【COPD英文教学讲解课件】COPD-Leads-to-Cor-Pulmonale

COPDLeadstoCorPulmonaleKatherineKarczewskiRN,BSN,CENMarch1,2012MSN621CourseObjectivesDefineCorPulmonaleintheChronicObstructivePulmonaryDisease(COPD)Patient.DefinebrieflyChronicObstructivePulmonaryDisease.IdentifyCommonSignsandSymptomsinthephysicalexamoftheCOPDPatientwiththediagnosisofCorPulmonale.OutlineRoutineDiagnosticTestsusedtoConfirmtheCorPulmonaleDiagnosis.RecognizeStandardTreatmentsusedforCOPDPatientswithCorPulmonale.CasePresentationA67yearoldmalepatientwellknowntoyourclinicwithalongstandingdiagnosisofCOPDpresentscomplainingofweakness,increaseddyspnea,andfatigue.Hehasbeenexperiencingthesesymptomsforseveralmonths.Thesymptomshavegottenworsedespitetheuseofhisinhalers.Hereportsthathehashadbilaterallowerlegedemaforthepastmonth.Whatdoyoususpectthispatienthasdeveloped?COPDtoCorPulmonale

ThesearethemechanismsthatoccurwhenCOPDbecomesCorPulmonale.NowletslookatthepathwayfromCOPDtoCorPulmonale.Alexandria.healthlibrary.Ca2008PathwayofCOPDtoCorPulmonaleCOPDisthemostcommoncauseofCorPulmonale.Achronicincreaseinpulmonaryvascularresistancecausestherightventricletodistendandundergohypertrophy.Whentherightventriclecannolongercompensate,itcausesanincreaseintherightventricularend-diastolicpressureandtherightatrialpressure;causingrightheartfailureknowasCorPulmonale.CorPulmonaleisamaladaptiveresponsetopulmonaryhypertension.(UptoDate,2012)ReviewAnincreasedPO2andincreasedPCO2.Tryagain!COPDisachronicdisordercausingadecreaseinO2tothepatient.DecreasedPO2andIncreasedPCO2Correct!BasedonwhatweknowaboutCOPDwhatwouldyouexpectthearterialbloodgasestoshow?COPDtoCORPulmonaleThechronicinflammationandhypoventilationcausesthepulmonaryvasoconstrictionandsignalsthekidneytoreleaseerythropoietininresponsetothelowoxygenlevels.Thisinturnstimulatesthebonemarrowtoproducereticulocyteswhicharereleasedintothebloodstreamtobecomeerythrocytes.Becauseofthechroniclowoxygenlevelsthisprocessiscontinuallyoccurringcausinganexcessofredbloodcells(polycythemia).COPDtoCorPulmonaleTheprogressionofCOPDresultsinchronichypoxicpulmonaryvasoconstriction,polycythemia,impairedgasexchangesecondarytomucusoverproductionandairtrappingwhichdestroysthepulmonaryvascularbedbecauseofdecreasedoxygensupply.Theprogressionleadstopulmonaryhypertension;whichputsastressontherightventriclecausingittodistendandhypertrophy.HypertrophytotherightventricleisknownasCorPulmonale.ClinicalPresentationoftheCorPulmonalePatientMostofthesymptomsofCorPulmonalearenotoftenrecognizedbecausethesymptomsofCOPDaresimilarandcanbeoverlooked.ThesymptomsofCorPulmonaleare:increasedweakness,dyspnea,andfatigue.Theclinicalexamisveryimportantindetectingthesesubtlefindings.Letslookattheclinicalexam.ClinicalExaminationofPatientThepatienthasjugularvenousdistension.Bilaterallowerextremitypittingedema.Thepatientuseshomeoxygenat2L/nasalcannulaatbedtime.Thepatientsrestingpulseoximeterreadingis90%onroomair.Aholosystolicmurmurattheleftlowersternalbordercharacteristicoftricuspidinsufficiency.Rightupperquadrantdiscomfortuponpalpation.ThepatientcomplainsofexertionaldyspneaandfatiguedespiteuseofAlbuterolinhalerandPulmicortinhaler.

Whydoesthepatienthavecontinueddyspnea,fatigue,andalowpulseoxdespitewearingoxygen?

