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Pulmonary Circulation

Pulmonary embolism

• A blockage of a main artery into the lungs by something that has traveled from somewhere else in the circulatory system
• Most often associated with a deep venous thrombosis.

Risk factors

• Virchow’s triad
• Imobility
• Hypercoagulable state
• Vessel injury
• Hyper-viscosity = polycythemia

Clinical Presentation

• Chest pain
• Dyspnea
• Shortness of breath
• Hemoptysis

Labs, Studies and Physical Exam Findings

• Tachypnea
• Tachycardia
• EKG – most often normal, but may have non specific S-T changes
• Hypoxemia
• Chest X-ray
  • Westermark sign
    • Hypovolemia distal to PE
  • Hampton hump
    • Wedge shaped opacity due to lung infarct
• Atelectasis
• Ventilation perfusion scan (VQ scan)
• Helical CT
• Require contrast dye
• Pulmonary angiography

Treatment

• Anticoagulation for 6-12 months
• Heparin is started right away for immediate treatment
• Warfarin for long term treatment
• Thrombolytics
• Inferior vena cava filter
• Embolectomy

Pulmonary hypertension

• Elevated pulmonary artery pressure
• Idopathic or primary pulmonary hypertension
  • Rare
  • Most commonly in young women
• Secondary pulmonary hypertension
• Anything that causes an increase in vascular resistance may be a cause
  • Left sided heart failure
  • Lung disease (COPD)
  • Pulmonary embolism
  • etc

Clinical Presentation

• Exertional dyspnea
• Exertional syncope
• Chest pain

Labs, Studies and Physical Exam Findings

• Splitting of S2
• Cyanosis
• Signs of right heart failure
  • Peripheral edema
  • Ascites
  • Elevated jugular venous pressure
• EKG
  • Right axis deviation secondary to right sided enlargement
• Chest X-ray
  • Right heart enlargement
• CT
  • Enlarged pulmonary arteries
• Echo is very helpful
• Right heart catheterization is the gold standard

Treatment

• 5 year survival rate is 50%
• Treat underlying cause for secondary pulmonary hypertension
• Pulmonary vasodilators
• Lung transplant

Cor pulmonale

• Right sided heart failure secondary to severe pulmonary disease

Causes

• Acute respiratory distress syndrome
• Pulmonary embolism
• COPD
• Severe asthma
• Sarcoidosis
• Lung trauma (including surgery)

Clinical Presentation

• Dyspnea
• Wheezing
• Chronic wet cough
• Edema
• Cyanosis

Labs, Studies and Physical Exam Findings

• Cyanosis and clubbing may be present
• Ascites and edema
• Increased jugular venous distention
• EKG
  • Tall peaked T waves (representing right atrial hypertrophy)
  • Right axis deviation (representing right ventricular hypertrophy)
  • On a 12 lead EKG lead I has a negative QRS and the aVF lead has a positive QRS
• Chest X-ray
  • Enlarged right ventricle
  • Enlarged pulmonary artery
• Echo – shows right sided hypertrophy and dysfunction
• Pulmonary function testing

Treatment

• Treat the underlying lung disease
• Oxygen

Study tip

GO to www.physicianassistantexamreview.com/paweek

<< Click here to get 40 Pulmonology questions straight from my book The Final Step >>