8 - Pulmonary Vascular Disease

normal range for pulmonary artery systolic pressure (PASP)

15-30 mmHg

normal range for pulmonary artery diastolic pressure (PADP)

4-12 mmHg

normal range for mean pulmonary artery pressure (MPAP)

9-16 mmHg

normal range for central venous pressure (CVP)

0-8 mmHg

pulmonary hypertension (PHTN)

increase in pulmonary blood pressure (MPAP > 25 mmHg)

causes of PHTN

• disorders of pulmonary artery vessels

• idiopathic

• familial

• connective tissue disease

• lupus

• HIV

• drugs

causes of PHTN

• disorders of pulmonary venous vessels

• left heart failure

• valvular disease

causes of PHTN

• disorders of hypoxemia

• COPD

• ILD

• hypoventilation

• sleep apnea

causes of PHTN

• disorders of pulmonary vessel obstruction

• thrombus/embolus

• tumors

• foreign material

• chronic lung disease

• MV

5-year survival rate of idiopathic PHTN

34%

complications of prolonged PHTN

• remodeling (fibrosis)

• cor pulmonale

manifestations of PHTN

• chest pain

• Reynaud’s

• orthopnea

• syncope

• change in heart sounds

• hypoxemia

• ECG changes

• large pulmonary artery

diagnosis of PHTN

• right heart catheterization (gold standard)

  • MPAP > 20 mmHg

• echocardiography

  • not reliable in mild to moderate cases

treatment of PHTN

• nitric oxide (NO)

  • riociguat (Adempas) (NO receptor agonist)

• calcium channel blockers

• anticoagulants

  • warfarin (INR 1.5-2.5)

• prostaglandin

  • epoprostenol (Flolan, Veletri)

  • treprostinil (Remodulin)

• endothelin receptor antagonist

  • bosentran (Tracleer)

• treat cor pulmonale

  • treat underlying cause

  • O₂

  • vasodilators (sildenafil)

pulmonary edema

excessive fluid from vascular bed → extracellular space and alveoli

• swelling of alveolar walls and interstitial spaces

sputum of pulmonary edema

frothy pink/white

types of pulmonary edema

• cardiogenic  (left heart failure)

• non-cardiogenic

  • ↑ capillary permeability

  • lymph insufficiency

  • ↓ intrapleural pressure

  • ↓ oncotic pressure

cardiogenic pulmonary edema

• CHF

typical demographics

• 65+ y.o., African-American

left ventricular failure

• transudate

• imbalance of oncotic and hydrostatic pressures

cardiogenic pulmonary edema

• manifestations

• anxiety

• delirium

• orthopnea

• paroxysmal nocturnal dyspnea

• cough

• fremitus

• fatigue

• crackles

• wheezing

• sweating

• cyanosis of digits

• peripheral pallor

cardiogenic pulmonary edema

• other causes

• dysrhythmias

• HTN

• CHD

• excessive fluid intake

• mitral/aortic valve disease

• cardiac tamponade

• pulmonary embolus

• renal failure

• rheumatic heart disease

• cardiomyopathy

non-cardiogenic pulmonary edema

• causes

• hypoxia

• ARDS

• inhaled toxins

• pneumonia

• thoracic radiation

• acute head injury

decreased oncotic pressure (rare)

• rapid fluid administration

• uremia

• hypoproteinemia

• acute nephritis

clinical findings for pulmonary edema

• electrolytes

low sodium, chloride, and potassium

clinical findings for pulmonary edema

• hemodynamics

increased:

• CVP (right atrium)

• PAP

• vascular resistance

• PCWP (left atrium)

decreased:

• cardiac output (C.O.)

medication to treat pulmonary edema

• antiarrhythmics

  • β blockers

  • calcium channel blockers

  • amiodarone

• positive inotropes

  • digitalis

  • dopamine

  • dobutamine

  • epinephrine

• vasodilators

  • nitroglycerin

  • nitropresside

  • α blockers

  • ACE inhibitors

• diuretics

• meds that increase oncotic pressure

  • albumin

  • mannitol

RT protocols for pulmonary edema

• O₂

• bronchial hygiene

• lung expansion (CPAP)

• meds: bronchodilators, alcohol (lowers surface tension; rarely used)

pulmonary embolus (PE)

blockage of pulmonary blood flow due to a blood clot or other material

pulmonary embolus (PE)

• pathophysiology

• blockage of blood flow

• infarction

• atelectasis

• consolidation

• bronchospasm

pulmonary embolus (PE)

• manifestations

• dyspnea

• pleuritic chest pain

• hemoptysis

• syncope

pulmonary embolus (PE)

• causes

• DVT

• fat

• air

• amniotic fluid

• bone marrow

• tumor

pulmonary embolus (PE)

• risks

• recent surgery

• immobility

• prior DVT/PE

• acute illness

• malignancy

• pregnancy/post-partum

• hypercoagulation

pulmonary embolus (PE)

• diagnosis

• CXR: usually normal

• CT angiography: 1st line

• ECG: ST/T wave changes

• V/Q scan: reliable in extreme cases

• pulmonary angiogram

DVT tests

• D-dimer

• venous ultrasound

• venography

• MRI

• MRA

• clot abnormalities

pulmonary embolus (PE)

• clinical findings: physical exam

• unexplained dyspnea

• tachycardia

• hypotension

• cyanosis

• hemoptysis

• peripheral edema

• JVD

• diminished chest expansion

• change in LOC

• abnormal heart sounds

• petechiae

• crackles

• wheezing

• pleural friction rub

pulmonary embolus (PE)

• clinical findings: ABGs

early

• hyperventilation with hypoxemia

late

• hypoventilation with hypoxemia

pulmonary embolus (PE)

• clinical findings: hemodynamics

increased

• CVP

• PAP

• PVP

decreased

• C.O.

• SVR

pulmonary embolus (PE)

• clinical findings: radiology

• infarct

• hyper-lucency

• pulmonary artery dilation

• cor pulmonale

• pleural effusion

pulmonary embolus (PE)

• management

• treat symptoms

• anticoagulants

  • fast-acting: heparin

  • long-acting: warfarin

• thrombolytics

  • streptokinase

  • alteplase

• inferior vena cava filter

• pneumatic compression

• embolectomy