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
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)
-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?
2. venous stasis
3. intimal injury
What does pulmonary arterial obstruction lead to?
1. Increased PVR
2. Redistribution of blood flow-->V/Q mismatch
4. RV pressure overload, ischemia
What are the PE risk factors?
1. Previous venous thromboembolism
3. Immobility, paralysis
5. Major surgery
8. Cardiac Disease
9. Long bone fractures
11. Nephrotic syndrome
13. Femoral lines
15. Hypercoag. states
What are the symptoms of a PE?
chest pain 88%
Loud S2 53%
Pulse >100 44%
What are diagnostic tests for PE?
-sensitive but not specific
Lower Extremity Ultrasound
-specific but not sensitive
What are the treatments for PE?
-coumadin for at least 6 months
3. IVC filter
-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