Test 4 - Ch. 20. Pulmonary Edema Flashcards
Question from back of the book:
Which of the following is an afterload reducer?
Nitroprusside
Question from back of the book:
What is the normal hydrostatic pressure in the pulmonary capillaries?
10 to 15 mm Hg
Question from back of the book:
What is the normal oncotic pressure of the blood?
25-30 mm Hg
Question from back of the book:
The left ventricular ejection:
- Correlates well with the brain natriuretic peptide values
- Provides a noninvasive measurement of cardiac contractility
Question from back of the book:
Which of the following are causes of cardiogenic pulmonary edema?
- Excessive fluid administration
- Mitral valve disease
- Pulmonary embolus
Question from back of the book:
As a result of pulmonary edema, the patient’s:
RV is decreased
Kerley B lines are suggestive of what?
Congestive Heart Failure - CHF
Pulmonary edema results from _______________.
Excessive movement of fluid from the pulmonary vascular system to the extravascular system and air spaces of the lungs.
As a result of the fluid movement, what happens to the alveolar walls and interstitial spaces?
They swell, as the swelling intensifies, the alveolar space tension increases and causes alveolar shrinkage and atelectasis.
The abundance of fluid in the interstitial spaces causes _____________________.
The lymphatic vessels to widen and the lymph flow to increase.
Pulmonary edema produces what type of pulmonary disorder?
Restrictive
What are the major pathologic or structural changes of the lungs associated with pulmonary edema?
- Interstitial edema
- Alveolar flooding
- Increased surface tension of alveolar fluids
- Alveolar shrinkage and atelectasis
- Frothy white (or pink) secretions throughout the tracheobronchial tree
The causes of pulmonary edema can be divided into what two major categories?
- Cardiogenic
- Noncardiogenic
According to the American Heart Association (AHA) 2018 Heart Disease and Stroke Statistic Update, what remains the no. 1 cause of death in the US?
Heart disease
Coronary heart disease accounts for ________ deaths in the US, killing over 366,800 people a year.
1 in 7
What is the overall prevalence for a myocardial infarction in the US in adults?
7.9 million, or 3%
In 2015, heart attacks claimed _______ lives in the US.
114,023
What is the estimated annual incidence of heart attacks in the US?
720,000 new attacks and 335,000 recurrent attacks
What is the average age of the first heart attack of a male and female?
Male: 65.6
Female: 72.0
Approximately every _______, an American will have a heart attack.
40 seconds
What was the estimated direct and indirect cost of heart disease in 2013 to 2014?
204.8 billion
What were the two out of ten most expensive conditions treated in the US hospitals in 2013?
- Heart attacks (12 billion)
- Coronary Heart Disease (9.0 billion)
Between 2013 and 2023, medical costs of coronary heart disease are projected to increase by ___________.
About 100%
Cardiac pulmonary edema occurs when _______________________.
The left ventricle is unable to pump out a sufficient amount of blood during each ventricular contraction.
The ability of the left ventricle to pump blood can be determined by the means of the _____________.
Left Ventricular Ejection Fraction (LVEF), with a noninvasive cardiac imaging procedure echocardiogram that reflects the patient’s left ventricular systolic contractility.
Poor ventricular function can also be caused by _________________.
- Increased ventricular stiffness
- Impaired myocardial relaxation
Called diastolic dysfunction and is associated with a relatively normal LVEF
Normal values for the LVEF range between __________.
55-70%
An LVEF less than _____% may confirm heart failure.
40
An LVEF less than ____% is life-threatening and cardiac arrhythmias are likely.
35
When the patient’s LVEF is low, the blood pressure inside the pulmonary veins and capillaries __________ as a result.
Increases or decreases?
Increases
This action causes fluid to be pushed through the capillary walls and into the alveoli in the form of a transudate.
Ordinarily, hydrostatic pressure of about ________ tends to move fluid out of the pulmonary capillaries into the interstitial space.
10-15 mm Hg
Ordinarily, hydrostatic pressure tends to move fluid out of the pulmonary capillaries into the interstitial space. This force is normally offset by colloid osmotic forces of about __________.
25-30 mm Hg
The colloid pressure is referred to as __________.
Oncotic pressure
What is oncotic pressure produced by?
Albumin and globulin in the blood.
The stability of fluid within the pulmonary capillaries is determined by what?
The balance between hydrostatic and oncotic pressures.
Movement of fluid in and of the capillaries is expressed by the _______________.
Starling equation
Of the four pressures, which are the only two that can be measured without any certainty?
Oncotic and hydrostatic pressures of the blood in the pulmonary capillaries
The oncotic and hydrostatic pressures within the ___________ cannot be readily determined.
