Download Pulmonary Hypertension - Ellen Kantor, SRNA, BSN, RN

Pulmonary Hypertension
Ellen Kantor, SRNA
University of Pennsylvania
N746- Summer 2013
Let’s Review…
 From RVpulmonic (semilunar valve)pulmonary artery
 From pulmonary veinLALVsystemic circulation
 Pulmonary vessels innervated by
sympathetic nervous system
 Alpha adrenergic- norepinephrine
causes vasoconstriction
 Beta adrenergic- such as isoproterenol
causes vasodilation
 Regulation of flow is mostly
passive and controlled by
OXYGEN.
Pulmonary Hypertension: Statistics
 Average age at diagnosis: 36 years
 Women > Men
 10-15 million people/million diagnosed each year
 3 year survival at time of diagnosis: approximately 50%
Pulmonary Hypertension
 NORMAL PRESSURES:
 Systolic: 15-30 mmHg
 Diastolic: 5-15 mmHg
 Mean: 10-20 mmHg
HYPERTENSION:
 Defined as a sustained pulmonary artery pressure of 40/20
mmHg and a mean pulmonary artery pressure of 25
mmHg.
Pulmonary Hypertension
 World Health Organization (WHO) classifies into 5 groups
I: idiopathic/primary pulmonary
arterial hypertension
V: miscellaneous
pulmonary
vasculature diseases
IV: chronic thromboembolic disease
II: pulmonary venous
hypertension
III: lung disease or hypoxemia
What went wrong?
 Patients have endothelial dysfunction where
there is a decrease in synthesis of vasodilators
such as NO and prostacyclin but an increase in
thromboxane and vascular endothelial growth
factor (vasoconstrictors).
Side note…
 Inhaled NO increased systemic O2 in hypoxemic newborns
with pulmonary hypertension.
 Decreased need for ECMO
Presenting Signs and Symptoms
 Symptoms are usually nonspecific
 Dyspnea
 Angina
 Nonproductive cough
 Clubbing
Ring a bell??
 Rarely, patients present with syncope and hemoptysis,
indicating severe disease.
Signs and Symptoms
 While providers are struggling to diagnose a cause of the patient’s
nonspecific symptoms, patients can experience acute
decompensation from hypoxia, hypercarbia, vasocontrictors,
increased sympathetic tone (ANXIETY), and increased pulmonary
vascular resistance (PVR) all leading to right heart failure.
Systemic effects
• Any abrupt increase in
PVR can lead to right
heart failure or
desaturation, further
leading to decreased
blood flow and
oxygenation of the left
heart, causing
decreased cardiac
output and ischemia.
Treatment Options
 Supplemental O2 at home
 Medication management: diuretics, anticoagulants, calcium
channel blockers, phosphodiesterase inhibitors, prostanoids,
endothelin receptor antagonists
 Surgical management
 Lung transplant
 Heart/lung transplant
 Pulmonary Thromboendarterectomy
Preoperative Management
 2D ECHO: gold standard
 EKG
 X RAY
 Labs: CBC, CMP (include LFTs)
 Spirometry (PFTs)
 Conduct an extensive ROS to identify moderate-severe
disease.
 Consider pre-operative Iloprost inhalation
 ***CONTINUE ALL MEDICATIONS ON DAY OF SURGERY
Preoperative Management
Intraoperative Management
 ***CONTINUE ALL MEDICATIONS ON DAY OF SURGERY
 Consider regional anesthesia, MAC
 Consider fiberoptic intubation
 Standard ASA monitors +/- ABG, a-line, central line, foley
 ***Any airway manipulation can cause activation of sympathetic
nervous system and cause a pulmonary hypertensive crisis.
 MOST IMPORTANTLY: avoid pulmonary
hypertensive crisis (hypoxemia, hypercarbia, metabolic
acidosis, hypothermia, airway manipulation)
Postoperative Management
 Interdisciplinary challenge
 Intermittent iloprost inhalation
 Long half life
 Continuous monitoring- O2 sats, pain, vital signs
 Consider continous regional analgesia to avoid high opioid doses
Case Report #1
Case Report #2
Case Report #3
References
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