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RESP - 1 > Pulmonary Vascular Disease > Flashcards

Pulmonary Vascular Disease Flashcards

1
Q

What is a pulmonary embolism?

A

Thrombus forms in venous system (usually deep veins of legs), all/part of it propagates + travels up IVC to heart and ends up in a pulmonary artery

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2
Q

What are risk factors for PE?

A

Recent major trauma/surgery
Cancer (large tumour pressing on veins –> venous stasis)
Significant cardiopulmonary disease, e.g. MI
Pregnancy
Inherited thromophilia
COPD

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3
Q

Why do major surgery/trauma predispose to PE?

A

Clotting system is activated and immobilisation/stasis

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4
Q

What are potential features of a PE?

A 
Chest pain (pleuritic)
SoB
Haemoptysis
Tachycardia
Tachypnoea
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5
Q

Why do you get haemoptysis in PE?

A

Blood clot in pulmonary artery –> tissue infarction (so cough up necrotic tissue)

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6
Q

Why do you get pleuritic chest pain in PE?

A

Inflamed lung rubs against chest wall

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7
Q

How might a massive PE present?

A

Syncope or cardiac arrest (e.g. if clot in main pulmonary artery)

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8
Q

What are signs of a small clot causing a PE?

A

Pyrexia, pleural rub (sounds like walking on snow), stony dullness to percuss at base (pleural effusion)

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9
Q

What are signs of a bilateral PE?

A

Tachycardia, tachypnoea, hypoxia

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10
Q

What are signs of a massive PE?

A

Shock - hypotension, tachycardia, tachypnoea, hypoxia

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11
Q

All patients presenting with signs/symptoms suggestive of a PE should have what?

A

CXR to exclude other pathology

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12
Q

What key change was made to the investigation and management of VTE in 2020?

A

Use of the pulmonary embolism rule out criteria - this should be used if there is low possibility of PE but you want more reassurance it is not a PE
Low probability is <15% if higher than this move straight to a two level PE wells score

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13
Q

What is the two level PE well score?

A

Clinical sx/sx of DVT (minimum of leg swelling + pain on palpation of deep veins) -3
Alt diagnosis less likely - 3
HR >100bpm - 1.5
Immobilisation >3 days/surgery in prev 4 weeks - 1.5
Prev. DVT/PE - 1.5
Haemopytsis - 1
Malignancy (on treatment, treated in last 6 months or palliative) - 1

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14
Q

What wells score indicates PE is likely?

A

> 4 points

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15
Q

If PE is likely what should you do?

A

Arranged immediate CTPA (if delay then start interim therapeutic anticoagulation until scan is performed)

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16
Q

What interim therapeutic anticoagulation is given for PE?

A

DOACs, e.g. apixiban or rivaroxiban

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17
Q

What should you do if PE is unlikely?

A

Arrange D-dimer
If +ve –> immediate CTPA (interim anticoagulation if unable to get it immediately)
If -ve –> PE unlikely, consider alt diagnosis

18
Q

If the patient has an allergy to contrast/renal impairment what should be done instead of a CTPA?

A

V/Q scan

19
Q

What are the classic ECG changes seen in PE?

A

Large S wave in lead I, large Q wave in lead III and inverted T wave in lead III (S1Q3T3)
Right bundle branch block + right axis deviation
Sinus tachycardia

20
Q

What do you typically see on CXR in PE?

A

Usually normal

21
Q

What (other than a current PE) may cause a V/Q mismatch on a V/Q scan?

A

Old PEs, AV malformations, vasculitis, prev. RT

22
Q

What is the gold standard investigation for diagnosing PE?

A

Pulmonary angiography

23
Q

List all the investigations that should be considered qfor a suspected PE

A 
FBC, biochemistry, ABG
CXR
ECG
D-dimer
CTPA
VQ scan 
ECHO
Thrombophilia testing?
24
Q

What is the PESI score?

A

PE severity index, based on age, sex, comorbs, physiological parameters

25
Q

What is the first line treatment for most people with VTE?

A

DOACs

26
Q

Where might patients with low risk PEs be managed?

A

As outpatients (assess risk using PESI score, with key requirements being haemodynamic stability, lack of comorbs and support at home)

27
Q

What DOACs are offered first line after a PE?

A

Apixiban or rivaroxaban

28
Q

What should be used if DOACs are not suitable for treating a PE?

A

LMWH followed by dabigatran or edoxaban or LMWH followed by vit K antagonist, e.g. warfarin

29
Q

What should be used to treat PE in severe renal impairment?

A

LMWH then UFH or LMWH then VKA

30
Q

What should be used to treat PE in those with antiphospholipid syndrome?

A

LMWH followed by VKA

31
Q

How long should all patients with PE be anticoagulated?

A

Min 3 months

32
Q

What is the first line treatment for massive PE with circulatory failure?

A

Thrombolysis

33
Q

What treatment can be given to those with recurrent PEs despite adequate anticoagulation?

A

IVC filters (these work by stopping clots formed in deep veins of leg moving to the pulmonary arteries)

34
Q

What is pulmonary hypertension?

A

Elevated BP in pulmonary artery tree (pulmonary arterial pressure >25mmHg)

35
Q

Who is primary PHT seen in ?

A

Young people - it is very serious and rare and requires treatment

36
Q

What are causes of pulmonary HTN?

A 
Primary - idiopathic
2ndary to chronic resp disease - any disease severe enough to cause bad hypoxia --> constriction of pulmonary capillary bed --> inc. pulmonary artery pressure
Secondary to L heart disease
Chronic thromboembolic PH (due to web and scar tissue formation)
Collagen vascular disease
Portal HTN
Congenital heart disease
HIV
37
Q

What are symptoms of PHT?

A

Exertional SoB
Chest tightness
Exertional presyncope or syncope

38
Q

What are signs of PHT?

A

Elevated JVP, RV heave, loud pulmonary 2nd heart sound, hepatomegaly, ankle oedema (due to inc. venous pressure in leg)

39
Q

What investigations are used in PHT?

A

ECG, LFTs, CXR, echo, VQ scans, CTPA, right heart catheterisation (allows direct measurement of arteral pressure)

40
Q

How is PHT managed?

A 
Treat underlying condition
Oxygen 
Anticoagulation 
Diuretics (if lots of oedema)
CCB, e.g. amlodipine 
Prostacycline (inhibits platelet activation and vasodilator)
Phosphodiesterase inhibitors
Endothelin receptor antagonists
41
Q

What surgery might be offered for organised thrombosis?

A

Thromoendarectomy (CTEPH) resection of organised thrombosis

RESP - 1 (27 decks)

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