PANCE Blueprint Pulmonary (12%)

Pulmonary hypertension

Patient will present as → a 43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has narrow splitting of S1. Radiographic findings (seen here) demonstrate peripheral “pruning” of the large pulmonary arteries

**Peripheral “pruning” of the large pulmonary arteries is characteristic of pulmonary hypertension in severe emphysema

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

Pulmonary hypertension is usually caused by an underlying disorder such as constrictive pericarditis, mitral stenosis, LV failure, mediastinal disease compressing the pulmonary veins

  • Mitral stenosis is the most common cause of pulmonary HTN due to a cardiac problem. The mitral valve is so tight blood can't pass into the left ventral which backs pressure up into the lungs.

The pressure can become so great that the right heart can no longer pump against the vascular resistance which leads to right heart failure and Cor Pulmonale

Difficult to diagnose early on as signs and symptoms are often related to underlying cause

  • CXR, CT, PFTs, ECHO etc.
  • Right heart catheterization is the GOLD STANDARD for diagnosis of pulmonary HTN

Identify and treat the underlying cause

Pulmonary HTN

Question 1
What is the diagnostic study of choice for pulmonary hypertension?
A
right heart catheterization
B
spirometry
Hint:
Patients initially undergo chest x-ray, spirometry, and ECG to identify more common causes of dyspnea,
C
chest X-ray
Hint:
Patients initially undergo chest x-ray, spirometry, and ECG to identify more common causes of dyspnea,
D
echocardiography
Hint:
pulmonary artery pressure is estimated by echocardiography
Question 1 Explanation: 
Gold standard for diagnosis is right heart catheterization. Pulmonary hypertension is increased pressure in the pulmonary circulation. It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels become constricted. Severe pulmonary hypertension leads to right ventricular overload and failure. Symptoms are fatigue, exertional dyspnea, and, occasionally, chest discomfort and syncope. Diagnosis is made by finding elevated pulmonary artery pressure (estimated by echocardiography and confirmed by right heart catheterization). Treatment is with pulmonary vasodilators and diuretics. In some advanced cases, lung transplantation is an option. Prognosis is poor overall if a treatable secondary cause is not found.
Question 2
An O2 saturation of 90% corresponds to what PO2 value?
A
90 mmHg
Hint:
See D for explanation.
B
80 mmHg
Hint:
See D for explanation.
C
70 mmHg
Hint:
See D for explanation.
D
60 mmHg
Question 2 Explanation: 
O2 sat values above 90% correspond with a PO2 >70 mmHg and values less than 94% represent hypoxemia. Less than 90% O2 sat warrants measurement of arterial blood gasses.
Question 3
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of
A
≥ 5 mm Hg
Hint:
See D for explanation
B
≥ 10 mm Hg
Hint:
See D for explanation
C
≥ 15 mm Hg
Hint:
See D for explanation
D
≥ 25 mm Hg
Question 3 Explanation: 
Blood pressure in the lungs is usually very low < 15 mm HG. In pulmonary hypertension the pressure increases > 25 mmHG at rest!
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Pulmonary embolism (ReelDx) (Prev Lesson)
(Next Lesson) Restrictive Pulmonary Disease (PEARLS)
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