Interstitial compartments
What happens when the hydrostatic pressure within the pulmonary capillaries rises to more than 25-30 mm Hg?
The oncotic pressure loses its holding force over the fluid within the vessels. Consequently, fluid starts to spill into the interstitial spaces and alveoli of the lungs.
Clinically, the patient with left ventricular failure often has what?
- Activity intolerance
- Weight gain
- Anxiety
- Delirium
- Dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Cough
- Fatigue
- Cardiac arrythmias (A-fib)
- Adventitious breath sounds
Because of poor circulation patients with left ventricular failure often has:
- Cool skin
- Diaphoresis
- Cyanosis of the digits
- Peripheral pallor
Major organ failure of the brain and kidney may be the result of ___________.
Hypoperfusion
What is the most common cause of pulmonary edema?
Increased pulmonary capillary hydrostatic pressure
State some common causes of cardiogenic pulmonary edema.
- Arrythmias (PVCs or bradycardia producing low cardiac output)
- Systemic hypertension
- Congenital heart defects
- Coronary heart disease
- Excessive fluid administration
- Left ventricular failure
- Mitral or aortic valve disease
- Myocardial infarction
- Cardiac tamponade
- Pulmonary embolus
- Renal failure
- Rheumatic heart disease
- Cardiomyopathies
What are some risk factors for coronary heart disease?
Pg. 313 (List isn’t finished)
- Age
- Males older than 45
- Females older than 55
- Family history of CHD
- Male relative with CHD: Younger than 55 years old
- Female relative with CHD: Younger than 65 years old
- Obesity
- Cigarette smoking
- Hypertension: Blood pressure >140/90 mm Hg or on antihypertensive agents
- High level of low-density-lipoprotein cholesterol
Noncardiogenic pulmonary edema is less common and develops as a results of what?
Left off at bottom of pg. 313
Damage to the lungs!
Describe noncardiogenic pulmonary edema.
Lung tissues become inflated and swollen and fluid can readily leak from the pulmonary capillaries into the alveoli.
What are some common causes of noncardiogenic pulmonary edema?
- Increased capillary permeability
- Lymphatic insufficiency
- Decreased intrapleural pressure
- High altitude pulmonary edema
- Decreased oncotic pressure
Pulmonary edema may develop as a result of increased capillary permeability stemming from ________________.
Infectious, inflammatory and other processes.
Other causes include:
- Alveolar hypoxia (E.g high altitude)
- ARDS
- Inhalation of toxic agents like chlorine, sulfur dioxide, nitrogen dioxides, ammonia and phosgene
- Pulmonary infections (certain pneumonias)
- Therapeutic radiation of the lungs
- Acute head injury (also known as cephalogenic pulmonary edema)
What happens should the normal lymphatic drainage of the lungs be decreased?
Intravascular and extravascular fluid begins to pool and pulmonary edema ensues.
Lymphatic drainage may be slowed because of _______________.
Obliteration or distortion of lymphatic vessels.
The lymphatic vessels may be obstructed by tumor cells in ________________.
Lymphangitic carcinomatosis
Why may increased systemic venous pressure slow lymphatic drainage?
Because lymphatic vessels empty into the systemic veins
Lymphatic insufficiency has also been observed after ___________.
Lung transplantation
The sudden removal of a pleural effusion can cause what type of edema?
Decompression pulmonary edema
High-altitude pulmonary edema (HADE) can occur in people who exercise at altitudes about ___________ without having first acclimated to the high altitude.
8000 ft.
Often affects recreational hikers and skiers.
Decreased oncotic pressure may be caused by what?
- Overtransfusion and/or rapid transfusion of hypotonic or normotonic intravenous fluids.
- Uremia
- Hypoproteinemia (E.g severe malnutrition)
- Acute nephritis
- Polyarteritis nodosa
Other causes of noncardiogenic pulmonary edema:
- Allergic reaction to drugs
- Excessive sodium consumption
- Drug overdose
- Metal poisoning
- Chronic alcohol ingestion
- Aspiration (E.g near drowning)
- CNS stimulation
- Encephalitis
- High altitudes (Greater than 8,000-10,000 ft)
- Pulmonary embolism
- Eclampsia
- Transfusion-related acute lung injury
The treatment of pulmonary edema is based on ______________.
The cause and severity.
The treatment of noncardiogenic pulmonary edema is largely supportive and aimed at ________________.
Ensuring adequate ventilation and oxygenation.
For cardiogenic pulmonary edema, what is the initial management?
