pulmonary circulation Flashcards
(122 cards)
1
Q
routine labs to diagnose Cor Pulmonale
A
CXR
EKG
Echo
2
Q
What is the most accurate way to diagnose Cor pulmonale
A
right heart catheterization
3
Q
how do we identify underlying lung disease of cor pulmonale?
A
spirometry
CT
V/Q scan
4
Q
how do we treat PEs in Cor pulmonale?
A
anticoag
thrombolytics
5
Q
How do we treat COPD in Cor Pulmonale?
A
bronchodilation and management of infxn
6
Q
When do we give oxygen therapy to Cor Pulmonale patients?
A
<88%
7
Q
chance of 5 year survival for COPD patients who develop cor pulmonale?
A
30%
8
Q
how does CF cause an acid-base imbalance?
A
pooling of excessively thick mucus obstructs airways causing hypoventilation.
9
Q
what is the single largest call of bronchiectasis
A
Cystic Fibrosis
10
Q
why might CF cause diarrhea or weight loss?
A
thick secretions in pancreatic duct make it difficult to release digestive enzymes -> poor absorption –> diarrhea (steatorrhea)
11
Q
VTE (venous thromboembolisms) encompass what 2 interrelated conditions?
A
DVTs and PEs
12
Q
where do most PEs occur from?
A
DVts in deep veins of LE
13
Q
what is the most important acute complication of DVT?
A
symptomatic PEs
14
Q
what is the leading cause of preventable in-hospital mortality
A
PEs
15
Q
definition of a thrombus
A
a solid mass composed of platelets and fibrin with a few trapped red and white blood cells that forms within a blood vessel
16
Q
definition of pleural effusion
A
an abnormal colelction of fluid in the pleural space resulting from excess fluid production or decreased absorption
17
Q
most common manifestation of pleural dz
A
pleural effusion
18
Q
Pleural effusions are most caused by
A
CHF (most)
cancer
pneumonia
19
Q
mechanism of pleural effusion
A
Altered permeability of pleural membranes
(Malignancy, PE)
Reduction in intravascular pressure
(Cirrhosis)
Increased capillary hydrostatic pressure
(CHF)
Reduction of pleural space pressure
(Meosthelioma (asbestos exposure))
Decreased lymphatic drainage due to blockage
(malignancy)
20
Q
two types of pleural effusion
A
transudates and exudates
21
Q
what kind of effusion does atelectasis or HF have?
A
transudates
22
Q
extravascular fluid with low protein in Pleural effusions
A
transudates
23
Q
what kind of effusion does Malignancy, pneumonia, PE, TB, pancreatitis have?
A
exudates
24
Q
extravascular fluid due to vessel alteration during inflammation, high protein, in pleural effusions
A
exudates
25
sex ratio in pleural effusion
even
26
who gets systemic lupus more?
women
27
who gets mesothelioma more?
men
28
who gets prancreatitis more?
men
29
who gets malignancies more?
women
30
presentation of pleural effusions
```
dyspnea
cough
chest pain
LE edema, orthopnea, PND
night sweats, fever, hemoptysis, weight loss --> TB
fever, purulent sputum --> pneumonia
```
31
symptoms that make you think effusion due to TB
night sweats
fever
hemoptysis
weight loss
32
symptoms that make you think effusion due to pneumonia
fever
| purulent sputum
33
no physical findings of effusions below this amount
300mL
34
physical findings of effusions?
```
dull to percussion
decreased tactile fremitus
diminished respiratory expansion
tracheal displacement
diminished/inaudible breath sounds
egophony
pleural friction rub
```
35
when does tracheal displacement occur and how?
when there's >1L of liquid in effusion and displaces TOWARDS effusion
36
egophony
"e" to "a"
37
is thoracentesis diagnostic or therapeutic?
both
38
what is CXR best used for?
CHF
39
physical findings on CXR for effusion?
rarely diagnostic
40
what does the fluid look like in an effusion when there's a malignancy?
redish
41
when do you do a needle biopsy with pleural effusions?
when you suspect TB or CA
42
normal amount to drain out of an effusion?
