AHN 552 UNIT 3 VERIFIED STUDY GUIDE (CHRIS)
Pulmonary HTN; Patho: - Answers - The abnormally high blood pressure is associated
with changes in the small blood vessels (capillaries) in the lungs, resulting in an
increased resistance to blood flowing through the vessels
-The primary pathologic mechanism in pulmonary hypertension is an increase in
pulmonary vascular resistance that leads to an increase in the pulmonary systolic
pressure greater than 30 mm Hg or the mean pressure greater than 20 mm Hg.
In a healthy adult, normal pulmonary artery pressure (PAP) ranges from 12 to 16 mmHg
3
For Pulmonary HTN
PAP > ?? mmHg at rest
PAP > ?? mmHg with activity - Answers - PAP > 25 mmHg at rest
PAP > 30 mmHg with activity
Pulmonary HTN: MOST Likely to get - Answers - -Women, usually age 40s to 50s, are
almost 2-4 times as more likely to present with idiopathic PAH than men
Pulmonary HTN: Class of Severity - Answers - Class I: Pulmonary hypertension without
limitation of physical activity. No dyspnea, fatigue, chest pain, or near syncope with
exertion.
Class II: Pulmonary hypertension resulting in slight limitation of physical activity. No
symptoms at rest but ordinary physical activity causes dyspnea, fatigue, chest pain, or
near syncope.
Class III: Pulmonary hypertension resulting in marked limitation of physical activity. No
symptoms at rest but less than ordinary activity causes dyspnea, fatigue, chest pain, or
near syncope.
Class IV: Pulmonary hypertension with inability to perform any physical activity without
symptoms. Evidence of right heart failure. Dyspnea and fatigue at rest and worsening of
symptoms with any activity.
Treat: Idiopathic PAH (IPAH) - Answers - ● Tracleer is most effective drug for Idiopathic.
Very expensive and some insurances do not cover
● Tracleer is a vasodilator. Takes one month to see results.
● Side effects of Tracleer include liver damage, hypotension.
● Revatio is another drug that can be used, viagra family. Be careful with nitrates
● Flolan is a 24 hour IV drug. Complex and 25k a year
,Familial PAH (FPAH)
-Autosomal dominant with little penetrance - Answers - -Means that it does not manifest
in all persons carrying the gene
-Makes is difficult to trace the family history. Associated with a mutation of the bone
morphogenetic protein receptor II gene (BMPR2).
Associated PAH (APAH)
MOST COMMON CAUSE - Answers - -MOST COMMON CAUSE IS left sided heart
failure
-Generally occurs later in life secondary to another disease process
-Connective tissue dz, HIV, Drugs (phen phen)
Pulmonary HTN:
Assessment & Clinical Findings - Answers - ● Dyspnea, fatigue, chest pain, and
syncope on exertion.
● Clubbing
● Anginal pain, nonproductive cough, malaise, and fatigue may be presen
● Narrow splitting of second heart sound with loud pulmonary component; findings of
right ventricular hypertrophy and heart failure in advanced disease. Loud p2
● Hemoptysis is a rare but life-threatening event in pulmonary hypertension usually
caused by the rupture of a pulmonary artery.
Pulmonary HTN:
Diagnostics & Findings - Answers - ● Electrocardiographic evidence of right ventricular
strain or hypertrophy and right atrial enlargement.
● Enlarged central pulmonary arteries on chest radiograph.
● Elevated right ventricular systolic pressure on two-dimensional echocardiography with
Doppler flow studies.
● CT of chest shows Enlargement of the right and left main pulmonary arteries is
common
● VQ lung scanning is a very sensitive test that can differentiate chronic
thromboembolic pulmonary hypertension from idiopathic pulmonary arterial
hypertension.
● Currently, pulmonary angiography is considered the most definitive diagnostic
procedure for defining the distribution and extent of disease in chronic thromboembolic
pulmonary hypertension.
Pulmonary HTN:
Management
● Primary therapy refers to treatment directed at the underlying cause of pulmonary
hypertension - Answers - ● 02
● Fluid Restrictions to decrease preload and workload
● Heart Transplant
,● First-line therapy consists of oral calcium channel blockers. However, these
medications should only be given to patients with positive acute vasodilator response
when tested in the cardiac catheterization laboratory because they may be harmful to
nonresponders.
