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foundations pulm exam > pulmonary vasculature > Flashcards

pulmonary vasculature Flashcards

1
Q

what MAP classifies pulmonary HTN?

A

> 25mm Hg at rest

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2
Q

differentiate primary pulmonary HTN from secondary pulmonary HTN

A

primary: 30-40 y/os, familial, unknown etiology
secondary: RHF from COPD, PE, sickle cell, HIV, cirrhosis, portal hypertension, appetite suppressive medication

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3
Q

what are drugs and toxins that could cause pulmonary arterial hypertension (Group 1)?

A

appetite suppressants, rapeseed oil and benfluorex (definite)
amphetamines
cocaine
SSRIs

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4
Q

what are causes of pulmonary venous hypertension (Group 2)

A

left heart disease
LV systolic/diastolic dysfunction
valvular heart disease

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5
Q

What is the most common cause of group 3 pulmonary hypertension?

A

COPD (lung disease or hypoxemia)

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6
Q

what is the most common cause of group 4 pulmonary HTN?

A

chronic thromboembolism

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7
Q

what are the causes of group 5 pulmonary arterial HTN?

A

hematologic
metabolic
systemic (sarcoidosis)
miscellaneous (tumor embolization, ESRD on HD)

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8
Q

what are the classes of pulmonary HTN per NYHA based on symptoms and functional status?

A 
class I: no limitation of physical activity, no symptoms
class II: pulm HTN slight limitation and ordinary physical activity causes dyspnea, fatigue, chest pain, or near syncope
class III: pulm HTN marked limitation of physical activity and no symptoms at rest but less than ordinary activity
class IV: pulm HTN with inability to perform physical activity, evidence of RHF, dyspnea and fatigue at rest
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9
Q

what is the number one sign and symptom of pulm HTN?

A

exertional dyspnea

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10
Q

what is a classic sign after exertion or warm shower with pulmonary HTN?

A

syncope

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11
Q

what may you see on physical exam for pulm HTN?

A 
JVD
paradoxical split of S2
loud P2 of S2
right-sided third heart sound
tricuspid regurgitation murmur (holosystolic) heard along the LSB
hepatomegaly
ascites
abdominal distension
lower extremity edema
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12
Q

what is carvallo’s sign?

A

a louder murmur heard from inspiration with tricuspid regurgitation

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13
Q

what sign occurs from shunting?

A

cyanosis from right-to-left shunt due to increased right atrial pressure

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14
Q

what would you see on EKG with pulm HTN?

A

typically normal

may see peaked P wave in the inferior and right-sided leads

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15
Q

what might you see on the ABGs for pulm HTN?

A

low PaO2 and SaO2

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16
Q

what is the gold standard for diagnosing pulm HTN?

A

right-sided cardiac catheterization

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17
Q

what is the transpulmonary gradient

A

drop in pressure across the pulmonary circulation which can be assessed by cardiac catheterization in order to differentiate arterial hypertension from venous hypertension

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18
Q

what is considered a significant acute vasodilator response with right heart cath?

A

drop in MAP of greater than 10 mm Hg (or 20%) to less than 40 mm Hg

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19
Q

what findings on PFTs is suggestive of pathologically increased pulmonary arterial pressure?

A

decreased single-breath diffusing capacity
normal FVC on spirometry
normal TLC on lung volume measurement
increased wasted ventilation on cardiopulmonary exercise

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20
Q

what diagnostic test would be used for group 4 pulmonary HTN?

A

pulmonary angiography - most definitive diagnostic procedure for defining the distribution and extent of disease in chronic thromboembolic pulmonary HTN

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21
Q

how would you treat group 1 PAH?

A

treat underlying cause
no primary therapies available
could try diltiazem or nifedipine, but only give to pts with positive acute vasodilator response

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22
Q

what are you treating in group 2 PVH?

A

treat left heart failure

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23
Q

how are you treating in group 3 PH?

A

supplemental O2 for 15 hours or more per day

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24
Q

how do you treat group 4 PH?

A 
anticoagulation
thromboendarterectomy recommended if surgically accessible for pts with class IV and have no response to other therapies
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25
Q

how do you treat group 5 PH?

A

treat underlying etiology

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26
Q

if pt is class I with PH, and no acute vasodilator response, how do you treat?

A

observation

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27
Q

if pt is class II with PH, and no acute vasodilator response, how do you treat?

A

ambrisentan plus tadalafil

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28
Q

if pt is class III with PH, and no acute vasodilator response, how do you treat?

A

ambrisentan plus tadalafil

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29
Q

if pt is class IV with PH, and no acute vasodilator response, how do you treat?

A

epoprostenol IV

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30
Q

what are examples of PDE5 inhibitors?