500-1000ml
43
effusion treatment
drainage
manage underlying etiology
pleurodesis
thoracostomy
44
installing an irritant into a space causing inflammation and fibrosis (decreases pleural space and prevents fluid buildup)
pleurodesis
45
what do they use to cause irritation in pleurodesis
talc powder
46
what meds do we use for effusions
antibiotics- infections
vasodilators- decrease preload
diuretics-decrease volume and edema
anticoagulants-PEs
47
most common exudative cause for effusions
parapneumonic
48
embolus definition
as a clot propagates, a piece may dislodge or fragment and embolize to pulmonary artery
49
when does a collapsed lung occur?
when air leaks in the pleural space
50
causes of pneumothorax
```
chest injury
underlying lung dz
ruptured air blebs
mechanical ventilation (PEEP)-too high
spontaneously
```
51
who gets more pneumothoraxes?
men
52
tall young man that comes to the ER with complaint of dyspnea
pneumothorax
53
risk factors for pneumothorax
```
male
smoking
20-40 yo
tall
underweight
genetics
COPD
mechanical ventilation
hx pneumo
```
54
pneumothorax symptoms
```
chest pain (sharp on affected side)
dyspnea (severity based on severity of pneumo)
```
55
complications of penumos
```
recurrence
persistent air leak
hypoxemia
cardiac arrest
respiratory failure
shock
```
56
collapsed lung on CT or CXR
BLACK
57
pneumothorax treatment
observation (most common)
needle or chest tube
surgery
**consult with surgeon
58
where does a small embolism settle?
distal bronchioles
59
where do massive emboli settle?
in the middle of the pulmonary trunk infarcting both lungs! AGH!
60
pathophysiology of VTE
pulmonary artery obstruction --> platelets release serotonin --> increase in pulmonary vascular resistance
61
pathophysiology of VTE
artery obstruction --> redistribution of blood flow --> poor gas exchange
62
increased pulmonary vascular resistance leads to
increased RV afterload and decreased CO which leads to RV failure
63
perfusion without ventilation
shunt
64
results in blood not traveling to the lungs therefore pulmonary blood flow is abnormally reduced and blood not get oxygenated --> cyanosis and hypoxia
right to left shunt
65
VTE risk factors (broad categories)
patient-related
disease states
surgical factors
hematologic d/o
66
patient related VTE risk factors
```
>40 y/o
obesity
varicose veins
OCP / HRT
immobility
long trips
pregnancy
smoking
prior DVT
antipsychotics
central venous line
admission < 6 mo
```
67
disease states VTE risk factors
```
malignancy
CHF
nephrotic syndrome
MI
IBD
spinal cord injury
pelvic, hip, long bone fx
COPD
paralytic stroke
chronic renal dz
```
68
surgical factors for VTE
```
hip surgery
pelvic surgery
CABG
urologic surgery
neurosurgery
```
69
hematologic disorders
```
factor 5 leiden
protein C or S deficiency
antithrombin III deficiency
antiphospholipid Ab
lupus anticoag
P-vera
```
70
3 factors that contribute to thrombosis (virchow's triad)
stasis
vessel wall injury
hypercoagulability
71
venous stasis contributors in virchow's triad
immobility
paralysis
a fib
LV dysfunction
72
vascular injury contributors in virchow's triad
indwelling
catheter
trauma
surgery
73
hypercoagulability contributors in virchow's triad
protein C and S
deficiency
antithrombin deficiency
malignancy
74
DVT symptoms
```
sudden swelling in affected limb
limb pain/tenderness
pain on dorsiflexion
dilated superficial collateral veins
cyanosis or pallor
warm skin over area of thrombosis
lack of distal pulses
```
75
PE symptoms
dyspnea + tachypnea
syncope, hypotension, cyanosis (massive PE)
pleuritic pain, cough, hemoptysis (small peripheral PE near pleura)
leg pain/swelling
DEATH!? :(
76
non thrombotic PEs
fat
tumor
air
catheter
77
Labs to diagnose DVTs
D-dimer, but non-specific
ABGs not helpful
venous u/s in high probability with + d-dimer
78
Labs to diagnose PEs
D-dimer is increased >90% in PE
not specific though, so only used to rule out PEs
ABGs not helpful
EKG nonspecific
79
what do you see on a CXR for PEs
normal
80
Venous U/S on PE diagnosis
loss of compressibility
81
diagnostic test of choice for PE
CT
82
most specific, gold standard for PE diagnosis
Pulmonary angiography
83
when to do pulmonary angiography for PE diagnosis
if high index of suspicion and all tests are negative
84
PE Diagnosis, what do we see on V/Q scan
if normal PE excluded
85
PE outcome
most deaths are sudden
prognosis is good if dx made and treatmnent started
5% re-embolize
86
PE treatment
anti-coags
thrombolytics
thrombectomy/embolectomy
inpatient vs outpatient
87
anti-coagulants for PE
heparin or LMWH x5d
| overlap with coumadin for 1st 4-5 days, continue for atleast 3 months (INR 2-3)
88
thrombolytics for PE
dissolves clots by activating plasminogen to plasmin, plasmin degrades fibrin
administer for hemodynamically unstable patients
89
ABSOLUTE contraindications for thrombolytics
```
GI bleed within 6 months
Active or recent internal bleeding
Hx of hemorrhagic stroke
Intracranial or intraspinal dz
Recent cranial surgery or head trauma
Pregnancy
```
90
thombectomy/embolectomy
Used less frequently due to incidence of rethrombosis
| Reserved for massive PE when absolute contraindication for thrombolysis is present
91
IVC filter as a treatment for PE treatment
Used for unstable PE
When there is a contraindication to anticoagulation
Or treatment failure to anticoagulation
92
when do we admit patients for PE?
