Chapter 21: Pulmonary Vascular Disease: Pulmonary Embolism and Pulmonary Hypertension

The sudden onset of which of the following signs and symptoms indicates a pulmonary embolism? 1. Bradycardia 2. Coughing out blood-streaked sputum 3. Cyanosis 4. Sudden shortness of breath a. 3, 4 b. 1, 2 c. 2, 3, 4 d. 1, 2, 3

ANS: D Bradycardia is not a sign or symptom that could indicate a pulmonary embolism.

Medications may be used to prevent pulmonary emboli include: 1. enoxaparin. 2. dalteparin. 3. tinzaparin. 4. reteplase. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3

ANS: D Enoxaparin, dalteparin, and tinzaparin are all low-molecular weight heparins that are anticoagulants used in the prevention of pulmonary emboli. Reteplase is a thrombolytic used in the treatment, not prevention, of pulmonary emboli.

A pulmonary embolus produces which of the following ventilation-perfusion abnormalities? a. True shunting b. Shunt effect c. Dead-space effect d. True dead space

ANS: D When an embolus lodges in the pulmonary vascular system, blood flow is reduced or completely absent distal to the obstruction. Consequently the alveolar ventilation beyond the obstruction is wasted, or dead space, ventilation, and no carbon dioxide-oxygen exchange occurs. The ventilation-perfusion distal to the pulmonary embolus is high and may even be infinite if there is no perfusion at all.

The best test for diagnosing a suspected pulmonary embolism is a(n): a. spiral volumetric computerized tomography pulmonary angiogram. b. ultrasonography. c. D-dimer blood test. d. chest radiograph.

ANS: A The spiral (helical) volumetric computed tomography pulmonary angiogram (CTPA) (also called a CT pulmonary angiography) with intravenous contrast is fast becoming the first-line test for diagnosing suspected pulmonary embolism.

Which of the following conditions is an indication of magnetic resonance imaging (MRI) use in a patient with a suspected pulmonary embolism? 1. Pregnancy 2. Asthma 3. End-stage renal disease 4. Emphysema a. 1, 3 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3

ANS: A A magnetic resonance imaging (MRI) scan of the chest may be used for individuals whose kidneys may be harmed by dyes used in x-ray tests and for women who are pregnant.

A pulmonary embolism causes which of the following major pathologic and structural changes in the lungs? 1. Alveolar consolidation 2. Mucosal edema 3. Alveolar atelectasis 4. Pleural friction rub a. 1, 3 b. 2, 4 c. 2, 3, 4 d. 1, 2, 3

ANS: A After a pulmonary embolism, alveolar consolidation and atelectasis can occur. Mucosal edema is associated with asthma. Pleural friction rub is associated with an empyema.

A patient is on warfarin therapy for the prevention of deep venous thrombosis (DVT). The respiratory therapist should advise the patient to avoid eating or drinking: a. broccoli and spinach. b. orange juice. c. coffee. d. peppers and onions.

ANS: A Patients on warfarin should be advised to avoid foods that are high in vitamin K (which affects blood clotting), such as broccoli, spinach and other leafy green vegetables, liver, grapefruit, and grapefruit juice. Green tea may also need to be avoided. Orange juice is high in potassium, but this is unrelated to warfarin therapy.

A pulmonary angiogram is usually ordered: a. as the first test to identify a pulmonary embolism. b. when other tests for a pulmonary embolism are inconclusive. c. in conjunction with a magnetic resonance image to identify a pulmonary embolism. d. in conjunction with an extremity venogram to identify a pulmonary embolism.

ANS: B The CTPA is increasingly being preferred to the previous gold standards for diagnosing a pulmonary embolism—ventilation-perfusion scanning or direct pulmonary angiography—because (1) the scan only requires an intravenous line, (2) the image resolution is very good, (3) the volumetric scanning allows the contrast material to be administered more economically and timed more precisely, and (4) the entire chest can be scanned in a single breath hold, or in several successive short breath holds.

Therapies used to treat pulmonary hypertension include: 1. albuterol. 2. diuretics. 3. digoxin. 4. reteplase. a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3

ANS: B Therapies commonly used to treat all types of PH include the following: • Diuretics—to help decrease fluid buildup—including swelling in ankles and feet. • Phosphodiesterase inhibitors, especially in group I patients. • Blood-thinning medications—to help prevent blood clots from forming or getting larger. • Cardiac glycosides (digoxin, etc.)—to help the heart to pump stronger or to control the heart rate. • Oxygen therapy—to treat hypoxemia. • Physical activity—to improve exercise tolerance. • Inhaled nitric oxide (iNO) therapy—may be helpful in groups I and IV. An oral agent which mimics the effect of the inhaled gas is now available (riociguat).

The death of lung tissue that may result from an obstruction of the pulmonary artery is called a: a. pulmonary embolism. b. pleural effusion. c. pulmonary infarction. d. pulmonary empyema.