A

sildenafil and tadalafil

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31
Q

what is a C/I to PDE-5 inhibitors?

A

concomitant use of PDE-5 inhibitors with any drug serving as a NO donor, which can lead to significant arterial hypotension

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32
Q

what are examples of ERAs? (endothelin receptor antagonists)

A

ambrisentan (selective ETa receptor antagonist)

bosentan (dual endothelin receptor antagonist)

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33
Q

what are examples of prostacyclins?

A

epoprostenol

treprostinil

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34
Q

never stop _______ in chronic patients suddenly

A

prostacyclins

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35
Q

what medications are used in treating the symptoms of pulmonary HTN?

A

furosemide for swelling
warfarin (ASA in children) for preventing blood clots in lungs
O2
exercise

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36
Q

Cor pulmonale is most commonly caused by?

A

COPD

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37
Q

define pneumoconiosis

A

general term given to any lung disease caused by inhaled dust deposited deep in the lungs

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38
Q

Severe lung disease can be a cause of ______

A

low cardiac output

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39
Q

RV volume and function differed depending on the degree of ______ present in pts with COPD

A

emphysema

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40
Q

what are symptoms of cor pulmonale?

A 
chest pain
exertional dyspnea
wheezing
cough
palpitations
fatigue
syncope or pre-syncope
dependent edema
*no symptom is 100% specific
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41
Q

what are signs of cor pulmonale?

A 
cyanosis
clubbing
JVD
tricuspid regurg
RV heave and/or gallop
RUQ pain
ascites
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42
Q

give details of cardiac chest pain

A

accompanied by a sense of anxiety or uneasiness
retrosternal or left precordial
pressure to the throat, lower jaw, shoulders, inner arms, upper abdomen or back
feeling of impending doom
nausea
diaphoresis

43
Q

what does the HEART score stand for and what is its purpose?

A 
History
EKG
Age
Risk factors
Troponin
*helps distinguish coronary chest pain in ED from non-coronary causes
44
Q

what will you see in vitals with cor pulmonale?

A

SpO2 decreased

may see elevated CVP

45
Q

what labs will you see in cor pulmonale?

A

polycythemia (CBC)

hypoxemia +/- hypercarbia (ABG)

46
Q

oximeter monitors __________ and not oxygen tension

A

hemoglobin saturation

47
Q

what will you see on the CXR for cor pulmonale?

A

pulmonary artery enlarged

right atrium dilated

48
Q

what do you see in right heart cath for cor pulmonale?

A

increased pulmonary artery pressure

increased vascular resistance

49
Q

what are the treatments for cor pulmonale?

A 
CPAP for sleep apnea
anticoagulation for blood clots
long-term O2 for hypoxic COPD pts
diuretics for RV volume overload
CCBs, prostacyclin analogues and ERAs for PAH
50
Q

what is the most common EKG finding for PE?

A

sinus tachycardia

51
Q

differentiate DVT vs PE

A

DVT is a blood clot in a deep vein

PE is an obstruction of the pulmonary artery or one of its branches by material that originated elsewhere in the body

52
Q

what does virchow’s triad consist of?

A

vessel wall injury
venous stasis
hypercoagulability

53
Q

what is the most common risk factor for VTE (venous thromboemoblisms)

A 
recent surgery (within last 3 months) due to virchow's triad
hip fracture repair most common
54
Q

what are the two most common hypercoagulable states with VTEs?

A

factor V leiden mutation

prothrombin gene mutation

55
Q

the use of _____ or _____ increases your risk for VTEs

A

oral contraceptives or hormone replacement therapy

56
Q

what are other risk factors for VTEs?

A 
antithrombin III deficiency
catheters
CHF
COPD
drug-induced lupus anticoagulant
immobilization
postpartum period
pregnancy
protein C/S deficiency
trauma
venous stasis
warfarin
57
Q

what may you see on physical exam for DVT?

A

swollen, discolored UE/LE
tenderness to palpation
superficial venous dilation
positive homan’s sign (calf tenderness with dorsiflexion of foot)

58
Q

what are complications of DVT?

A

PE

post-thrombophlebitic syndrome

59
Q

what risk factor is commonly associated with UE DVT?

A

catheter placement

60
Q

what is the purpose of Wells criteria and what do different scores mean?

A

tells you the probability of having a DVT
0 or less = low
1-2 moderate
3 or more = high

61
Q

what is a highly sensitive test for DVT diagnosing?

A

D-dimer

62
Q

what are causes of elevated D-dimer?

A 
DVT
PE
post-operative state
malignancy
pregnancy
63
Q

what is the test of choice in imaging for DVTs?

A

compression ultrasonography (US)

64
Q

what is the most common cause of PE?