when they need anticoagulants
massive PEs
hemodynamically instable
93
when do we send PE patients home?
hemodynamically stable
94
help of thromboprophylaxis for PE
reduces DVT
| reduces PE
95
Medical prophylaxis for PE
12 hours before surgery
| immediately after 7-10 days
96
mechanical prevention for PE
pneumatic compression
early ambulation
TED stockings
Exercise while sedentary
97
definition of pulmonary HTN
characterized by elevated pulmonary arterial pressure and secondary right ventricular failure
98
what's the outcome of pulmonary HTN when untreated?
progressively fatal if untreated
99
what is primary pulmonary HTN
idiopathic pulmonary arterial HTN
100
causes of secondary pulmonary hypertention (PH)
```
PE
COPD
connective tissue disorder
sleep apea
congenital heart defects
sickle cell anemia
cirrhosis
AIDS
living at high altitudes
cocaine
pulmonary fibrosis
left-sided heart failure
```
101
what is PH pathophysiology
endothelial insult (hormonal or mechanical) causing vascular scarring, endothelial dysfunction, and intimal and smooth muscle proliferation
102
does IPAH have a cure?
no
103
what does untreated IPAH lead to
right sided heart failure and death
104
average time from symptom onset to disease is?
approximately 2 years
105
what are early symptoms like?
non-specific
dyspnea
weakness
recurrent syncope
106
is a CXR helpful for PH workup?
maybe
107
what imaging is extremely helpful if underlying problem of PH is right and left ventricular dysfunction?
echo
108
what imaging is helpful if the underlying problem for PH is interstitial or thromboembolic disease?
high resolution CT and VQ scan
109
what imaging is helpful if underlying problem in PH is thromboembolic disease
pulmonary angiography
110
what should we do to treat PH?
refer to a specialist!
111
what medications treat PH?
```
CCB
vasodilators
PDE-5 inhibitors
endothelial receptor agonists
diuretics
anticoagulants
soluble guanylate cyclase (sGC)
```
112
definition of Cor pulmonale
an alteration in the structure and function of the right ventricle secondary to disease of the lung, thorax, or pulmonary circulation
113
what does chronic cor pulmonale result in?
right ventricular hypertrophy
114
pathophysiology behind right ventricular hypertrophy in cor pulmonale
adaptive response to long-term increase in pressure
individual muscle cells grow thicker and change to drive the increased contractile force required to move blood against greater resistance
115
what does acute core pulmonale result in
dilation in response to acute increased pressure (PE or acute respiratory distress syndrome) (ARDS)
116
is pulmonary vascular resistance increased or decreased in cor pulmonale?
increased
117
```
relative levels of..
RV afterload
CO
RV failure..
in Cor pulmonale
```
increased RV afterload
decreased CO
decreased RV failure
118
two major causes of cor pulmonale
pulmonary vascular changes
| chronic hypoxic pulmonary vasoconstriction
119
what vascular changes cause cor pulmonale?
PE
chemical agents
disease
120
what is the most common cause of cor pulmonale?
COPD
121
nonspecific symptoms of cor pulmonale
```
fatigue
tachypnea
exertional dyspnea
cough
anginal chest pain
hemoptysis
hoarseness
```
122
nonspecific signs of cor pulmonale
```
increased chest diameter
labored respiratory efforts with chest wall retractions
distended neck veins
cyanosis
wheezes or crackles
split S2
systolic ejection murmur with click
S3/4 with systolic tricuspid regurg
pitting edema
```