ANS: C A pulmonary infarction causes the death of lung tissue. This can happen when a pulmonary embolism (a clot that moves from another part of the body to the lung) significantly disrupts pulmonary blood flow. A pleural effusion is the leakage of fluid into the pleural space around a lung. An empyema is the accumulation of pus in the pleural space.

A patient's D-dimer blood test results show a value of 550 ng/mL. How should these results be interpreted? a. The patient does not have a pulmonary embolism. b. The patient's anticoagulant level is acceptable. c. The patient has increased level of fibrinogen. d. The patient is having a heart attack.

ANS: C The D-dimer blood test (also called the fibrinogen test) is used to check for an increased level of the protein fibrinogen—an integral component of the blood-clotting process. The test is relatively simple and fast; it entails drawing a blood sample, and the results can be available in less than 1 hour. D-dimer values higher than 500 ng/mL are considered positive—which may suggest the possibility of blood clots. However, it should be emphasized that there are many conditions that can increase an individual's D-dimer level, including recent surgery.

Which of the following are included in the management of pulmonary embolism? 1. Oxygen 2. Vitamin K 3. Heparin 4. Warfarin a. 1, 4 b. 2, 3 c. 1, 3, 4 d. 1, 2, 3

ANS: C The treatment of pulmonary embolism usually begins with treating the symptoms. Oxygen is administered per the Oxygen Therapy Protocol. This is typically followed by the administration of slow-acting, oral anticoagulant warfarin (Coumadin, Panwarfarin). Heparin and warfarin are given together for 5 to 7 days, until blood tests show that the warfarin is effectively preventing clotting.

Which of the following are preventive measures taken with patients at high risk for thromboembolic disease? 1. Drink lots of water. 2. Dangle your legs over the edge of the bed before getting up. 3. Walk frequently. 4. Wear compression stockings. a. 1, 3 b. 2, 4 c. 1, 3, 4 d. 1, 2, 3

ANS: C There is no advantage to dangling your legs rather than just getting out of bed. Prolonged bed rest is known to lead to blood clots. All of the other listed options are helpful in preventing blood clots.

Which of the following are major mechanisms that contribute to the pulmonary hypertension commonly seen in a patient with a pulmonary embolism? 1. Decreased cross-sectional area of the pulmonary vascular system 2. Vasoconstriction induced by alveolar hypoxia 3. Reflexes from the aortic and carotid sinus baroreceptors 4. Vasoconstriction induced by humoral agents a. 1, 4 b. 2, 3 c. 1, 2, 4 d. 2, 3, 4

ANS: C Three things can lead to pulmonary hypertension after a pulmonary embolism: less area for blood to flow through, alveolar hypoxia, and released humoral agents (serotonin and prostaglandin). Baroreceptors are stimulated by hypotension and cause the heart rate to increase.

Bronchospasm may happen after a pulmonary embolism. Which of the following can lead to this bronchospasm? 1. Localized hypoxemia 2. Localized hypercapnia 3. Localized hypocapnia 4. Release of cellular mediators from platelets a. 1, 2 b. 2, 4 c. 1, 2, 3 d. 1, 3, 4

ANS: D A pulmonary embolism can result in hypocapnia and hypoxemia in the local alveoli. In addition, there is the release of cellular mediators from platelets. All of these can cause bronchospasm.

Which of the following are associated with the formation of a deep vein thrombosis (DVT)? 1. Blood vessel injury 2. Age greater than 40 years 3. Hypercoagulability 4. Venous stasis a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 3, 4

ANS: D Age is not directly linked to the development of a DVT. The other three listed options make up Virchow's triad of the primary factors that lead to a DVT.

In order to prevent pulmonary emboli, a filter may be placed into which of the following vessels to prevent clots from being carried into the pulmonary circulation? a. Subclavian vein b. Pulmonary artery c. Femoral artery d. Inferior vena cava

ANS: D An inferior vena cava vein filter may be surgically placed in the inferior vena cava to prevent clots from being carried into the pulmonary circulation. The effectiveness and safety of these filters are not well established and, in general, they are only recommended in some high-risk patients. Edema distal to the filters is a complicating factor.

The respiratory therapist is listening to the heart sounds of a patient with a suspected pulmonary embolus. The therapist could expect to hear: 1. increased second heart sound (S2). 2. increased splitting of the second heart sound (S2). 3. third heart sound (S3). 4. fourth heart sound (S4). a. 1 b. 2, 3 c. 2, 3, 4 d. 1, 2, 3

ANS: D As a result of the pulmonary embolus and the increase in pulmonary vascular resistance, the following heart sounds could be expected: increased second heart sound (S2), increased splitting of the second heart sound (S2), and third heart sound (ventricular gallop). The fourth heart sound would not be an expected finding.

Predisposing factors of pulmonary emboli include: 1. varicose veins. 2. smoking. 3. obesity. 4. asthma. a. 2, 4 b. 1, 3 c. 1, 2, 4 d. 1, 2, 3

ANS: D Asthma does not predispose a person to having pulmonary emboli.