Pulmonary Circulation, embolism, hypertension, edema, and ARDS

Question 1

Define dead space and the significance when a PE is present

Answer 1

some areas of the lung are perfused but have atelectasis and are not well ventilated
a consequence of PE is increased alveolar dead space

Question 2

Define primary (idiopathic) pulmonary hypertension

Answer 2

One in a million disease – usually females in their mid 30s
3 year survivial 48-67%, hereditary predisposition with autosomal dominance.
Risk factors: drug use, collagen vascular disease, HIV, liver disease
Symptom: dyspnea

Question 3

3 predisposing factors of a PE

Answer 3

stasis, hypercoagulability, initial injury

Question 4

Most common signs of PE

Answer 4

dyspnea, pleauritic chest pain, cough, leg swelling, leg pain

Question 5

Most common symptoms of PE

Answer 5

tachypnea, rales, tachycardia, fourth heart sound, increased pulmonary component of S2, DVT

Question 6

What 2 findings on an EKG can indicate a PE?

Answer 6

S1Q3T3 pattern (ST segment depression in lead 1, Q wave present in lead 3 and T wave inversion in lead 3)
New onset of Atrial fibrillation

Question 7

What is the gold standard for dx of PE

Answer 7

Pulmonary angiogram

Question 8

What does D-dimer test indicate

Answer 8

It is a fibrin split byproduct found in PE. Has a high sensitivity (>90% chance if it’s negative you don’t have it)

Question 9

What is a V/Q scan used for

Answer 9

For pulmonary embolism

Question 10

What happens to ABG with a PE

Answer 10

O2 levels less than 80

CO2 levels less than 40

Question 11

What is Group 2 Pulmonary HTN d/t?

Answer 11

Cardiac disease: Increased pulmonary flow, elevated pulmonary venous pressure

Question 12

What is Group 3 Pulmonary HTN d/t

Answer 12

Lung disease: COPD, Interstitial lunmg disease, hypoxemia

Question 13

What is Group 4 Pulmonary HTN d/t?

Answer 13

Chronic thromboembolic disease: can be from a PE

Question 14

What is Group 5 Pulmonary HTN d/t?

Answer 14

Multifactoral or uncertain factors: sarcoidosis, sickle cell disease, CKD, HIV related

Question 15

Evaluation tests for pulmonary HTN

Answer 15

Pulse oximetry, ABG, Echocardiogram

Question 16

Pathophysiology of pulmonary edema

Answer 16

fluid in the pulmonary interstitial spaces and alveoli

Question 17

Etiology of pulmonary edema

Answer 17

cardiogenic: left heart failure

non-cardiogenic

Question 18

Clinical presentation of pulmonary edema

Answer 18

progressive worsening of dyspnea over several hours
has to sit upright
BP elevated or low
lungs may have rales, wheezes
pulse could be anything
skin pale, cool, diaphoretic

Question 19

Tx of pulmonary edema

Answer 19

oxygen, NTG (decrease preload and afterload), Diuresis with a loop diuretic

Question 20

What is the Diff Dx for Pulmonary Embolism

Answer 20

Pneumonia
Pleurisy
MI
Asthma
Pneumothorax
Pleural effusion
Pulmonary Edema
Musculoskeletal chest pain

Question 21

Identify signs that might alert the examiner the presence of a pulmonary embolus (PE).

Answer 21

• tachypnea
• rales
• tachycardia
• fourth heart sound
• increased pulmonary component of S2
• DVT
• diaphoresis
• temp > 38.5 degrees C
• wheezes
• Homan’s sign
• RV lift
• pleural friction rub,
• S3
• cyanosis

Question 22

Identify symptoms that might alert the examiner the presence of a pulmonary embolus (PE).

Answer 22

• dyspnea
• pleuritic chest pain
• cough
• leg swelling
• leg pain
• hemoptysis
• palpitations
• wheezing
• angina-like pain

Question 23

Describe the specificity of each test with regard to differential diagnosis for PE.

Answer 23

A pulmonary angiogram is the gold standard for evaluating a PE.
Other tests may include:
-Chest x-ray (may shows the presence of infiltrations, atelectasis, vessel cutoff [Westermark’s sign, enlarged right descending pulmonary artery [Palla’s sign], and elevated hemidiaphragms)
-EKG (non-specific ST-T changes, left axis deviation, right bundle branch block, S1Q3T3 pattern, new onset of atrial fibrillation may be an indicator of PE)
-Labs (CBC [non-specific], D-dimer [high sensitivity with low specificity], INR, ELISA, V/Q scan [normal scan may rule out PE], duplex ultrasound of lower extremities, and spiral CT [better for central clots, not as good for peripheral, better than V/Q if chest x-ray is abnormal or patient has COPD]).

Harrison’s Principles of Internal Medicine or the WELLS Criteria for PE may be used to rule in/out PE.

Question 24

Describe pulmonary vascular and cardiac complications associated with PE.

Answer 24

• Decreased vascular flow due to clot in lungs, so lung not perfused properly (reduces gas exchange)
• Elevated blood pressure in pulmonary circuit due to clot (can cause pulmonary HTN)
• Can cause edema, fibrosis, or inflammation
• Can lead to right heart failure or biventricular failure

Question 25

Evaluation of secondary pulmonary hyptertension would include:

Answer 25

Pulse ox or ABG, chest x-ray (may be normal or show enlarged central pulmonary arteries), EKG (may show RVH), PFT, CT scan, V/Q scan, sleep apnea if OSA suspected, Echo, R sided catheterization with vasodilator testing and exercise testing