COPD Leads to Cor COPD Leads to Cor PulmonalePulmonale

Katherine Karczewski Katherine Karczewski RN,BSN,CENRN,BSN,CEN

March 1, 2012March 1, 2012

MSN 621MSN 621

Course ObjectivesCourse Objectives

Define Cor Pulmonale in the Chronic Obstructive Define Cor Pulmonale in the Chronic Obstructive Pulmonary Disease(COPD) Patient.Pulmonary Disease(COPD) Patient.

Define briefly Chronic Obstructive Pulmonary Define briefly Chronic Obstructive Pulmonary Disease.Disease.

Identify Common Signs and Symptoms in the Identify Common Signs and Symptoms in the physical exam of the COPD Patient with the physical exam of the COPD Patient with the diagnosis of Cor Pulmonale.diagnosis of Cor Pulmonale.

Outline Routine Diagnostic Tests used to Confirm Outline Routine Diagnostic Tests used to Confirm the Cor Pulmonale Diagnosis.the Cor Pulmonale Diagnosis.

Recognize Standard Treatments used for COPD Recognize Standard Treatments used for COPD Patients with Cor Pulmonale.Patients with Cor Pulmonale.

Case PresentationCase Presentation

A 67 year old male patient well known to your A 67 year old male patient well known to your clinic with a longstanding diagnosis of COPD clinic with a longstanding diagnosis of COPD presents complaining of weakness, increased presents complaining of weakness, increased dyspnea, and fatigue. He has been experiencing dyspnea, and fatigue. He has been experiencing these symptoms for several months. The these symptoms for several months. The symptoms have gotten worse despite the use of symptoms have gotten worse despite the use of his inhalers. He reports that he has had bilateral his inhalers. He reports that he has had bilateral lower leg edema for the past month.lower leg edema for the past month.

What do you suspect this patient has developed?What do you suspect this patient has developed?

COPDCOPD

COPD may involve chronic inflammation and COPD may involve chronic inflammation and obstruction of the pulmonary airways with obstruction of the pulmonary airways with excess mucus production that causes excess mucus production that causes obstruction and a mismatch of ventilation obstruction and a mismatch of ventilation and perfusion. and perfusion.

The alveolar tissue is destroyed, along with The alveolar tissue is destroyed, along with a loss in the elastic fibers which impairs the a loss in the elastic fibers which impairs the expiratory phase. This loss also increases expiratory phase. This loss also increases air trapping and collapse of the airway air trapping and collapse of the airway structures.structures.

This is seen in the arterial blood gases as a This is seen in the arterial blood gases as a decreased PO2 and an increased PCO2.decreased PO2 and an increased PCO2.

What is Cor Pulmonale in the COPD What is Cor Pulmonale in the COPD Patient?Patient?

The progress of COPD results in right sided The progress of COPD results in right sided heart failure. The right ventricle has heart failure. The right ventricle has become hypertrophied and dilated and its become hypertrophied and dilated and its function has become compromised due to function has become compromised due to pulmonary hypertension associated with pulmonary hypertension associated with COPD.COPD.

COPD to Cor PulmonaleCOPD to Cor Pulmonale

These are the mechanisms that occur These are the mechanisms that occur when COPD becomes Cor Pulmonale. Now when COPD becomes Cor Pulmonale. Now lets look at the pathway from COPD to lets look at the pathway from COPD to Cor Pulmonale.Cor Pulmonale.

Alexandria.healthlibrary.Ca 2008

Pathway of COPD to Cor PulmonalePathway of COPD to Cor Pulmonale COPD is the most common cause of Cor COPD is the most common cause of Cor

Pulmonale. Pulmonale. A chronic increase in pulmonary vascular A chronic increase in pulmonary vascular

resistance causes the right ventricle to distend resistance causes the right ventricle to distend and undergo hypertrophy. When the right and undergo hypertrophy. When the right ventricle can no longer compensate, it causes ventricle can no longer compensate, it causes an increase in the right ventricular end-diastolic an increase in the right ventricular end-diastolic pressure and the right atrial pressure; causing pressure and the right atrial pressure; causing right heart failure know as Cor Pulmonale.right heart failure know as Cor Pulmonale.

Cor Pulmonale is a maladaptive response to Cor Pulmonale is a maladaptive response to pulmonary hypertension.pulmonary hypertension.

(Up to Date, 2012)(Up to Date, 2012)

ReviewReview

An increased PO2 and increased PCO2.

Try again! COPD is a chronic disorder causing a decrease in O2 to the

patient.