● Inotropes (ie, Digoxin) → ↑ CO
● Diuretics → ↓ Intravascular & Venous Return
● CCBs & other vasodilators → ↓ Myocardial Workload and O2 consumption
● Bronchodilators → Relax smooth muscle and ↑ airway patency
● β-blockers → ↓ cardiac workload and improve oxygenation
● Anticoagulant Therapy → avoid blood clots
Tuberculosis:
*** CXR appearance*** page 1814
● Primary Tuberculosis - Answers - Tuberculosis:
*** CXR appearance*** page 1814
● Primary Tuberculosis
● Primary tuberculous infiltrates can occur in any lobe.
● A pneumonic infiltrate with enlarged hilar or mediastinal nodes should strongly
suggest the diagnosis. The infiltrate usually is homogeneous and most commonly
involves a single lobe.
● Other findings include
○ Moderate to large pleural effusion
○ Miliary TB, which is characterized by the presence of innumerable 1- to 3-mm
noncalcified nodules dispersed throughout both lungs with mild basilar predominance
○ Tuberculomas: well-circumscribed nodular lesions of the parenchyma thought to be a
result of healed primary TB
○ Ghon Focus: calcified scar from healed primary TB
○ Simon's foci: calcified secondary foci of infection
○ Ranke complex: a Ghon Focus associated with calcified hilar nodes
CXR Findings in Primary TB (6) - Answers - 1) Associated hilar/mediastinal
lymphadenopathy may be the only distinguishing feature from bacterial pneumonia and
strongly suggests TB
2) Innumeralbe 1-3mm noncalcified nodules in both lungs with mild basilar
predominance=military TB
3) Moderate to large pleural effusion that increases with age
4) Abscess
5) Ghon focus (healed TB, calcified well circumscribed nodule/scar)
6) Simon's foci (calcified secondary foci of infection)
7) Ranke complex (Ghon focus with calcified hilar nodes)
TB x ray
is considered the radiologic hallmark of primary TB in children but is seen less
commonly in adults. - Answers - ● Lymphadenopathy
, When it is present, adenopathy usually is unilateral and associated with parenchymal
infiltrate .
It may occur bilaterally or, more rarely, may be an isolated finding on chest radiography.
TB x ray
is more common in young children. As a result, atelectasis, resulting from airway
compression by adjacent enlarged nodes - Answers - ● Massive hilar adenopathy
Post Primary Tuberculosis x ray
● Cavitation should alert ED personnel to the potential high infectivity of the patient and
the potential for associated complications, such as bronchogenic spread of TB, when an
area of caseous necrosis liquefies, with consequent communication with the bronchial
tree.
○ A hazy, parenchymal reaction around a cavity with an ill-defined wall strongly
suggests an active lesion - Answers - ● Typically appears as an upper lung infiltrate or
consolidation, with or without cavitation.
● Also occurs in the lower lung
● Bronchogenic spread can occur, leading to involvement of multiple lobes.
● Bilateral upper lobe disease is extremely likely to be TB
● Initial lesions
○ Poorly defined, heterogeneous alveolar opacity called an exudative lesion
○ Not purely exudative in that they are associated with a fibrotic pattern of nodules and
a few fine, linear densities
Post Primary Tuberculosis x ray
● Cavitation should alert ED personnel to the - Answers - potential high infectivity of the
patient and the potential for associated complications, such as bronchogenic spread of
TB, when an area of caseous necrosis liquefies, with consequent communication with
the bronchial tree.
○ A hazy, parenchymal reaction around a cavity with an ill-defined wall strongly
suggests an active lesion
What does post-primary TB typically look like on CXR - Answers - 1) Upper lung
infiltrate or consolidation, with or without cavitation
2) Bilat upper lobe disease is extremely likely to have TB
***Hospital management in suspicious cases to prevent transmission*** pages 1821,
1829 - Answers - ● Rapid identification through ED triage screening
● Immediate respiratory isolation
● Negative pressure rooms.
