Pulmonary Hypertension

Question 1

Pulmonary Hypertension

Answer 1

• PULMONARY HYPERTENSION IS CHARACTERIZED BY ELEVATED PULMONARY ARTERIAL PRESSURE AND SECONDARY RIGHT HEART VENTRICULAR FAILURE.

Question 2

ENDOTHELIAL DYSFUNCTION

Answer 2

VASCULAR SMOOTH MUSCLE DYSFUNCTION
- VASCULAR INJURY
Conditions such as
- collagen vascular disease (lupus or RA)
- congenital heart disease
- anorexigens (specific appetite depressants)
- Stimulants (Cocaine or amphetamine use)
- portal hypertension
- HIV

Question 3

PULMONARY HYPERTENSION PATHOPHYSIOLOGY

Answer 3

• Normally the pulmonary vascular bed can handle the blood volume delivered by the right ventricle.
• If the pulmonary vascular bed is destroyed or obstructed it can not handle whatever flow or volume of blood it receives.
• Increased blood flow then increases the pulmonary artery pressure increasing pulmonary vascular resistance
• Elevated pulmonary artery pressure resulting in resistance to blood flow in the pulmonary circulation (normally low pressure/resistance)
• An insult (hormonal, mechanical, or other) leads to pulmonary endothelial injury (smooth muscle proliferation, vascular scarring) causing pulmonary hypertension
• May be idiopathic (primary) or secondary to other disorders such as heart failure or congenital heart defects
• Secondary often due to COPD with constriction of the pulmonary vessels secondary to hypoxia and acidosis
• Cor pulmonale is enlarged right ventricle secondary to pulmonary hypertension (usually related to COPD)

Question 4

Potential & Actual Complications

Answer 4

• Right-sided heart failure
• May be fatal
• Right ventricular hypertrophy/ cor pulmonale

Question 5

COMPARISON OF PULMONARY ARTERIES; NORMAL VS CONSTRICTION

Answer 5

Question 6

PULMONARY HYPERTENSION Priority Assessments

Answer 6

• Dyspnea on exertion, shortness of breath, fatigue, chest pain with exertion, dizziness, or syncope
• May progress to dyspnea at rest or with eating
• Early heart failure symptoms (right side heart failure) including peripheral edema, hepatomegaly, distended neck veins
• Pulse oximetry

Question 7

PULMONARY HYPERTENSION CLINICAL MANIFESTATIONS

Answer 7

• Dyspnea (exertion or rest)
• Chest pain
• Weakness, fatigue, syncope, occasional hemoptysis
• Signs of Right-sided heart failure

Question 8

PULMONARY HYPERTENSION DIAGNOSTIC FINDINGS

Answer 8

• Chest x-ray
  — enlarged right ventricle or pulmonary artery
• ECG
  — peaked p waves, ST-segment depression, tall R waves, T- wave inversion
• *Echocardiogram (most defining diagnostic means)
• Right Heart Cath
  — MPAP >25 mm Hg
• Pulmonary Function Studies
  — slight decrease in vital capacity and lung compliance
• ABGs to assess for hypoxemia
  — (PaO2 decreased)
• pulmonary artery catheter (Central Venous catheter)

Question 9

PULMONARY HYPERTENSION MEDICAL MANAGEMENT

Answer 9

• Manage underlying condition if cause is known
  — In secondary pulmonary hypertension, treatment is most focused on management of the underlying disorder
• Oxygen
  — Low flow oxygen to keep saturations above 90%. O2 may be long-term to correct hypoxemia
• Diuretics
• Anticoagulation
• Digoxin
• Exercise training

Question 10

PULMONARY HYPERTENSION PHARMACOLOGIC THERAPY

Answer 10

• diuretics (reduce edema)
  —
• anticoagulants (reduce production of thrombi)
  —
• vasodilators (decrease pressure in vessels)
• Endothelin antagonists
  — Bosentan (Tracleer)
  — 2x daily; monitor liver function (ALT/AST)
• Digoxin
  — may improve right ventricle contractility
• Calcium channel blockers
  — first drug of choice*
  — amlodipine
  — nifedipine
  — virapamil
  — vasodilates to reduce pressure in the pulmonary artery and on the right ventricle
• Prostanoids
  — IV or aerosolized bc of short half life
  — Epoprostenol (Flolan)
  —- INH or IV not both
  — half life: 3-5 mins
  — make sure you have second bag ready
  — Iloprost (Ventavis)
  — Treprostinil (Remodulin)
• Phosphodiesterase-5 inhibitors: (second choice)
  — promotes pulmonary vasodilation
  —- Sildenafil (Revatio, Viagra)
  —- Vardenafil (Levitra)
  —- Tadalafil (Cialis, Adcirca)
• do not use with nitroglycerin-causes hypotension

Question 11

PULMONARY HYPERTENSION SURGICAL MANAGEMENT

Answer 11

• heart transplant
• Lung transplantation
  — difficult to get

Question 12

PULMONARY HYPERTENSION NURSING MANAGEMENT

Answer 12

• Identify patients at high risk
• Education on medication and home oxygen therapy
• Emotional and Psychosocial aspects
• Support groups

Question 13

COR PULMONALE

Answer 13

• High pressure in the pulmonary arteries
• Fluid back up in the right ventricle
• Right ventricle may dilate and become enlarged

Question 14

Pulmonary hypertension pressures

Answer 14

Normal: 25/10
Hypertension: can get up to 85/ 40