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MD2 Foundation > Pulmonary Emboli and Pulmonary Hypertension > Flashcards

Pulmonary Emboli and Pulmonary Hypertension Flashcards

1
Q

Why don’t pulmonary pressure increase with increased cardiac output, for example, during exercise?

A

Dilatation and recruitment of pulmonary vessels

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2
Q

What are the causes of pulmonary hypertension?

A

Increased left atrial pressure
Increased pulmonary blood flow
Increased pulmonary vascular resistance

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3
Q

What are some causes of increased left atrial pressure?

A

Mitral stenosis
Left ventricular dysfunction
Diastolic dysfunction

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4
Q

What are some causes of increased pulmonary blood flow?

A

Left to right shunts
High flow states
Excess central volume

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5
Q

What are the causes of increased pulmonary vascular resistance?

A 
Vasoconstriction
- Low alveolar O2
Obstruction
- Embolism
- Primary pulmonary hypertension
Obliteration
- Arteritis
- Emphysema
- Pulmonary fibrosis
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6
Q

What is the mechanism of right ventricular failure?

A

Pulmonary hypertension (PA pressure >25 mmHg) > right ventricular dilatation and hypertrophy >

  • Increased systemic venous pressure > extravasation of fluid into tissues and peritoneal/pleural space
  • Poor cardiac output > gas exchange reduced > hypoxaemia, particularly with exertion
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7
Q

What are the symptoms of pulmonary vascular disease?

A 
Shortness of breath
- Sudden
- Gradual onset
Syncope/collapse
Lassitude
Swelling of ankles
Cough
Chest pain, often pleuritic
Haemoptysis
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8
Q

What are the signs of pulmonary vascular disease?

A 
Signs of pulmonary hypertension
- Right ventricular heave
- Loud P2, 4th heart sound
- Prominent V wave in JVP
Sings of right heart failure
- Elevated JVP +/- v waves
- Tricuspid regurgitation
- Ascites
- Pulsatile liver
Signs of cause
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9
Q

Where do pulmonary emboli come from?

A

Most commonly detach from deep vein thrombosis in leg
Fat; eg: post trauma
Air; eg: post laproscopic surgery
Amniotic fluid

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10
Q

What is the pathogenesis of thrombosis?

A 
Stasis
- Inpatient
- After some surgical procedures
- Prolonged immobility
Hypercoagulable state
- Genetic abnormalities; eg: factor deficiencies
- Malignancy
- Polycythaemia
- Pregnancy
- Medication
Abnormal vessels; eg: post trauma
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11
Q

What are the clinical features of pulmonary embolism?

A 
Need to have high level of suspicion in certain clinical situations
Collapse and hypoxaemia
Widened Aa gradient of unclear cause
Pleuritic chest pain of unclear cause
Unexplained breathlessness
Evidence of pulmonary hypertension of unclear cause
Risk factors
Evidence of DVT
- Calf pain
- Calf swelling
Medium clot burden
- Dyspnoea
- Pleuritic chest pain
- Cough
- Haemoptysis
- Fever
Examination
- Tachypnoea
- Tachycardia
- Pleural rub/effusion
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12
Q

What is Wells criteria?

A

Clinical assessment of pulmonary embolism

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13
Q

What are the investigations for pulmonary embolism?

A 
D-dimer
Troponin
ECG
Ventilation/perfusion (VQ) scan
CTPA
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14
Q

Describe the D-dimer test

A

Fibrin degradation product
Good sensitivity
Not specific
Negative predictive value excellent with low clinical probability of PE

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15
Q

Describe measuring troponin in the diagnosis of pulmonary embolism

A

Elevated in 30-50% of large PEs
Not sensitive nor specific
Can be marker of prognosis

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16
Q

Describe using an ECG in the diagnosis of pulmonary embolism

A

Abnormal in up to 70% of patients

Not specific

17
Q

Describe the use of a VQ scan in the diagnosis of pulmonary embolism

A

Combine with clinical probability
- High clinical and high probability VQ = 95% likelihood of having PE
Normal scan virtually rules out PE
Many patients fall into intermediate group so further tests often needed

18
Q

Describe the use of a CTPA in the diagnosis of pulmonary embolism

A

Diagnostic test of choice
May detect other pulmonary abnormalities
Low risk of PE if negative
Combine with clinical probability

19
Q

What are other, less common, investigations for diagnosing pulmonary embolism?

A 
Echocardiogram
- Abnormalities present in 30-40% of PE cases
- May be useful in massive PE
Venous ultrasound
- Not routine
- May be helpful
Pulmonary angiography
- Gold standard
- Rarely done
20
Q

What is the treatment of PE?

A 
Respiratory support
Haemodynamic support
Thrombolytic therapy
- Reduces some complications
- Reserved for most severe cases
Inferior vena cava (IVC) filter
- If failure of/contraindication to anticoagulation/further PE might be lethal
Anticoagulation
- ASAP
- Heparins
- Warfarin for longer-term use (3-6 months standard)
21
Q

What are some newer agents available for anticoagulation in the treatment of pulmonary embolism?

A

Rivaroxiban
Apixaban
Dabigatran

22
Q

What are the investigations required for COPD with right heart failure (cor pulmonale)?

A 
Basic bloods
- FBE
- U&Es
- LFTs
Arterial blood gases
CXR
Lung function
?Sleep study
Echocardiogram
23
Q

What is the management for COPD with evidence of right heart failure?

A 
Cease smoking
Oxygen
Pulmonary rehab
Bronchodilator therapy
Diuretics
24
Q

What are the diagnostic classifications for pulmonary hypertension?

A

Pulmonary arterial hypertension
Pulmonary hypertension with left heart disease
Pulmonary hypertension with chronic lung disease/hypoxaemia
Pulmonary hypertension due to chronic thrombotic and/or embolic disease
Miscellaneous

25
Q

What are the possible causes of pulmonary arterial hypertension?

A 
Idiopathic
Familial
Related to
- Connective tissue diseases
- HIV
- Portal hypertension
- Anorexigens
- Congenital heart diseases
Persistent pulmonary hypertension of the newborn
Pulmonary arterial hypertension with venule/capillary involvement
26
Q

What are the possible causes of pulmonary hypertension with left heart disease?

A

Atrial/ventricular

Valvular

27
Q

What are the possible causes of pulmonary hypertension with chronic lung disease or hypoxaemia?

A

COPD
Interstitial lung diseases
Sleep-disordered breathing
Developmental abnormalities

28
Q

What are the possible causes of pulmonary hypertension due to chronic thrombotic and/or embolic disease?

A

Thromboembolic obstruction of proximal pulmonary artery
Thromboembolic obstruction of distal pulmonary artery
Non-thrombotic pulmonary embolism

29
Q

What are the possible causes of miscellaneous pulmonary hypertension?

A

Sarcoidosis

30
Q

What is the prognosis for pulmonary hypertension if left untreated?

A

Very poor prognosis

MD2 Foundation (42 decks)

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