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Pulmonary Vascular Disease Pulmonary Embolism
Pulmonary Arterial Hypertension
PCU Series - Pulmonary 2015
Objectives
• Understand pulmonary embolism
• Review implications for thoracic surgery and post-op care
• Set up and manage chest tube
Pulmonary Embolism
• Clot (thrombotic emboli) or other embolic matter (fat or other material) that lodges in the pulmonary artery or pulmonary arterioles and disrupts blood flow to a region of the lungs
• Pulmonary emboli commonly arise from the deep veins in the thigh
• Can arise from embolic disease
• Virchow triad • Venous stasis, hypercoagulability, and injuries to the endothelial cells that line
the vessels
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Pulmonary Embolism
Pulmonary Embolism •Hemodynamic consequences
• Pulmonary vascular hypertension • Pulmonary vascular constriction • Increased right ventricular workload • Decreased left ventricular preload, decreased cardiac
output and blood pressure, shock
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Pulmonary Embolism •Assessment and diagnosis
• Clinical presentation and symptoms • ABGs
• D-Dimer
• 12-lead electrocardiogram • Chest radiograph
• Echocardiogram • V/Q scan
• Pulmonary angiogram • Lower extremity deep vein thrombosis studies
• Spiral computed tomography scan
Pulmonary Embolism
•Medical management • Clot dissolution
• Catheter directed thrombolysis • Surgical embolectomy with fibrinolytic tPA
• Reversal of pulmonary hypertension • Inotropic agents • Fluid administration to increase right ventricular
preload
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Pulmonary Embolism
•Medical management • Prevention of recurrence
• Anticoagulation • Heparin infusion
• Warfarin (Coumadin) for long-term management • Coagulation studies
• Partial thromboplastin time to monitor heparin • International normalized ratio to monitor warfarin
• Interruption of inferior vena cava (Greenfield filter)
Nursing Management
• Prevention of PE always in focus • Recognition of at-risk patients for
deep vein thrombosis and PE • Intermittent pneumatic compression
devices
• Active/passive range of motion • Adequate hydration
• Progressive ambulation
• Optimizing oxygenation and ventilation • Monitoring for bleeding
• Patient and education
Pulmonary Hypertension
•Definition • Mean pulmonary artery pressure 5-10 mm Hg above
normal or above 20 mm Hg • Pulmonary arterial hypertension • Pulmonary hypertension due to thrombotic or embolic
disease
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Types of Pulmonary Arterial Hypertension
• Small vessel disease • Refers to disease involving the small blood vessels in the lungs • Treatment involves vasodilation, platelet inhibition supportive
therapy
• Large vessel disease • Refers to disease involving the large blood vessels in the lungs • Treatment involves surgical removal of thrombus
Types of Small Vessel Pulmonary Arterial Hypertension
• Idiopathic (IPAH): has no known cause • Familial (FPAH): genetically linked •Diseases Associated with . . . (APAH)
• Collagen vascular disease • Congenital systemic-to-pulmonary shunts • Portal hypertension • HIV Infection • Drugs / Toxins • Other
Associated Pulmonary Arterial Hypertension (APAH)
• Disease states that predispose the development of pulmonary arterial hypertension are • Collagen vascular disease
• It is estimated that ~ 30% of patients with Scleroderma have PAH
• Drugs/Toxins • Methamphetamine and cocaine
• Diet drugs such as Fen-Phen, Pondimin or Redux
• Portal Hypertension • HIV Infection • Congenital Heart Disease
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Pathophysiology of Small Vessel Pulmonary Arterial Hypertension
• Pulmonary Arterial Hypertension (PAH) is caused by a dysfunctional endothelium which leads to an overgrowth of cells in the smooth muscle
• As pulmonary hypertension progresses, the smooth muscle surrounding the pulmonary blood vessels thickens causing the blood vessel to narrow
• This causes increased resistance to forward blood flow and congestion
• The right ventricle must work harder to push against this increased pressure
• As the disease progresses, the right heart becomes enlarged and heart failure ensures
What is the Endothelium and how does it work? • One cell thick, it lines the
inner lumen of blood vessels
• These life-supporting cells are triggered by substances to adjust their number and arrangement to constrict or vasodilate according to local body requirements
Endothelial Functions and Vasoactive Substances • The endothelium balances these substances according to the body’s
needs
• Overproduction of these substances causes an imbalance
• Substances • Vasodilators
• Prostacyclin
• Nitric Oxide
• Vasoconstrictors • Endothelin
• Angiotensin II
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Presenting Signs and Symptoms
Symptoms
Dyspnea on exertion
Fatigue
Syncope
Anginal chest pain
Hemoptysis
