PANCE Blueprint Pulmonary (10%)

Pulmonary Circulation (PEARLS)

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

Cor pulmonale Right ventricular enlargement and eventually failure secondary to lung disorder that causes pulmonary artery HTN


  • Echocardiogram or radionuclide imaging; sometimes right heart catheterization

TX: Diagnose and treat the underlying condition before cardiac structure change becomes irreversible

    • Diuretics not helpful! May be harmful


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 Blood pressure in the lungs is usually very low 15/5. In pulmonary hypertension, the pressure increases > 25 mmHg at rest

  • Usually caused by an underlying disorder (constrictive pericarditis, mitral stenosis = MC, LV failure, mediastinal disease compression pulmonary veins)
    • Mitral stenosis: mitral valve = tight so blood can’t pass into left ventricle ⇒ pressure backs up to lungs
  • When the right heart can’t pump against vascular resistance ⇒ right heart failure = cor pulmonale
  • Presentation: Dyspnea on exertion, fatigue, chest pain, edema
  • Physical Exam: Loud pulmonic component of second heart sound (P2); Jugular venous distension; Ascites; Hepatojugular reflux; Lower limb edema

Diagnose with a right heart catheterization (gold standard)  → most accurate measure of pressures

  • CXR
    • Enlarged pulmonary arteries
    • Lung fields may or may not be clear, dependent on the underlying cause
  • Echocardiogram
    • Increased pressure in pulmonary arteries, right ventricles → dilated pulmonary artery
    • Dilatation/hypertrophy of right atrium, right ventricle
    • Large right ventricle → bulging septum
  • ECG → Right heart strain pattern: T wave inversion in right precordial (V1–V4), and inferior leads (II, III, aVF)

TX: identify and treat the underlying cause

Pneumothorax (ReelDx) (Prev Lesson)
(Next Lesson) Cor pulmonale
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