Pulmonary Vascular Disease

require mechanical ventilation

high cervical injuries (C1 to C2)

Sudden loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction (as by a clot) of a blood vessel of the brain.

stroke

- mitral valve disease - left ventrical failure - pulmonary embolus

what are the cardiogenic causes of pulmonary edema?

- descending musle weakness

what are the characteristics of Myasthenia Gravis?

- V/Q Scan - Pulmonary angiogram - Spiral CT Scan

what are the test done to diagnose a pulmonary embolism?

Contributes to the stiff lungs which occurs in the late stage of the disease

A decrease in surfactants in ARDS?

Pulmonary Embolism

A patient who is being mechanically ventilated shows an increased Vd/Vt ratio. Which of the following could be responsible?

consequences of neuromuscular disorders.

Atelectasis leading to hypoxia, central sleep apnea and hypertension

A. scans and spiral CT B. Pulmonary angiography

Because of the high mortality rate, it is important to make a definitive diagnosis of pulmonary embolus. What two tests are reasonably sensitive and reliable in confirming this diagnosis?

An increase in the pressure in the pulmonary arteries that could result from a large number of conditions that affect the lung vessels, lung parenchyma, and/or the heart; an elevation in mean pulmonary arterial pressure greater than or equal to 25 mm Hg at rest

Define pulmonary hypertension.

A. 20 to 50 years is most common but can occur at any age. B. More females than males C. 7% of the cases are familial. D. Dyspnea, angina, and syncope E. Only 33% live for 5 years after diagnosis.

Describe the epidemiology of IPH in terms of age, gender, symptoms, mortality, and genetic factors.

A. It is good at detecting large abnormalities and ruling out other causes. B. Not good at identifying smaller PE. Quality is not always good enough to detect problems in really sick patients and radiologist experience matters.

Discuss advantages and disadvantages of helical CT scans for PE.

A human genetic disease caused by a sex-linked recessive allele; characterized by progressive weakening and a loss of muscle tissue.

Duchenne muscular dystrophy

When blood vessels are blocked in the lung, the heart has to work much harder. If oxygenation is affected, the heart does not get the energy it needs. Cardiac output could drop due to low blood

Explain how pulmonary embolism (PE) affects the heart and lungs as they try to function together. (Just give the basic idea.)

It is multifactorial, but essentially alveolar hypoxia (low PAO2) causes pulmonary vasoconstriction which increases PVR and pulmonary blood pressure.

Explain the role of alveolar hypoxia in the development of pulmonary hypertension.

A. Streptokinase B. Urokinase C. Tissue plasminogen activator

Give three examples of thrombolytic drug

ascending paralysis.

Guillain-Barre Syndrome (GBS)

- immune disorder of the peripheral nervous system and frequently occurs after a febrile illness.

Guillain-Barre syndrome

Thrombolytics lyse existing clots. Anticoagulants prevent new clot formation. The drugs are not usually given together.

How are thrombolytics different from anticoagulants? Can they be given together?

ABGs are not helpful in the diagnosis as the associated abnormalities, hypoxemia, and hypercarbia are nonspecific. They are done to assess patients' pulmonary and acid-base status and to guide pulmonary management.

How helpful are arterial blood gases (ABGs) in ruling out PE? What benefit does an ABG provide in these cases?

- High protein Cerebrospinal Fluid (CSF) - slow impulse transmission

How is Guillain-Barre syndrome diagnosed?

Basically by ruling out all the other possible causes; ECG, echo, scan, CT, CXR, and PFTs.

How is IPH diagnosed?

While x-ray is frequently abnormal, it is not specific enough in most cases. It really helps to rule out pneumothorax and other causes, so it is important.

How is the chest radiograph helpful in diagnosing pulmonary embolism?

200,000 to 300,000

How many people develop thromboembolic disease each year in the United States?

60% to 100% are toxic for ARDS patients. ARDS patients should be ventilated with minimum FIO2 and higher PEEP for oxygenation

How much FIO2 should ARDS patients be put under?

done at least every 4 hr to monitor muscle strength of neuromuscular pts

How often should VC and NIF measurement are done and what is being tested?

combination of kyphosis and scolisis, which may produce a severe restrictive lung defect as a result of poor lung expansion

Kyphoscoliosis

Antibodies against presynaptic calcium channels at the neuromuscular junction 50% of the cases are associated with small cell carcinoma of the lung

Lambert-Eaton Syndrome

Pulmonary embolectomy, catheter tip embolectomy, and catheter tip fragmentation

List the mechanical options available for treatment of massive PE

Tachypnea, Crackles, Tachycardia

List the three most frequent physical findings associated with PE.

A. Tachycardia B. ST-segment depression

List the two most common ECG abnormalities associated with PE.

Dyspnea, Pleuritic pain

List the two most common symptoms of PE.

The D-dimer ELISA can be used in outpatient clinics and emergency departments to exclude PE in patients with a low to moderate suspicion. In-patients have comorbid conditions, so an elevated D-dimer level is expected.

One rapid blood test has been developed to help rule out embolism. Why isn't D-dimer as good for some inpatients?

A. Pharmacologic prophylaxis 1. Low-dose subcutaneous heparin 2. Warfarin (Coumadin) 3. Low-molecular-weight heparin (or heparinoids, dextran) (Fondaparinux [Arixtra] is a new drug) B. Mechanical prophylaxis 1. Early ambulation 2. Elastic stockings 3. Pneumatic calf compression devices

Prophylaxis for DVT is either pharmacologic or mechanical. Give three examples of each.