Palpitations
Signs
Prominent right ventricular impulse
Right-sided third heart sound (S3)
Hepatomegaly
Peripheral edema
Jugular vein distention
Diagnostic Evaluation of PAH
• Right heart catheterization is the Diagnostic Gold Standard! • Clinically it is diagnosed as:
• Sustained elevation of mean pulmonary arterial pressure to > 25 mmHg at rest or >30 mmHg with exercise, with a mean pulmonary capillary and left arterial pressure < 15 mmHg at rest
Other Diagnostic Tests for PAH
• Six Minute Walk • Pulmonary function tests • Pulmonary angiogram • Liver function tests / liver ultrasound • Blood tests for HIV / Hepatitis / Anorexic agents • Thyroid function tests • Collagen vascular evaluation • Vascular studies
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Goals of PAH Therapy
To Improve
To Prevent
• Quality Of Life
• Exercise Capacity
• Hemodynamics
• Functional Class
• Survival
• Clinical Worsening
• Premature Death
Diagnosis
• CXR
• EKG
• Echocardiogram
• VQ scan
• Pulmonary function tests
• Serological testing
• 6 minute walk test
Treatment
•Oxygen
•Diuretics
•Anticoagulants
•Vasodilators, e.g. Viagra
• Endothelin receptor agonists –Flolan –Tracleer –Remodulin –Ventavis
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PAH Drug Classification Drugs that Act on the
Endothelin Pathway
Drugs that Act on the
Nitric Oxide Pathway
Phosphodiesterase-5
Inhibitors & Nitric Oxide
Drugs that Act on the
Prostacyclin
Pathway
Prostacyclin Analogs
Tracleer
(Bosentan) PO
Revatio (Sildenafil ~
Viagra)
PO
Flolan
(Epoprostenol)
IV
Letairis
(Ambrisentan)
PO
Nitric Oxide
(Inhaled)
Acute Use
Remodulin &
Tyvaso
(Treprostinil)
Sub-Q, IV, Inhaled
Cialis
(Adcira)
PO
Ventavis
(Iloprost)
Inhaled
Thoracic Surgeries Pulmonary Thromboendarterectomy
Lung Cancer
PCU Series - Pulmonary 2015
Thoracic Surgery
• Types of surgery • Thoracotomy • Pneumonectomy • Endarterectomy
• Preoperative care • Patient evaluation
• Pulmonary function tests • Cardiac evaluation
• Surgical considerations
Respiratory Disorders - PCU Series 2013 27
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Thoracic Surgery
• Postoperative nursing management • Optimizing oxygenation and ventilation • Preventing atelectasis
• Patient position and early ambulation • Deep breathing and incentive spirometry
• Pain management
• Maintaining the chest tube system • Help patient return to adequate activity level
Respiratory Disorders - PCU Series 2013 28
Post Op Management Thoracic Surgery
• Oxygen therapy
• Watch for dysrhythmias – SVT’s common with pulm resections
• Radiation therapy when indicates
• Thoracentesis and pleurodesis
• Pain management
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Chronic Thromboembolic Pulmonary Hypertension
•Diagnosed in pulmonary hypertensive patient
•Assess thrombus accessibility
•Distinct angiographic patterns
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Pulmonary Thromboendarterectomy
• Endarterectomy
• Median sternotomy
• Coronary bypass machine with deep hypothermia
• Circulatory arrest periods of less than 20-25 minutes
• Usual post open-heart problems • Arrhythmias • Bleeding
• Wound / nosocomial infections • Delirium
• pleural / pericardial effusions
• Pulmonary vascular changes related to inflammatory response and reperfusion
• Post-PTE Hypoxemia
Preoperative Postoperative
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Lung Cancer
• Bronchogenic carcinomas arise from epithelium of respiratory tract
• Epidemic in USA
• Most common cause is cigarette smoking • Heavy smokers have a 20 times’ greater chance of developing lung
cancer than nonsmokers • Smoking is related to cancers of the larynx, oral cavity, esophagus,
and urinary bladder
• Risks as low as nonsmoker 15 years after quitting!!
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Lung Cancer
• 12 different cell types of lung cancer
• Primary carcinomas receive blood supply from bronchial arteries or other pulmonary circulation
• 4 most common are:
• Non–small cell lung cancer • Squamous cell carcinoma
• Adenocarcinoma
• Large cell carcinoma (undifferentiated)
• Small cell carcinoma
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Non-Small Cell Lung Cancer
• Squamous Cell • 30% of lung cancers and on the decline
• Usually located near hilus and project into bronchi
• Symptoms • Non productive cough, hemoptysis
• Pneumonia, atelectasis
• Chest pain (late sign)
• Mets occur late in disease course
• Treatment • Surgical resection
• Chemotherapy if late, limited effectiveness
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Non-Small Cell Lung Cancer • Adenocarcinoma
• 35-40% of lung cancers • Tumor arising from lymph glands in peripheral
areas of lung • Usually small in size
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Surgical Interventions
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Surgical Management
• Lobectomy
• Pneumonectomy
• Segmentectomy (wedge resection)
Respiratory Disorders - PCU Series 2013 41