● PPE with appropriate face masks
Pulmonary HTN; Patho: - Answers - The abnormally high blood pressure is associated
with changes in the small blood vessels (capillaries) in the lungs, resulting in an
increased resistance to blood flowing through the vessels
-The primary pathologic mechanism in pulmonary hypertension is an increase in
pulmonary vascular resistance that leads to an increase in the pulmonary systolic
pressure greater than 30 mm Hg or the mean pressure greater than 20 mm Hg.
In a healthy adult, normal pulmonary artery pressure (PAP) ranges from 12 to 16 mmHg
3
For Pulmonary HTN
PAP > ?? mmHg at rest
PAP > ?? mmHg with activity - Answers - PAP > 25 mmHg at rest
PAP > 30 mmHg with activity
Pulmonary HTN: MOST Likely to get - Answers - -Women, usually age 40s to 50s, are
almost 2-4 times as more likely to present with idiopathic PAH than men
Pulmonary HTN: Class of Severity - Answers - Class I: Pulmonary hypertension without
limitation of physical activity. No dyspnea, fatigue, chest pain, or near syncope with
exertion.
Class II: Pulmonary hypertension resulting in slight limitation of physical activity. No
symptoms at rest but ordinary physical activity causes dyspnea, fatigue, chest pain, or
near syncope.
Class III: Pulmonary hypertension resulting in marked limitation of physical activity. No
symptoms at rest but less than ordinary activity causes dyspnea, fatigue, chest pain, or
near syncope.
Class IV: Pulmonary hypertension with inability to perform any physical activity without
symptoms. Evidence of right heart failure. Dyspnea and fatigue at rest and worsening of
symptoms with any activity.
Treat: Idiopathic PAH (IPAH) - Answers - ● Tracleer is most effective drug for Idiopathic.
Very expensive and some insurances do not cover
● Tracleer is a vasodilator. Takes one month to see results.
● Side effects of Tracleer include liver damage, hypotension.
● Revatio is another drug that can be used, viagra family. Be careful with nitrates
● Flolan is a 24 hour IV drug. Complex and 25k a year
,Familial PAH (FPAH)
-Autosomal dominant with little penetrance - Answers - -Means that it does not manifest
in all persons carrying the gene
-Makes is difficult to trace the family history. Associated with a mutation of the bone
morphogenetic protein receptor II gene (BMPR2).
Associated PAH (APAH)
MOST COMMON CAUSE - Answers - -MOST COMMON CAUSE IS left sided heart
failure
-Generally occurs later in life secondary to another disease process
-Connective tissue dz, HIV, Drugs (phen phen)
Pulmonary HTN:
Assessment & Clinical Findings - Answers - ● Dyspnea, fatigue, chest pain, and
syncope on exertion.
● Clubbing
● Anginal pain, nonproductive cough, malaise, and fatigue may be presen
● Narrow splitting of second heart sound with loud pulmonary component; findings of
right ventricular hypertrophy and heart failure in advanced disease. Loud p2
● Hemoptysis is a rare but life-threatening event in pulmonary hypertension usually
caused by the rupture of a pulmonary artery.
Pulmonary HTN:
Diagnostics & Findings - Answers - ● Electrocardiographic evidence of right ventricular
strain or hypertrophy and right atrial enlargement.
● Enlarged central pulmonary arteries on chest radiograph.
● Elevated right ventricular systolic pressure on two-dimensional echocardiography with
Doppler flow studies.
● CT of chest shows Enlargement of the right and left main pulmonary arteries is
common
● VQ lung scanning is a very sensitive test that can differentiate chronic
thromboembolic pulmonary hypertension from idiopathic pulmonary arterial
hypertension.
● Currently, pulmonary angiography is considered the most definitive diagnostic
procedure for defining the distribution and extent of disease in chronic thromboembolic
pulmonary hypertension.
Pulmonary HTN:
Management
● Primary therapy refers to treatment directed at the underlying cause of pulmonary
hypertension - Answers - ● 02
● Fluid Restrictions to decrease preload and workload
● Heart Transplant
,● First-line therapy consists of oral calcium channel blockers. However, these
medications should only be given to patients with positive acute vasodilator response
when tested in the cardiac catheterization laboratory because they may be harmful to
nonresponders.