Decreased PO2 and Increased PCO2

Correct!

Based on what we know about COPD Based on what we know about COPD what would you expect the arterial what would you expect the arterial blood gases to show?blood gases to show?

COPD to COR PulmonaleCOPD to COR Pulmonale

The chronic inflammation and The chronic inflammation and hypoventilation causes the pulmonary hypoventilation causes the pulmonary vasoconstriction and signals the kidney to vasoconstriction and signals the kidney to release erythropoietin in response to the low release erythropoietin in response to the low oxygen levels. oxygen levels.

This in turn stimulates the bone marrow to This in turn stimulates the bone marrow to produce reticulocytes which are released into produce reticulocytes which are released into the bloodstream to become erythrocytes. the bloodstream to become erythrocytes.

Because of the chronic low oxygen levels this Because of the chronic low oxygen levels this process is continually occurring causing an process is continually occurring causing an excess of red blood cells (polycythemia).excess of red blood cells (polycythemia).

COPD to Cor PulmonaleCOPD to Cor Pulmonale

The progression of COPD results in chronic The progression of COPD results in chronic hypoxic pulmonary vasoconstriction, hypoxic pulmonary vasoconstriction, polycythemia, impaired gas exchange polycythemia, impaired gas exchange secondary to mucus overproduction and air secondary to mucus overproduction and air trapping which destroys the pulmonary trapping which destroys the pulmonary vascular bed because of decreased oxygen vascular bed because of decreased oxygen supply.supply.

The progression leads to pulmonary The progression leads to pulmonary hypertension; which puts a stress on the right hypertension; which puts a stress on the right ventricle causing it to distend and hypertrophy. ventricle causing it to distend and hypertrophy.

Hypertrophy to the right ventricle is known as Hypertrophy to the right ventricle is known as Cor Pulmonale.Cor Pulmonale.

Clinical Presentation of the Cor Clinical Presentation of the Cor Pulmonale PatientPulmonale Patient

Most of the symptoms of Cor Pulmonale Most of the symptoms of Cor Pulmonale are not often recognized because the are not often recognized because the symptoms of COPD are similar and can be symptoms of COPD are similar and can be overlooked. The symptoms of Cor overlooked. The symptoms of Cor Pulmonale are: increased weakness, Pulmonale are: increased weakness, dyspnea, and fatigue.dyspnea, and fatigue.

The clinical exam is very important in The clinical exam is very important in detecting these subtle findings.detecting these subtle findings.

Lets look at the clinical exam.Lets look at the clinical exam.

Clinical Examination of PatientClinical Examination of Patient

The patient has jugular venous distension.The patient has jugular venous distension. Bilateral lower extremity pitting edema.Bilateral lower extremity pitting edema. The patient uses home oxygen at 2L/nasal The patient uses home oxygen at 2L/nasal

cannula at bedtime.cannula at bedtime. The patients resting pulse oximeter reading is The patients resting pulse oximeter reading is

90% on room air.90% on room air. A holosystolic murmur at the left lower sternal A holosystolic murmur at the left lower sternal

border characteristic of tricuspid insufficiency.border characteristic of tricuspid insufficiency. Right upper quadrant discomfort upon palpation.Right upper quadrant discomfort upon palpation. The patient complains of exertional dyspnea and The patient complains of exertional dyspnea and

fatigue despite use of Albuterol inhaler and fatigue despite use of Albuterol inhaler and Pulmicort inhaler.Pulmicort inhaler.

Why does the patient have continued Why does the patient have continued dyspnea, fatigue, and a low pulse ox dyspnea, fatigue, and a low pulse ox

despite wearing oxygen?despite wearing oxygen?

The progression of the COPD causing changes in The progression of the COPD causing changes in respiratory function. The increased mucus respiratory function. The increased mucus production and increased resistance to outflow production and increased resistance to outflow cause the increased SOB and fatigue.cause the increased SOB and fatigue.

The low pulse oximeter reading is a result of the The low pulse oximeter reading is a result of the worsening ventilation-perfusion imbalance in the worsening ventilation-perfusion imbalance in the lungs and increased pulmonary hypertension.lungs and increased pulmonary hypertension.

(Up to Date, 2012)(Up to Date, 2012)

Why doesWhy does the patient have jugular vein the patient have jugular vein

distention, peripheral edema, and right distention, peripheral edema, and right upper quadrant discomfort?upper quadrant discomfort?