- Directed at the use of digitalis
- Supplemental oxygen
- Assisted ventilation if necessary
- Loop diuretics for volume overload
The therapeutic intervention to address the patient’s circulatory system has what following three main goals?
- Reduction of pulmonary venous return (preload reduction)
- Reduction of systemic vascular resistance (afterload reduction)
- Inotropic support (treatment of reduced cardiac contractility)
Reduction of the preload increases/decreases pulmonary capillary hydrostatic pressure and reduces fluid transudation in the pulmonary interstitium and alveoli.
Increases
Inotropic agents are used to treat what?
Hypotension or signs of organ hypoperfusion
Reduction of afterload increases ________ and improves renal perfusion, which in turn allows for diuresis in the patient with fluid overload.
Cardiac output
What are some preload reducers?
- Nitroglycerin (Nitro-bid, Minitran, Nitrostat)
- Loop diuretics (e.g furosemide)
- Morphine sulfate
What are some afterload reducers?
- Captopril
- Enalapril
- Nitroprusside
A competitive angiotension-converting enzyme (ACE inhibitor and reduces angiotension II levels.
Enalapril (Vasotec)
Which drugs prevents the conversion angiotensin I and angiotensin II and is a potent vasodilator?
Captopril
With Captopril, afterload and cardiac output usually improve in _______________.
10 to 15 minutes
What is this drug?
A potent, direct smooth-muscle relaxing agent that primarily reduces afterload. It may also mildly reduce preload.
Nitroprusside (Nitropress)
Name some positive inotropic agents.
- Dobutamine
- Dopamine
- Norepinephrine
- Milrinone
A natural occuring catecholamine with potent alpha-receptor and mild beat-receptor activity. It stimulates beta1-adrenergic and alpha-adrenergic receptor, increasing myocardial contractility, heart rate, and vasoconstriction.
Norepinephrine
______________ is a naturally occurring catecholamine that acts as a precursor to norepinephrine.
Dopamine
What is considered a cornerstone in the treatment of cardiogenic pulmonary edema?
Loop diuretics (E.g furosemide)
A very effective, predictable and rapid-acting medication for preload.
Nitroglycerin (Nitro-bid, Minitran, Nitrostat)
_______________ are presumed to decreased preload through diuresis and direct vasodilation.
Loop diuretics (E.g furosemide)
Name this medication.
A synthetic catecholamine that mainly has beta1-receptor activity but also has some beta2-receptor and alpha-receptor activity. Commonly used for patients with mild hypotension.
Dobutamine
List the physical examination associated with pulmonary edema.
- Tachypnea
- Hypertension
- Tachyacardia
Cheyne-Stokes breathing may be seen in what type of pulmonary edema patients?
Patients with severe left-sided heart failure and pulmonary edema.
A patient is said to have ______ when dyspnea increases while the patient is lying in a recumbent position.
Orthopnea
What is the physical examination of a patient with pulmonary edema?
- Increased RR
- Increased HR and BP
- Cheyne-Stokes Respirations
- Paroxysmal Nocturnal Breathing
- Orthopnea
- Cyanosis
- Cough and Sputum (Frothy & Pink)
- Increased tactile and vocal fremitus
- Crackles and wheezing
What are some radiological findings associated with pulmonary edema?
- Kerley A & B lines
- “Bat wing” or “butterfly” pattern
- Left ventricular hypertrophy
- Dilated pulmonary arteries
- Transudate pleural effusion
- Bilateral fluffy opacities with a predominant central position in the chest
BNP levels below 100 mg/mL indicate _______________.
No heart failure
BNP levels of 100 to 300 mg/mL indicate _______________.
Heart failure may be present
BNP levels above 300 mg/mL indicate _______________.
Mild heart failure
BNP levels above 600 mg/mL indicate _______________.
Moderate heart failure
BNP levels above 900 mg/mL indicate _______________.
Severe heart failure
Norepinephrine is usually reserved for patients with ___________.
Severe hypotension (Systolic BP less than 70 mm Hg)
Examples of antidysrhythmic agents.
- Digitalis
- Procainamide
- Metoprolol
What is sometimes administered to increase the patient’s oncotic pressure in an effort to offset increased hydrostatic forces of cardiogenic edema, if the patient’s osmotic pressure is extremely low?
Albumin
What are some abnormal tests and procedures of pulmonary edema?
- Low serum potassium
- Low serum sodium
- Low serum chloride
What are the preload reducers?
- Nitroglycerin
- Loop diuretics (Furosemide)
- Morphine sulfate
What are the afterload reducers?
- Captopril
- Enalapril (Vasotec)
- Nitropurusside