● Inotropes (ie, Digoxin) → ↑ CO
● Diuretics → ↓ Intravascular & Venous Return
● CCBs & other vasodilators → ↓ Myocardial Workload and O2 consumption
● Bronchodilators → Relax smooth muscle and ↑ airway patency
● β-blockers → ↓ cardiac workload and improve oxygenation
● Anticoagulant Therapy → avoid blood clots
Tuberculosis:
*** CXR appearance*** page 1814
● Primary Tuberculosis - Answers - Tuberculosis:
*** CXR appearance*** page 1814
● Primary Tuberculosis
● Primary tuberculous infiltrates can occur in any lobe.
● A pneumonic infiltrate with enlarged hilar or mediastinal nodes should strongly
suggest the diagnosis. The infiltrate usually is homogeneous and most commonly
involves a single lobe.
● Other findings include
○ Moderate to large pleural effusion
○ Miliary TB, which is characterized by the presence of innumerable 1- to 3-mm
noncalcified nodules dispersed throughout both lungs with mild basilar predominance
○ Tuberculomas: well-circumscribed nodular lesions of the parenchyma thought to be a
result of healed primary TB
○ Ghon Focus: calcified scar from healed primary TB
○ Simon's foci: calcified secondary foci of infection
○ Ranke complex: a Ghon Focus associated with calcified hilar nodes
CXR Findings in Primary TB (6) - Answers - 1) Associated hilar/mediastinal
lymphadenopathy may be the only distinguishing feature from bacterial pneumonia and
strongly suggests TB
2) Innumeralbe 1-3mm noncalcified nodules in both lungs with mild basilar
predominance=military TB
3) Moderate to large pleural effusion that increases with age
4) Abscess
5) Ghon focus (healed TB, calcified well circumscribed nodule/scar)
6) Simon's foci (calcified secondary foci of infection)
7) Ranke complex (Ghon focus with calcified hilar nodes)
TB x ray
is considered the radiologic hallmark of primary TB in children but is seen less
commonly in adults. - Answers - ● Lymphadenopathy
, When it is present, adenopathy usually is unilateral and associated with parenchymal
infiltrate .
It may occur bilaterally or, more rarely, may be an isolated finding on chest radiography.
TB x ray
is more common in young children. As a result, atelectasis, resulting from airway
compression by adjacent enlarged nodes - Answers - ● Massive hilar adenopathy
Post Primary Tuberculosis x ray
● Cavitation should alert ED personnel to the potential high infectivity of the patient and
the potential for associated complications, such as bronchogenic spread of TB, when an
area of caseous necrosis liquefies, with consequent communication with the bronchial
tree.
○ A hazy, parenchymal reaction around a cavity with an ill-defined wall strongly
suggests an active lesion - Answers - ● Typically appears as an upper lung infiltrate or
consolidation, with or without cavitation.
● Also occurs in the lower lung
● Bronchogenic spread can occur, leading to involvement of multiple lobes.
● Bilateral upper lobe disease is extremely likely to be TB
● Initial lesions
○ Poorly defined, heterogeneous alveolar opacity called an exudative lesion
○ Not purely exudative in that they are associated with a fibrotic pattern of nodules and
a few fine, linear densities
Post Primary Tuberculosis x ray
● Cavitation should alert ED personnel to the - Answers - potential high infectivity of the
patient and the potential for associated complications, such as bronchogenic spread of
TB, when an area of caseous necrosis liquefies, with consequent communication with
the bronchial tree.
○ A hazy, parenchymal reaction around a cavity with an ill-defined wall strongly
suggests an active lesion
What does post-primary TB typically look like on CXR - Answers - 1) Upper lung
infiltrate or consolidation, with or without cavitation
2) Bilat upper lobe disease is extremely likely to have TB
***Hospital management in suspicious cases to prevent transmission*** pages 1821,
1829 - Answers - ● Rapid identification through ED triage screening
● Immediate respiratory isolation
● Negative pressure rooms.
● PPE with appropriate face masks
