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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

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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

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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)

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