Cor Pulmonale patients have pulmonary Cor Pulmonale patients have pulmonary hypertension which strains the right ventricle of hypertension which strains the right ventricle of the heart. Pulmonary hypertension causes right the heart. Pulmonary hypertension causes right sided heart failure and is characterized by:sided heart failure and is characterized by:

1. Jugular vein distension1. Jugular vein distension 2. Peripheral edema of legs and ankle2. Peripheral edema of legs and ankle 3. Right upper quadrant pain from hepatic3. Right upper quadrant pain from hepatic congestion (hepatomegaly)congestion (hepatomegaly)

(Up to Date, 2012)(Up to Date, 2012)

Why do we hear a holosystolic Why do we hear a holosystolic murmur?murmur?

The increased intensity of the S2 heart The increased intensity of the S2 heart sound (the split second heart sound) is a sound (the split second heart sound) is a secondary effect of pulmonary secondary effect of pulmonary hypertension.hypertension.

The tricuspid valve insufficiency is caused The tricuspid valve insufficiency is caused by a regurgitation of blood because of by a regurgitation of blood because of pulmonary hypertension.pulmonary hypertension.

(Klabunde, 2011)(Klabunde, 2011)

ReviewReview

Increased mucus production, increased

right sided heart failure, and

progression of COPD.Yes!

Increased cardiac output and Decreased

pulmonary vascular resistance.

No. We know cor pulmonale has

decreased cardiac output and increased

PVR.

Leukemia.No we know that polycythemia is present in cor

pulmonale patients.

Lets Review. Why does the Cor Lets Review. Why does the Cor Pulmonale Patient have increased Pulmonale Patient have increased dyspnea, fatigue, and weakness?dyspnea, fatigue, and weakness?

Diagnostic Tests for the Cor Pulmonale Diagnostic Tests for the Cor Pulmonale Patient Patient

1.1. Chest Radiograph (CXR)Chest Radiograph (CXR)2.2. Electrocardiogram (EKG)Electrocardiogram (EKG)3.3. Echocardiogram (ECHO)Echocardiogram (ECHO)4.4. Pulmonary Function Test (PFT)Pulmonary Function Test (PFT)

Chest RadiographChest Radiograph

The radiograph would show an enlarged The radiograph would show an enlarged pulmonary artery due to pulmonary pulmonary artery due to pulmonary hypertension. The lateral view would show hypertension. The lateral view would show a loss of retrosternal air space due to the a loss of retrosternal air space due to the enlargement of the right ventricle.enlargement of the right ventricle.

(Up to Date, 2012)

Chest RadiographChest Radiograph

Learningradiology.com 2012

ElectrocardiogramElectrocardiogram

The EKG would possibly show a right bundle The EKG would possibly show a right bundle branch block and right axis deviation branch block and right axis deviation because of the right ventricle hypertrophy because of the right ventricle hypertrophy and atrial enlargement. There will be and atrial enlargement. There will be dominant R waves in V1 and V2 and dominant R waves in V1 and V2 and prominent S waves in V5 and V6 because of prominent S waves in V5 and V6 because of right ventricular hypertrophy. Increased P right ventricular hypertrophy. Increased P wave amplitude in Lead II due to right atrial wave amplitude in Lead II due to right atrial enlargement.enlargement.

(Up to Date, 2012)(Up to Date, 2012)

EchocardiogramEchocardiogram

The echocardiogram will show right The echocardiogram will show right ventricular hypertrophy, right ventricular ventricular hypertrophy, right ventricular dilation and tricuspid regurgitation due to dilation and tricuspid regurgitation due to right atrial enlargement. right atrial enlargement.

(Up to Date, 2012)(Up to Date, 2012)

Pulmonary Function TestPulmonary Function Test

The pulmonary function test will indicate The pulmonary function test will indicate an impaired diffusion capacity due to the an impaired diffusion capacity due to the acidotic pH. It may also show a restrictive acidotic pH. It may also show a restrictive ventilatory defect.ventilatory defect.

(Up to Date, 2012)(Up to Date, 2012)

Right Heart CatheterizationRight Heart Catheterization

This is considered the gold standard for Cor This is considered the gold standard for Cor Pulmonale Diagnosis.Pulmonale Diagnosis.

The patient who presents with chest pain and The patient who presents with chest pain and has nondiagnostic or normal results of the has nondiagnostic or normal results of the chest radiograph, echocardiogram, EKG, and chest radiograph, echocardiogram, EKG, and pulmonary function tests will have a right pulmonary function tests will have a right heart catheterization done to confirm the heart catheterization done to confirm the diagnosis.diagnosis.

