressure? Edema protein Conc?
cool
narrow
>20 wedge pressure
low protein in edema
In low pressure pulmonary edema are the extremities warm or cold?Pulse pressure? Wedge pressure? Edema protein Conc?
warm and well perfused
wide
How do you treat low pressure pulmonary edema?
-fix the underlying problem
-lower the hydrostatic pressures
-oxygen (but recognize that this is a shunt)
mechanical ventilation
-high peep-distends the alveoli-keeps them from collapsing-tethered interstitial space more negative-redistribute water into interstitial space
-low tidal volumes
salvage therapy-ECMO (extra corporeal membrane oxygen)
What leads to a Pulmonary Embolism?
N/O
- Hypercoagulability
- venous stasis
- intimal injury
What does pulmonary arterial obstruction lead to?
N/O
- Increased PVR
- Redistribution of blood flow–>V/Q mismatch
- Hyperventilation
- RV pressure overload, ischemia
What are the PE risk factors?
- Previous venous thromboembolism
- > 40
- Immobility, paralysis
- Malignancy
- Major surgery
- Trauma
- Obesity
- Cardiac Disease
- Long bone fractures
- CVA
- Nephrotic syndrome
- Estrogens
- Femoral lines
- Parturition
- Hypercoag. states
What are the symptoms of a PE?
N/O
Symptoms chest pain 88% dyspnea 84% apprehension 59% cough 53% hemoptysis 30% syncope 13%
Signs RR>16 92% Rales 58% Loud S2 53% Pulse >100 44% Temp>37.8 44% Phlebitis 32% Gallop 34% DIaphoresis 36% Edema 24% Murmur 23% Cyanosis 19%
What are diagnostic tests for PE?
D-dimer -sensitive but not specific Lower Extremity Ultrasound -specific but not sensitive V/Q scan pulmonary angiography Ct angiography
What are the treatments for PE?
- prevention
- anticoagulation
- heparin
- coumadin for at least 6 months - IVC filter
- Thrombolytics
- only proven to improve survival in shock - surgical/catheter thrombectomy
What are normal pulmonary artery pressures?
20/10
What is primary pulmonary hypertension vs secondary pulmonary hypertension?
Primary: vast majority are sporadic and only 6% are familiar with an autosomal dominant mode of inheritance
Secondary:
-decrease in the cross sectional area of the pulmonary vascular bed
-increased pulmonary blood flow
-Chronic obstructive or interstitial lung disease
-Recurrent pulmonary embolism
Antecedent heart disease
