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Flashcards in Pulmonary Circulation Deck (16)

What is high pressure pulmonary edema?

Cardiogenic pulmonary edema
-Elevated LVEDP causes elevated hydrostatic pressures which result in increased edema formation
PE: JVD, S3, Hepatosplenomegaly, edema, cool extremities, thready pulse
CXR: vascular engorgement, peripheral infiltrates, cephalization, kerley B lines, pleural effusions are common

Causes-LV systolic or diastolic dysfunction, mitral valve disease, hyperkalemia with normal cardiac function


What are the treatments of high pressure pulmonary edema?

1. oxygen, noninvasive mask ventilation
2. decrease preload
-nitrates, diuretics, venodilators
3. decrease afterload
-ACE inhibitors, hydralazine
4. Increase contractility
-dobutamine, milrinone


What is low pressure pulmonary edema?

Acute respiratory distress syndrome (ARDS) or acute lung injury
-increased permeability (leaky capillaries) causes increased edema
Follows any of a number of insults
-most commonly sepsis, trauma, pancreatitis
Edema has protein concentration approaching serum

PE: lack signs of elevated filling pressures, if sepsis is the underlying cause then typically warm extremities, bounding pulses and wide pulse pressure

-refractory hypoxemia is early problem then hypercapnia becomes the problem

CXR: diffuse four quadrant fluffy infiltrates. pleural effusions and cardiomegaly are rare


What does the swan ganz catheter do?

gives you left atrial and what would be left ventricle end diastolic pressure


In high pressure pulmonary edema are the extremities warm or cold? Pulse pressure? Wedge pressure? Edema protein Conc?

>20 wedge pressure
low protein in edema


In low pressure pulmonary edema are the extremities warm or cold?Pulse pressure? Wedge pressure? Edema protein Conc?

warm and well perfused


How do you treat low pressure pulmonary edema?

-fix the underlying problem
-lower the hydrostatic pressures
-oxygen (but recognize that this is a shunt)
mechanical ventilation
-high peep-distends the alveoli-keeps them from collapsing-tethered interstitial space more negative-redistribute water into interstitial space
-low tidal volumes

salvage therapy-ECMO (extra corporeal membrane oxygen)


What leads to a Pulmonary Embolism?

1. Hypercoagulability
2. venous stasis
3. intimal injury


What does pulmonary arterial obstruction lead to?

1. Increased PVR
2. Redistribution of blood flow-->V/Q mismatch
3. Hyperventilation
4. RV pressure overload, ischemia


What are the PE risk factors?

1. Previous venous thromboembolism
2. >40
3. Immobility, paralysis
4. Malignancy
5. Major surgery
6. Trauma
7. Obesity
8. Cardiac Disease
9. Long bone fractures
10. CVA
11. Nephrotic syndrome
12. Estrogens
13. Femoral lines
14. Parturition
15. Hypercoag. states


What are the symptoms of a PE?

chest pain 88%
dyspnea 84%
apprehension 59%
cough 53%
hemoptysis 30%
syncope 13%

RR>16 92%
Rales 58%
Loud S2 53%
Pulse >100 44%
Temp>37.8 44%
Phlebitis 32%
Gallop 34%
DIaphoresis 36%
Edema 24%
Murmur 23%
Cyanosis 19%


What are diagnostic tests for PE?

-sensitive but not specific
Lower Extremity Ultrasound
-specific but not sensitive
V/Q scan
pulmonary angiography
Ct angiography


What are the treatments for PE?

1. prevention
2. anticoagulation
-coumadin for at least 6 months
3. IVC filter
4. Thrombolytics
-only proven to improve survival in shock
5. surgical/catheter thrombectomy


What are normal pulmonary artery pressures?



What is primary pulmonary hypertension vs secondary pulmonary hypertension?

Primary: vast majority are sporadic and only 6% are familiar with an autosomal dominant mode of inheritance
-decrease in the cross sectional area of the pulmonary vascular bed
-increased pulmonary blood flow
-Chronic obstructive or interstitial lung disease
-Recurrent pulmonary embolism
Antecedent heart disease


What is the treatment of pulmonary hypertension?

1. treat the underlying disease
2. best selective pulmonary vasodilator is oxygen
3. calcium channel blockers can sometimes lower pulmonary pressures
4. All other vasodilators cause systemic hypotension before pulmonary vasodilation
5. Endothelin receptor blockers
6. cyclic GMP phosphodiesterase type 5 inhibitors (sildenafil)
7. Prostaglandins may work if the pulmonary vessels are still reactive
8. consider anticoagulation
9. lung transplant

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