(Up to Date, 2012)(Up to Date, 2012)

ReviewReview

Stress test, CXR, and echo.

No! this may be ordered to confirm

CHF diagnosis.

Chest radiograph, EKG, Echo and

PFT.Yes !

CXR, ABG’s and sputum specimen.

Try again!This may be used to

diagnose a lung infection.

What diagnostic tests do you order to What diagnostic tests do you order to confirm the Cor Pulmonale diagnosis?confirm the Cor Pulmonale diagnosis?

3 Major Physiological Goals of 3 Major Physiological Goals of Cor Pulmonale TreatmentCor Pulmonale Treatment

1. Reduce the right ventricular after load 1. Reduce the right ventricular after load causing a reduction of the pulmonary causing a reduction of the pulmonary artery pressure.artery pressure.

2. Decrease right ventricular pressure.2. Decrease right ventricular pressure.

3. Improve the contractility of the right 3. Improve the contractility of the right ventricle.ventricle.

Treatment of Patients with Cor Treatment of Patients with Cor PulmonalePulmonale

Oxygen therapy for patients with Oxygen therapy for patients with hypoxemia. hypoxemia.

The oxygen will improve hypoxic The oxygen will improve hypoxic vasoconstriction. Oxygen also may vasoconstriction. Oxygen also may improve pulmonary artery pressure and improve pulmonary artery pressure and pulmonary vascular resistance and pulmonary vascular resistance and polycythemia associated with hypoxia.polycythemia associated with hypoxia.

(Up to Date,2012)(Up to Date,2012)

Treatment (cont.)Treatment (cont.)

Diuretic therapy to improve right ventricular Diuretic therapy to improve right ventricular function due to increased right ventricular function due to increased right ventricular pressures. pressures.

Diuretics must be used carefully because cor Diuretics must be used carefully because cor pulmonale patients are preload dependent and an pulmonale patients are preload dependent and an under filling of the right ventricle may decrease under filling of the right ventricle may decrease the stroke volume and increase their symptoms. the stroke volume and increase their symptoms.

The diuretics may also increase the patients risk The diuretics may also increase the patients risk of developing arrhythmias and metabolic acidosis of developing arrhythmias and metabolic acidosis because of the loss of potassium from the because of the loss of potassium from the diuretics.diuretics.

(Up to Date, 2012)(Up to Date, 2012)

Treatment (cont.)Treatment (cont.)

Inotropic agents are used to increase the Inotropic agents are used to increase the right ventricle contractility and decrease right ventricle contractility and decrease the right ventricle afterload by inducing the right ventricle afterload by inducing pulmonary vasodilation.pulmonary vasodilation.

(Up to Date,2012)(Up to Date,2012)

ConclusionConclusion

Reduce right venticular afterload.

Yes! That is one!

Decrease right ventricular pressure.

Yes! That is two!

Improve the contractility of the

right ventricle.

Yes! That is three!

What are the 3 major physiological What are the 3 major physiological goals we carry out when treating a goals we carry out when treating a patient with Cor Pulmonale?patient with Cor Pulmonale?

COPD to Cor PulmonaleCOPD to Cor Pulmonale

COPD is the fourth leading cause of death COPD is the fourth leading cause of death in the United States. COPD leads to Cor in the United States. COPD leads to Cor Pulmonale. Nurse Practitioners will be Pulmonale. Nurse Practitioners will be expected to manage the treatment of expected to manage the treatment of patients with Cor Pulmonale.. The patients with Cor Pulmonale.. The management of Cor Pulmonale will focus management of Cor Pulmonale will focus on the extent of the lung disease and on the extent of the lung disease and heart failure of the patient. heart failure of the patient.

ReferencesKlabunde, R. (2011). . In Cardiovascular

Physiological Concepts (2nd ed., ). Philadelphia, PA: Lippincott Williams & Wilkins.

Klings, E. (2011, August 17th). Cor Pulmonale Retrieved February 20, 2012 from Up to Date online textbook: http://www.uptodate.com.

Porth, C. M., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States (8th ed., ). Philadelphia, PA: Lippincott Williams & Wilkins.

alexandria.health library.ca. (2008). http://alexandriahealthlibrary.ca/documents/notes/bom/unit_8a/micopd_001.png

intprop.lf2.cuni.cz/.../ekg1/ekg-copd.htm. (nd.). http://intprop.lf2.cuni.cz/.../ekg1/ekg-copd.htm