TheprogressionoftheCOPDcausingchangesinrespiratoryfunction.TheincreasedmucusproductionandincreasedresistancetooutflowcausetheincreasedSOBandfatigue.Thelowpulseoximeterreadingisaresultoftheworseningventilation-perfusionimbalanceinthelungsandincreasedpulmonaryhypertension.(UptoDate,2012)

Whydoes

thepatienthavejugularveindistention,peripheraledema,andrightupperquadrantdiscomfort?CorPulmonalepatientshavepulmonaryhypertensionwhichstrainstherightventricleoftheheart.Pulmonaryhypertensioncausesrightsidedheartfailureandischaracterizedby:1.Jugularveindistension2.Peripheraledemaoflegsandankle3.Rightupperquadrantpainfromhepaticcongestion(hepatomegaly)(UptoDate,2012)Whydowehearaholosystolicmurmur?TheincreasedintensityoftheS2heartsound(thesplitsecondheartsound)isasecondaryeffectofpulmonaryhypertension.Thetricuspidvalveinsufficiencyiscausedbyaregurgitationofbloodbecauseofpulmonaryhypertension.(Klabunde,2011)ReviewIncreasedmucusproduction,increasedrightsidedheartfailure,andprogressionofCOPD.Yes!IncreasedcardiacoutputandDecreasedpulmonaryvascularresistance.No.WeknowcorpulmonalehasdecreasedcardiacoutputandincreasedPVR.Leukemia.Noweknowthatpolycythemiaispresentincorpulmonalepatients.LetsReview.WhydoestheCorPulmonalePatienthaveincreaseddyspnea,fatigue,andweakness?DiagnosticTestsfortheCorPulmonalePatientChestRadiograph(CXR)Electrocardiogram(EKG)Echocardiogram(ECHO)PulmonaryFunctionTest(PFT)ChestRadiograph

Theradiographwouldshowanenlargedpulmonaryarteryduetopulmonaryhypertension.Thelateralviewwouldshowalossofretrosternalairspaceduetotheenlargementoftherightventricle.(UptoDate,2012)ChestRadiographL2012Electrocardiogram

TheEKGwouldpossiblyshowarightbundlebranchblockandrightaxisdeviationbecauseoftherightventriclehypertrophyandatrialenlargement.TherewillbedominantRwavesinV1andV2andprominentSwavesinV5andV6becauseofrightventricularhypertrophy.IncreasedPwaveamplitudeinLeadIIduetorightatrialenlargement.(UptoDate,2012)Echocardiogram

Theechocardiogramwillshowrightventricularhypertrophy,rightventriculardilationandtricuspidregurgitationduetorightatrialenlargement.(UptoDate,2012)PulmonaryFunctionTest

ThepulmonaryfunctiontestwillindicateanimpaireddiffusioncapacityduetotheacidoticpH.Itmayalsoshowarestrictiveventilatorydefect.(UptoDate,2012)RightHeartCatheterizationThisisconsideredthegoldstandardforCorPulmonaleDiagnosis.Thepatientwhopresentswithchestpainandhasnondiagnosticornormalresultsofthechestradiograph,echocardiogram,EKG,andpulmonaryfunctiontestswillhavearightheartcatheterizationdonetoconfirmthediagnosis.(UptoDate,2012)ReviewStresstest,CXR,andecho.No!thismaybeorderedtoconfirmCHFdiagnosis.Chestradiograph,EKG,EchoandPFT.Yes!CXR,ABG’sandsputumspecimen.Tryagain!Thismaybeusedtodiagnosealunginfection.WhatdiagnostictestsdoyouordertoconfirmtheCorPulmonalediagnosis?3MajorPhysiologicalGoalsof

CorPulmonaleTreatment1.Reducetherightventricularafterloadcausingareductionofthepulmonaryarterypressure.2.Decreaserightventricularpressure.3.Improvethecontractilityoftherightventricle.TreatmentofPatientswithCorPulmonaleOxygentherapyforpatientswithhypoxemia.Theoxygenwillimprovehypoxicvasoconstriction.Oxygenalsomayimprovepulmonaryarterypressureandpulmonaryvascularresistanceandpolycythemiaassociatedwithhypoxia.(UptoDate,2012)Treatment(cont.)Diuretictherapytoimproverightventricularfunctionduetoincreasedrightventricularpressures.Diureticsmustbeusedcarefullybecausecorpulmonalepatientsarepreloaddependentandanunderfillingoftherightventriclemaydecreasethestrokevolumeandincreasetheirsymptoms.Thediureticsmayalsoincreasethepatientsriskofdevelopingarrhythmiasandmetabolicacidosisbecauseofthelossofpotassiumfromthediuretics.(UptoDate,2012)Treatment(cont.)Inotropicagentsareusedtoincreasetherightventriclecontractilityanddecreasetherightventricleafterloadbyinducingpulmonaryvasodilation.(UptoDate,2012)ConclusionReducerightventicularafterload.Yes!Thatisone!Decreaserightventricularpressure.

Yes!Thatistwo!Improvethecontractilityoftherightventricle.Yes!Thatisthree!Whatarethe3majorphysiologicalgoalswecarryoutwhentreatingapatientwith