A

DVT

65
Q

what are the three PE classifications for hemodynamic effect?

A

massive PE (SBP <90 or drop in SBP > 40 from baseline for a period > 15 min; go into obstructive shock)
submassive PE
nonmassive

66
Q

what are the major S&S of PE?

A

SOB or DOE
plueritic pain
tachypnea

67
Q

Wells criteria better for PE or DVT?

A

PE

use US for DVT

68
Q

list the Wells criteria

A 
clinical symptoms of DVT
other dx less likely than PE
HR > 100
immobilization >3 days or previous sx in past 4 weeks
previous VTE
hemoptysis
malignancy
69
Q

how to treat a stable vs unstable pt with PE?

A

stable - proceed with further diagnostic work-up

unstable - oxygen, IV fluids, BP support, ICU, consider thrombolytics

70
Q

what labs do you get for PE?

A 
same as DVT
CBC/BMP
PT/INR
aPPT
D-dimer
71
Q

what cardiac biomarker may be increased in pt with PE?

A

troponin

72
Q

what are most common EKG findings with PE?

A

sinus tachycardia

non-specific T wave changes

73
Q

what is the “classic” EKG with PE?

A

S1Q3T3

74
Q

US and CXR are _____ for PE

A

non-diagnostic

75
Q

define Hampton’s Hump

A

CXR finding specific to PE

pleura-based shallow wedge-shaped consolidation in the lung periphery with the base against the pleural surface

76
Q

define Pulmonary Wedge Sign

A

10% of PE cause pulmonary infarction, resulting in wedge sign

77
Q

what is a positive V/Q Scan?

A

scan is + if there is 1 or more “mismatch”

78
Q

what is the most common way to diagnose PE?

A

CTA - diagnostic when intraluminal pulmonary arterial filling defect is surrounded by contrast

79
Q

what is the gold standard for diagnosing PE?

A

angiogram - reserved for pts who have had non-diagnostic tests for PE and treatment with anticoagulants is controversial

80
Q

what may you find on an echo with PE?

A

RV dilatation, hypokinesis or failure
increased RV pressure
marked tricuspid regurgitation

81
Q

what are the main treatments of VTE?

A

IV/oral anticoagulants

thrombolytics

82
Q

what are the types of anticoagulants?

A 
IV unfractionated heparin
LMWH
fondaparinux
warfarin
NOACs
83
Q

which anticoagulant do you give in initial treatment of VTE?

A

IVUH

84
Q

how do we reverse IVUH?

A

protamine

85
Q

what are we monitoring in IVUH?

A

CBC, aPTT, anti-Xa

86
Q

what is the indication for LMWH (lovenox)?

A

outpatient tx of DVT and stable PE

87
Q

do you monitor LMWH?

A

no

88
Q

what reverses LMWH?

A

protamine

89
Q

which populations is LMWH indicated for?

A

CrCl <30, elderly, obese

90
Q

what is warfarin indicated for?

A

long-term treatment of VTE

91
Q

what do you monitor in warfarin?

A

PT/INR

92
Q

what is the therapeutic INR range?

A

2.0-3.0

93
Q

how to reverse warfarin?

A

vitamin K, fresh frozen plasma

94
Q

pt should remain on heparin a minimum of _____ days or ____ days after their INR is therapeutic

A

5 days

2 days

95
Q

what is the indication for NOACs?

A

DVT/PE and nonvalvular Afib

96
Q

which of the NOACs can do dialyses?

A

dabigatran (pradaxa)

97
Q

how long should the duration of tx be for VTEs?

A

1st VTE if provoked: 3 months
1st idiopathic VTE: 3-6 months
recurrent VTEs: indefinite

98
Q

thrombolytics used for ______ with PE

A 
unstable pts
examples:
massive PE/cardiogenic shock
severe hypoxemia
substantial perfusion deficit on V/Q scan
RV dysfunction
extensive DVT
99
Q

what are examples of thrombolytics?

A

streptokinase
urokinase
r-tPA

100
Q

what are the indications for doing IVC filters?

A

absolute C/I to anticoagulation
recurrent PE despite adequate anticoagulation
complication of anticoagulation
hemodynamic or respiratory compromise

101
Q

what are prophylactic measures against DVTs?

A 
sequential compression devices (SCDs)
TED hose (thromboembolic deterrent)
low dose SQ heparin and lovenox in hospital
102
Q

can a clinically stable pt with DVT or PE be treated as an outpatient?

A

yes, lovenox or NOACs are appropriate for outpt treatment of DVT and stable PE

103
Q

who is responsible for monitoring pt’s anticoagulation?

A

PCP, cardiologist, or anticoagulation clinic

foundations pulm exam (10 decks)

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