Pulmonology

Question 1

Causes of pulmonary thromboembolism?

Answer 1

• Venous thromboembolism (VTE) from suprapopliteal veins femoral veins(Pelvic veins in pregnancy).

• Inherited cause : Factor V Leiden mutation (M/c).

• Acquired causes : Antiphospholipid antibody syndrome (M/c), nephrotic syndrome, post orthopedic surgery, malignancy (Adenocarcinoma), COPD.

Question 2

Massive pulmonary embolism c/f?

Answer 2

Hypotension
RV dilatation leads to septum pushed to left leads to small lv leads to decreased CO

Question 3

Submassive pulmonary embolism clinical features?

Answer 3

No hypotension.

RV dilatation + markers of RV ischemia ↑ (NT proBNP, trop I).

If both markers are ↑ : High risk.

If any one ↑ : Low risk.

Question 4

Non-massive pulmonary embolism features?

Answer 4

No hypotension. No RV dilatation or biomarker rise. Presents with recurrent pneumonia.

Question 5

Symptoms of pulmonary embolism?

Answer 5

• Unexplained dyspnea with clear lung fields.(m/c)
• Chest pain (Pleuritic). (2nd m/c)
• Syncope
• Cough with hemoptysis (Non-massive).
• Sudden cardiac death.

Question 6

Signs of pulmonary embolism?

Answer 6

• Tachycardia, tachypnea.
• S3, ↑ JVP : Acute right heart failure.
• Clear lung fields.
• ↓ breath sounds, rales

Question 7

ABG findings in pulmonary embolism?

Answer 7

Hypoxemia
respiratory alkalosis
widening of (A-a) O 2gradient

Question 8

EKG in pulmonary embolism?

Answer 8

T inversion in V1 to V4 correlates with severity.

S1Q3T3.

Question 9

Findings seen in echo in pulmonary embolism?

Answer 9

• RA & RV dilatation, septal push, small LV.
• Cardiac tamponade.
• Mc Connell’s sign : Hypocontractile RV free wall + hypercontractile apex.

Question 10

Imaging in pulmonary embolism?

Answer 10

IOC -CTPA (CT pulmonary angiography).

• Clot.
• Pulmonary artery dilatation.
• RV dilatation.
• Polo mint sign : Thin rim of contrast persists around a central filling defect d/t thrombus.

Question 11

interpretation of Well’s score?

Answer 11

High risk → CTPA.
Low risk → D-dimer.
Score ≤4 : PE unlikely

Question 12

Well’s score?

Answer 12

Clinical signs of DVT: 3
Alternate diagnosis less likely than pulmonary embolism: 3
Heart rate >100/min: 1.5
Recent surgery or immobilisation: 1.5
Previous pulmonary embolism or DVT: 1.5
Hemoptysis: 1
Malignancy: 1

Question 13

Management of pulmonary embolism?

Answer 13

Start anticoagulation : Unfractionated heparin (80 U/kg) or low molecular weight heparin (1 mg/kg s/c) followed by warfarin to maintain INR of 2-3.
If massive (or) submassive high risk :
• Thrombolysis (Alteplase 100 mg i/v over 2 hours x 14 days).
• If thrombolysis is C/I : Embolectomy.

After thrombolysis → Anticoagulation : Newer oral anticoagulants (NOAC) better than warfarin.

If submassive low risk (or) non-massive : Continue anticoagulation.

If patient is not a candidate for NOAC : IVC filter.

Question 14

Pulmonary hypertension ?

Answer 14

Resting mean pulmonary artery pressure ≥20 mmHg with right sided heart catheterisation.

Question 15

Types of pulmonary hypertension?

Answer 15

A. Due to ↑ pulmonary vascular resistance (PVR)

Type 1: Pulmonary artery hypertension (PAH). Plexiform arteriopathy d/t remodelling/ vasoconstriction/thrombosis.
Type 3: Lung related causes : ILD, c/c bronchitis.
Type 4: C/c thromboembolic pulmonary hypertension.

B. Due to ↑Left atrial pressure (LAP)

Type 2: D/t cardiac causes.

Question 16

PVR wood units in types of pulmonary hypertension?

Answer 16

PVR <3 Wood units in type 2.
PVR >3 Wood units in other types.

Question 17

PAH causes?

Answer 17

Idiopathic : Should be termed idiopathic after ruling out
• Limited systemic sclerosis.
• Toxins : Rapeseed oil.
• Serotonergic substances : Fenfluramine.
• BMPR-2 mutation.
• Infections : HIV, Schistosomiasis
• Portal hypertension.

Question 18

Clinical features of PAH?

Answer 18

Fatigue (M/c symptom).
Breathlessness
Chest pain due to RV ischemia

Question 19

Examination findings of PAH?

Answer 19

• Loud, palpable P2.
• Parasternal heave.
• Epigastric pulsations.
• 2 nd ICS pulsations.
• High pitched pansystolic murmur along left sternal border which ↑ on inspiration 2 0 to PAH : Hypertensive tricuspid regurgitation.
• High pitched early diastolic murmur d/t pulmonary regurgitation or pulmonary artery dilatation : Graham steel murmur.

Question 20

Evaluation of PAH?

Answer 20

1. Echo : Pulmonary artery dilatation, RV function, TR.
2. PFT : FEV1/FVC normal, FVC normal, DLCO ↓.
3. Polysomnography & HRCT : To rule out obstructive sleep apnea syndrome & ILD.
4. V/Q scan : To rule out c/c thromboembolic PAH (Rx : Pulmonary endarterectomy).
5. 6 minute walk test : Predictor of survival.

Question 21

PAH management?

Answer 21

Supportive care :

• Avoid pregnancy.
• Oral anticoagulants.
• Long term oxygen therapy.
• Diuretics for RHF.

Specific therapy :

• CCB.
• Endothelin receptor antagonists (ERA).
• PDE 5 inhibitors.
• Prostanoids.
• Guanylyl cyclase stimulants.