PANCE Blueprint Pulmonary (10%)

Pulmonary Circulation (PEARLS)

The NCCPA™ PANCE  Pulmonary Content Blueprint addresses three types of pulmonary circulation disorders

Cor pulmonale Right ventricular failure secondary to pulmonary hypertension

  • Etiology: COPD (most common), pulmonary embolism, acute respiratory distress syndrome
  • Physical Exam: Lower extremity edema, neck vein distention, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2
  • EKG: S1Q3T3


Pulmonary embolism (ReelDx) Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs

  • More than 90% originate from cots in the deep veins of the lower extremities
  • Presents with dyspnea (most common) and pleuritic chest pain
  • R/F: Virchow’s triad = hypercoagulable state, trauma, venostasis (surgery, cancer, oral contraceptives, pregnancy, smoking long bone fracture/fat emboli)
  • Homan’s sign: (Dorsiflexion of the foot causes pain in calf) indicative of deep vein thrombosis
  • EKG: TACHYCARDIA (most common), S1Q3T3 (rare), non-specific ST wave changes

Diagnosis: Well’s Score is used to assess the probability of pulmonary embolism

  • Spiral CT = initial method of identifying
  • Pulmonary angiography = gold standard definitive
  • CXR: Westermark sign or Hampton hump (triangular or rounded pleural base infiltrate adjacent to hilum)
  • VQ scans are "old school"= perfusion defects with normal ventilation (normal VQ rules out PE; abnormal – non-specific)
  • Venous duplex ultrasound of lower extremities (normal test does not exclude PE)
  • ABG = respiratory alkalosis secondary to hyperventilation
  • D-dimer

Tx: Heparin is the anticoagulant of choice for the acute phase with factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) and oral direct thrombin inhibitors (dabigatran) thereafter

Pulmonary hypertension Mean pulmonary artery pressure is ≥ 25 mmHg at rest (8-20 mmHg at rest is considered normal)

  • May cause right ventricular hypertrophy
  • Presentation: Dyspnea on exertion, fatigue, chest pain, edema
  • Diagnose with a right heart catheterization
  • Physical Exam: Loud P2, systolic ejection click, parasternal lift
Pneumothorax (ReelDx) (Prev Lesson)
(Next Lesson) Cor pulmonale
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