- sputum is watery, frothy, and pink in color.

What are the "classic" symptoms of a patient with pulmonary edema?

- scarring - fibrosis - multi organ failure - severe shunting

What are the "late stage" features ARDS?

- peripheral alveolar infiltrates - air bronchograms - sparing of costrophrenic angles - normal cardiac size

What are the characteristics of ARDS on a C-Xray?

Tachycardia Tachypnea Cough

What are the most common symptoms seen with Pulmonary Embolus?

Thrombolytics -- ØStreptokinase (Streptase) Ø Urokinase (Abbokinase) Ø Alteplase (Activase) Ø Reteplase (Retavase)

What are the treatments for Pulmonary Embolism?

Breathing test/assessment such as Vital Capacity (VIC) and Negative Inspiratory Force (NIF)

What can be used to monitor a patient's respiratory muscle strength with Guillain Barre Syndrome?

- viral pneumonia - trauma - near drowning - gastric aspirations

What can cause ARDS?

- decreased surfactants - pulmonary edema - shunts - atelectasis - refractory hypoxemia

What does ARDS cause?

Acute Respiratory Distress Syndrome (poor oxygenation caused by leaky capillaries)

What does ARDS stand for?

excessive amounts of protein enters the pulmonary interstitium and alveoli

What is Pulmonary edema?

a Greenfield filter is inserted into the inferior vena cava below the renal veins, and is able to trap emboli larger than 3 mm in diameter

What is a Greenfield filter? where is it placed?

A condition in which one or more arteries in the lungs become blocked by a blood clot.

What is a pulmonary embolism?

thickened alveolar-capillary membrane

What is a sign of ARDS?

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

What is myasthenia gravis

difficulty breathing while lying down commonly seen in patients with Congestive Heart Failure

What is orthopnea?

- The Tensilon test uses the drug Tensilon (generic name: edrophonium) to diagnose myasthenia gravis. - Tensilon prevents the breaking down of the chemical acetylcholine, which then helps stimulate the muscles. - A patient has myasthenia gravis if his or her muscles get stronger after being injected with Tensilon.

What is the Tensilon test?

CPAP+10 &100%

What is the first line of therapy for Pulmonary edema

as low as 4-6 ml/kg

What is the level of Tidal Volume used on ARDS patients?

25-30 mmHg

What is the normal colloid pressure?

10-15mmHg

What is the normal hydrostatic pressure?

O2 therapy and if the patient is a smoker, smoking cessation

What is the only treatment that improves survival in patients with COPD and pulmonary hypertension? What treatments might help?

Increased right heart pressure, increased resistance, and poor cardiac output.

What is the primary hemodynamic consequence of PE?

A large segmental perfusion defect without corresponding ventilation defect is highly suggestive of PE. When ventilation and perfusion defects match in a lung segment, there is a lower probability.

What is the relationship of the ventilation (V) and perfusion (Q) portions of scans in making a high-probability diagnosis of PE?

A. Heparin B. Inhibits coagulation C. Bleeding, thrombocytopenia

What is the standard pharmacologic therapy for existing DVT or PE? What is the mechanism of action? What are the risks?

Loss of pulmonary vascular bed and increased blood viscosity play a role. In addition, hyperinflation may compress pulmonary vasculature, which would increase PVR.

What other factors seen in COPD contribute to this condition?

When DVT is present and the patient has poor reserves. Filters may also be used with chronically immobilized patients and when anticoagulants are contraindicated.

When are vena cava filters indicated?

- near drowning - smoke inhalation - thermal burn

When can ARDS occur?

They usually form in the deep veins of the pelvis or legs. A few, 3%, form in the right heart. Stasis, or sluggish blood flow, is often the culprit. The immobilized patient is at risk. So are long distance air travelers. Coagulation is another factor. Atrial arrhythmias can also throw clots into the lung because the right atrium does not pump effectively.

Where are they most likely to form first?

From long bone fractures

Where do most pulmonary fat embolism originate?

Iloprost, Treprostinil

Which drug treatment is given via inhalation?

phrenic nerve (C3-C5 on the spinal cord)

Which nerve innervates the diaphragm?

Pulmonary angiography

Which of the following is the most appropriate test to confirm the presence of a suspected PE?

Older or bedridden patients have the most risk. Trauma or heart failure are risky situations.

Which patient population or situations have the most risk for this sort of pathology?

Compression ultrasonography

Which test is considered the "gold standard" for the diagnosis of DVT?

Supplemental oxygen (O2) results in an increased alveolar partial pressure of O2, which causes pulmonary vasodilation and reducing PVR and possibly HTN.

Why is it so important to provide oxygen as needed to keep up the patient's saturations in this condition?

Pulmonary embolus

a patient presents in the ED with severe dyspnea and complains of chest pain. His respiratory rate is 24 and his minute volume is 14 L. ABG results show pH 7.44, PaCO2 37, PaO2 100. What is the most likely cause of a normal CO2 when a patient has a large increase in minute ventilation?

Acute pulmonary embolus

a ventilation/perfusion scan reveals a defect in perfusion in the right lower lobe without corresponding decrease in ventilation. Which of the following is the most probable diagnosis?