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OS 213 Respiratory Exam 2 > Pulmonary Vascular Diseases and Cor Pulmonale > Flashcards

Pulmonary Vascular Diseases and Cor Pulmonale Flashcards

1
Q

Major Role of Pulmonary Circulation:

A

Bring blood into close proximity with air so that gas exchange can occur

Consists of arteries, capillaries, and veins

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2
Q

It is a High Volume, Low Pressure System

A

Pulmonary Circulation

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3
Q

Major Role of bronchial circulation

A

Supply blood to airways

1/3 blood flow through the bronchial circulation empties into the azygos vein

2/3 of blood flow through the bronchial circulation empties into the pulmonary capillaries

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4
Q

Low Volume; High Pressure system

A

Bronchial Circulation

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5
Q

Venous Thromboembolic Disease

A

Includes deep vein thrombosis and pulmonary emboli

abrupt onset of dyspnea, Right pleuritic pain

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6
Q

Diagnosis of DVT

A

Venography
Impedance plethysmography
Compression ultrasonagrophy

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7
Q

Standard diagnostic tool, injection of dye

A

Venography

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8
Q

Non invasive, sensitive and specific

A

Impedence plethysmography

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9
Q

Non-invasive, sensitive and specific. Test of choice for diagnosis of DVT

A

Compression Ultasonography

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10
Q

Most common pulmonary disorder among hospitalized patients

A

Pulmonary Embolism

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11
Q

Pathogenesis of Pulmonary Embolism

A

Most often detached portions of venous thrombi that dislodge andbtravel through the central veins to the pulmonary arteries

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12
Q

Major sources of clinically imporatant pulmonary emboli (>50% originate below the knee)

A

Femoral, iliac, and pelvic veins

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13
Q

Virchows triad

A

Endothelial injury
Stasis of flow
Activation of clotting

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14
Q

Pulmonary embolism is most frequent in…..

A

Lower lobes, and right lung

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15
Q

Emboli obstruct blood flow

A 
Alveolar dead space
Bronchoconstriction
Decreased surfactant production
Hypoxemia
Pulmonary hypertension
Shock (saddle embolus)
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16
Q

VE

A

equal to the sum of alveolar ventilation and dead space ventilation

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17
Q

Clinical features of Pulmonary Embolism

A

No specific signs or symptoms

Anticoagulation is started on suspicion of PE and stopped only when PE is ruled out

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18
Q

Most common symptom of PE

A

Dyspnea

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19
Q

calf pain on dorsiflexion of foot

A

Homan’s sign

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20
Q

Effects of pulmonary Embolism

A

Increased pulmonary vascular resistance

Impaired gas exchange

alveolar hyperventilation

Increased airway resitance

Decreased pulmonary compliance

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21
Q

Increased pulmonary vascular resistance

A

vascular obstruction or neurohumoral agents like serotonin

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22
Q

Impaired gas exchange

A

increase alvolar dead space from vascular obstruction and hypoxemia from alveolar hypoventilation in non-obstructive lung

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23
Q

Alveolar hyperventilation

A

reflex stimulation or irritant receptors

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24
Q

Increased airway resistance

A

Bronchoconstriction

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25
Q

Decreased pulmonary compliance

A

Lung edema, lung hemorrhage or loss of surfactant

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26
Q

CXR of PE

A

Hampton’s Hump

Peripheral wedge-shaped opacification abutting the pleura. SIgnifying pulmonary infarction distal to a pulmonary embolism

Westermark’s sign
-dilatation of pulmonary vessels proximal to embolism along with collapse of distal with a sharp cut-off

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27
Q

Ventilation Perfusion Scans

A

useful if Normal

28
Q

Angiogram of PE

A

Pulmonary angiography is the gold standard

29
Q

CT angiography

A

detect alternative pulmonary abnormalities that may explain the patient’s symptoms and signs

30
Q

Pulmonary Embolism ECG and ABG

A

ECG rules out other inflammatory lefe threathening conditions

Tachycardia, ST depression most common

ABG findings most commonly show hypoxemia and hypocapnia

15-25% have PO2 >80mmHg

31
Q

D-dimers

A

Level <500 mg/L rules out PE

32
Q

Physiologic Effects of Pulmonary Embolism

A

Hypoxemia

- INcreased blood flow through regions of physiologic shunt or poor V/Q matching

33
Q

Landmark study in the clinical probability of venous thromboembolism occuring

A

PIOPED study

34
Q

V/Q scan

A

IV push of radioisotope-tagged albumin and radio-labeled gas in inhaled

Gamma radiation produced by radioisotopes show distribution of blood flow and ventilation

35
Q

Pulmonary Embolism Management

A

Use Knee-high 30-400 mm elastic stocking on affected legs

Prevents further clot formation and clot being brought further into the system

36
Q

Pulmonary Embolism and DVT management

A

Continue injected anticoagulant and hospitalization until patient is saafely assured

37
Q

Prophylaxis of DVT

A

Heparin or fondaparinux is most commonly used

38
Q

What type of heparin is used?

