Clinical features and diagnosis of pulmonary vascular diseases

1. PULMONARY EMBOLISM
CLINICAL features &
Diagnosis

2. .
• Life threatening causes of chest pain and shortness of breath “DYSPNOEA
• Pain sharp worse fro deep breathe “often called pleuritic pain”.
• They may present with HEMOPTYSIS
• The patient may have stable vital signs (blood pressure, heart rate, respiratory rate, and
oxygen saturation) but frequently presents with an elevated heart rate.
• A severe pulmonary embolus can present with shock or cardiac arrest, particularly when a
large clot blocks the outflow of blood from the right side of the heart to the lungs (saddle
embolus).
• Depending on the amount of blood clot (clot burden or clot load),
• oxygen saturation can be variably compromised as can the blood pressure and heart
rate. In a classic presentation,
•The heart rate and respiratory rate are elevated as the body tries to compensate.

3. INVESTIGATION
ATERIAL BLOOD
• PaCO2– Partial pressureofCO2in the blood ,critical in regulating levels and
maintaining body ph
• PaCO2is maintained at 5.3 kPa (40 mmHg)
• D- dimer and other circulating markers.
• D-dimers is a specific degradation product released into the circulation when
cross-linked fibrin undergoesendogenosis.
• An elevated D-dimer is limited value, as it occursin a numberofconditions
including P.E

4. .
• Take note of the chest pain and
breathlessness
• Physical examination will concentrate
Heart and lungs
Since the chest pain may
be presenting complains of heart attack
Pneumonia,
pneumothorax ( collapsed lung)
And dissection of an
aortic aneurysm
• The physical exam will also include
looking for signs of a D.V.T in an
extremely
warmth
swelling
redness , and
tenderness.
• NB note that the signs associated with deep vein thrombosis
may be completely absent even in the PRESENTS of a clot.

5. ‘
• Full blood count
• Electrolytes
• BUN (blood urea nitrogen)
• Creatinine blood test
• Chest x-ray, and
• Electrocardiogram
• The chest x-ray is often normal in P.E
• The EKG/ECG may be normal, but usually
demonstration a rapid heart rate
• So called sinus tachycardia (heart > 100 bpm).
• If there is significant blockage in a pulmonary
artery.
• It acts like a dam and it harder for the heart to
push blood pas t the obstruction clot or clots.
• This can result in the change in the electrical
signal passing through the heart by stretching
the heart muscle, revealed on a EKG a so called
right heart strain.
• Since the cost of missing the diagnosis of P.E can
be death, the approach to diagnosis is to prove
that no P.E exists.

6. PULMONARY Hypertension

7.  Fatigue
 Hoarseness
 Difficulty breathing (dyspnoea)
 Dizziness
 Palpitations
 Fainting spells ( syncope )
 Swelling of legs and ankles ( edema)
 Bluish Lips, skin ( cyanosis )
 Chest pain

8. .
 A complete history and physical exam is done.
 An electrocardiogram (ECG) may show a strain on the right side of your
 heart.
 Blood tests are done to indicate how much oxygen is in your blood, or to test
 if you have a collagen vascular disease.
 A chest x-ray may show a large pulmonary artery and right-sided heart. This
 test may also show diseases of the lung such as
 emphysema.
 A lung scan is done to show the blood supply
 in your lungs
 A CT or CAT scan is a computerized x-ray
 that can get a better view of the lungs and your
 heart.
 Echocardiogram uses sonar (sound waves) to
 show the pumping function of your heart and how the valves work.
 A pulmonary function test is done to measure the volume of air in your
 lungs. Results are obtained by breathing into a mouth piece while exercising
 on a treadmill or bicycle.
 An exercise tolerance test will require you to walk on a treadmill as fast as
 you can for 6 minutes to evaluate how much exercise you can do before you
 have symptoms.
 A right heart catheterization is the most accurate way to diagnose
 pulmonary hypertension. A small tube or catheter is put into a vein in your
 neck and then guided into the right side of your heart and pulmonary artery to
 measure pressures.

9. Clinical features Pulmonary edema
 Cardiogenic pulmonary edema
◦ ischemia with or without myocardial infarction
◦ exacerbation of chronic systolic or diastolic heart
failure, and dysfunction of the mitral or aortic valve
◦ paroxysmal nocturnal dyspnea or orthopnea
 Noncardiogenic pulmonary edema
◦ pneumonia
◦ sepsis
◦ aspiration of gastric contents
◦ major trauma associated with the administration of
multiple blood-product transfusions

10. Laboratory Testing
 Electrocardiography
 Elevated troponin
levels
 Measurement of
electrolytes, the
serum osmolarity,
and a toxicology
screen
 Serum amylase and
lipase

11. Laboratory Testing
 BNP level below 100 pg per milliliter
indicates that heart failure is unlikely
(negative predictive value, >90 percent)
 BNP level greater than 500 pg per
milliliter indicates that heart failure is
likely (positive predictive value, >90
percent)
 BNP is secreted predominantly by the
cardiac ventricles in response to wall
stretch or increased intracardiac pressures

12. Laboratory Testing
 BNP levels between 100 and
500 pg per milliliter provide
inadequate diagnostic
discrimination
 BNP can also be secreted by
the right ventricle, and
moderate elevations have
been reported in patients
with acute pulmonary
embolism, cor pulmonale,
and pulmonary hypertension

14. Echocardiography
 The first approach to assessing left
ventricular and valvular function in
patients in whom the history, physical and
laboratory examinations, and the chest
radiograph do not establish the cause of
pulmonary edema
 Less sensitive in identifying diastolic
dysfunction
 Does not rule out cardiogenic pulmonary
edema

15. Pulmonary-Artery Catheterization
 Assess the pulmonary-artery occlusion
pressure
 Is considered the gold standard for
determining the cause of acute pulmonary
edema
 Monitoring of cardiac filling pressures, cardiac
output, and systemic vascular resistance
 Common complications included hematoma
at the insertion site, arterial puncture,
bleeding, arrhythmias, and bloodstream
infection

16. Clinical Presentation AV
malformations
 Present as:
◦ Mass lesion
◦ Birthmarks
◦ Atypical varicosities
◦ Limb enlargement
 Most are evident at birth,
except AVM which present at
early childhood or
adolescence.

17. Staging of AVMs
Stage Manifestation
Stag I
Quiescence
Cutaneous blush or warmth
Stage II
Expansion
Bruit, thrill or other signs of
expansion
Stage III
Destruction
Pain, bleeding, ulceration or infection
Stage IV
Decompensati
on
Cardiac Failure

18. Diagnosis
 Essentially by Imaging studies:
US (initial evaluation)
CT scan, CT Angiography
MRI, MRA (leading imaging modality)
Conventional Angiography
1. Diagnosis
2. Determine the extent of the lesion
3. Search for associated abnormalities