Review Article
best: (Crit Care Med 2007;35:2037)
(Clinical Pulmonary Medicine 2004;11(1):40)
Cor pulmonale is pulmonary hypertension in the setting of respiratory disease either acute or chronic, it does not require right heart failure thought that is sometimes a sequelae
Divided into primary, which is idiopathic (PPH or IPH) and secondary, from a cause outside of the lung vasculature.
While acute disease may be reversible, vascular remodeling in chronic disease may be permanent
PPH
unknown etiology, there have been associations with amphetamine diet aids, contaminated rapeseed oil, and contaminated l-tryptophan.
Patients present with substernal chest pain or pressure, exertional dyspnea, fatigue, and possibly syncope.
Diagnostics
Chest x-ray will show prominent pulmonary arterial vasculature
ECG will may show right ventricular hypertrophy
High resolution CT, Perfusion nuclear scanning, MRI, and angiography may all be useful. Cardiac cath may be needed as well. Lung biopsy may be a final, necessary step to make a diagnosis of cause for PH.
Therapy
Correct hypoxemia
PaO2<55 or PaO2<59 with Crit>55, p pulmonale, or edema should be treated with chronic supplemental O2
CCBs, Iv nitroglycerin, IV Prostacyclin, epoprostenol (Flolan), eventual lung transplantation
vasodilator therapy is not without risks as it can cause systemic hypotension or worsen PH b/c if the pulmonary diameter is fixed, it will just cause decreased RH pressures without affecting pulmonary.
at risk for venous thromboembolic disease
chronic VTE can also be the cause of pulmonary hypertension and often the patient will have dramatic improvement if the clot is removed
can cause pulmonary hypertension
PAH associated with syncope, vasovagal, and sudden death
hypoxemia and hypercarbia are both vasoconstrictors
sleep apnea to pulm htn to apnea to worsening pulm htn
coumadin o2 diuretics
1. Get Intervia (empty IV bag) and light proof plastic bag.
2. Mix Flolan with sterile diluent
3. Inject Flolan into intervia
4. Place Ice on both sides in light-proof bag
5. Use normal IV tubing, no filter required.
6. Convert pt’s 24 hour rate to hourly rate