A

unfractionated

39
Q

Management DVT

A

Heparin

Thrombolytic Agents

40
Q

Management of PE

A

Preserving oxygenation and circulation are paramount. If circulation is impaired, consider clot lysis, drug or mechanical

Similar regimen to DVT
-first line heparin followed by oral coumarin

41
Q

Supportive measures include:

A

Oxygen therapy
Analgesia
Hypotension and shock are treated with vasopressors and fluids

42
Q

If patients are stable within 3 days of PE

A

they can be safely transferred out, as long as the condition that led to clot formation has been resolved

43
Q

Mean pulmonary artery pressure >25 mmHg at rest or MPAP >30mmHg with exercise, with increased pulmonary vascular resistance and normal left ventricular function

A

Pulmonary arterial hypertension

44
Q

Associated with congenital heart disease, collagen vascular disease, liver cirrhosis

A

Pulmonary Hyertension

45
Q

Increased BP in the pulmonary arteries

A

PAH

46
Q

Increased BP in the pulmonary veins

A

PVH

47
Q

A blood clot breaks off from a deep vein

A

PE

48
Q

A progressive disorder, primarly affects small pulmonary arterioles, Proliferation and remodeling of endothelial and smooth muscle cells

A

PAH

mPAP >25 mmHg
mPAP >30 mmHg

49
Q

Devolopment of IPAH

A

Genetic Predisposition probably required

Follows insult to arterial endothelium

Damage results in vasoconstriction

Maybe caused by abnormal transport of potassium and calcium

50
Q

Clinical Features of PAH

A

Dyspnea (60%)
Angina (50%)
Syncope (8%)
Others: Cough, hemoptysis, hoarseness and reynaud’s phenomenon

51
Q

Management of PAH

A

Supplemental Oxygen (SaO2>90%)

52
Q

Anticoagulation with coumadin

A

Adjust to keep INR-2

53
Q

Vasodilators (Ca Channel Blockers)

A

May usedigoxin and diuretics to manage side effects

NO is preferred

Very short half life
Does not affect CO
Enhances V/Q mismatching

54
Q

Pulmonary Hypertension COPD

A

Alveolar hypoxia causes vasoconstriction and eventually medial hypertrophy, fibrosis and lumen narrowing

Leads to HPN

Severity of COPD with severity of HPN

55
Q

Symptoms of PAH

A

Slowly progressive shortness of breath

As the condition worsens, chest pain or fainting (syncope) with exertion can occur

56
Q

Pulmonary Venous Hypertension

A

Shortens of breath, due to the CHF - shortness of breath may be worse while lying flat, when BP is uncontrolled, or when extra fluid is present

57
Q

Clinical Classification of Pulmonay Hypertension

A

Group 1: Pulmonary arterial hypertension

Group 2: Pulmonary hypertension due to left heart disease

Group 3: Pulmonary hypertension due to lung disease and/or hypoxia

Group 4:
Chronic thromboembolic pulmonary hypertension (CTEPH)

Group 5: Pulmonary hypertension with unclear multifactorial mechanism

58
Q

hypertrophy of the RV resulting from diseases affecting the function and or structure of the lung, except when these pulmonary alterations are the result of diseaealterations are the result of disease that primarily affect the left side of the heart or congenital heart disease

A

COR PULMONALE

59
Q

Etiologies of PAH

A

Lungs and Airways

Vascular Occlusion

Abnormal Respiratory Control

60
Q

Etiology of Cor pulmonale (Thoracic Cage)

A

Kyphosis >180 degrees

Scoliosis >120 degrees

Thoracoplasty

Pleural fibrosis

61
Q

Pathologic features of Cor Pulmonale

A

Lung: consistent with specific diseases

Common feature: Microvascular hypertrophy

Hallmark: RVH

  • 60-200 g>0.5 cm
  • RV/LV <2.5

LVH
Carotid body hypertrophy

62
Q

Diagnostic Tests for Cor Pulmonale

A

CXR: depends on underlying lung condition but usually shows enlarged main PA segment (>16mm)

ECG: P pulmonale (peaked p wave), RA enlargement, RVH

Doppler Echocardiography: RVH, poor RV contactility with low EF, evidences of moderate to severe PH

63
Q

Cor Pulmonale: Differential Diagnosis

A

Cor pulmonale from primary underlying lung disease such as COPD, Sleep disordered breathing

vs

Cardiac Diseases such as RHD with MS, COngenital Heart disease with systemic-pulmonary shunt

64
Q

Therapeutic Strategies for Cor Pulmonale

A

Diet and lifestyle

Interventions

65
Q

Interventions in cor pulmonale

A

Treat underlying cause

Continuous oxygen 2-3L/mn

Diuretics

Phlebotomy

Digoxin

Pulmonary vasodilators

beta adrenergic agents

Reduce ventilation/perfusion imbalance

OS 213 Respiratory Exam 2 (15 decks)

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