Cor pulmonale

Cor pulmonale is alteration in the structure and function of the right ventricle (RV) of the heart. The overall five-year survival rate for cor pulmonale complicating COPD is approximately 50%.

1. COR PULMONALE -MR. MIGRON RUBIN

2. INTRODUCTION Pulmonary hypertension is often the common link between lung dysfunction and the heart in cor pulmonale. cor pulmonale commonly has a chronic and slowly progressive course, acute onset or worsening cor pulmonale with life-threatening complications can occur.

3. KEY WORDS Cor pulmonale- It is alteration in the structure and function of the right ventricle (RV) of the heart. Proliferation- It is the growth or production of cells by multiplication of parts. Lingula - The lingula is a combined term for the two lingular bronchopulmonary segments of the left upper lobe: superior lingular segment. inferior lingular segment.

4. ANATOMY OF HUMAN HEART Pericardium The heart sits within a fluid-filled cavity called the pericardial cavity. The walls and lining of the pericardial cavity are a special membrane known as the pericardium. Pericardium is a type of serous membrane that produces serous fluid to lubricate the heart and prevent friction between the ever beating heart and its surrounding organs.

5. Structure of the Heart Wall The heart wall is made of 3 layers: epicardium, myocardium and endocardium. Epicardium- The epicardium is the outermost layer of the heart wall and is just another name for the visceral layer of the pericardium. Myocardium -The myocardium is the muscular middle layer of the heart wall that contains the cardiac muscle tissue. Myocardium makes up the majority of the thickness and mass of the heart wall and is the part of the heart responsible for pumping blood. Endocardium .- Endocardium is the simple squamous endothelium layer that lines the inside of the heart.

6. Chambers of the Heart The heart contains 4 chambers: the right atrium, left atrium, right ventricle, and left ventricle.

7. Valves of the Heart Atrioventricular valves. The atrioventricular (AV) valves are located in the middle of the heart between the atria and ventricles and only allow blood to flow from the atria into the ventricles. The AV valve on the right side of the heart is called the tricuspid valve because it is made of three cusps (flaps ). Semilunar valves. The semilunar valves, so named for the crescent moon shape of their cusps, are located between the ventricles and the arteries that carry blood away from the heart. The semilunar valve on the right side of the heart is the pulmonary valve, so named because it prevents the backflow of blood from the pulmonary trunk into the right ventricle.

8. Conduction System of the Heart The conduction system starts with the pacemaker of the heart—a small bundle of cells known as the sinoatrial (SA) node . The AV node is located in the right atrium in the inferior portion of the interatrial septum. The AV node picks up the signal sent by the SA node and transmits it through the atrioventricular (AV) bundle.

9. LUNGS The lungs are located in the chest on either side of the heart in the rib cage. They are conical in shape with a narrow rounded apex at the top and a broad base that rests on the diaphragm . The apex of the lung extends into the root of the neck, reaching shortly above the level of the sternal end of the first rib.

10. The lungs are surrounded by the pulmonary pleurae. The pleurae are two serous membranes. Between the pleurae is a potential space called the pleural cavity containing pleural fluid. Each lung is divided into lobes by the invaginations of the pleura as fissures. The fissures are double folds of pleura that section the lungs and help in their expansion. The lobes of the lungs are further divided into bronchopulmonary segments based on the locations of bronchioles .The segmental anatomy is useful clinically for localizing disease processes in the lungs.

11. Right Lung -The right lung has both more lobes and segments than the left. It is divided into three lobes, an upper, middle, and a lower, by two fissures, one oblique and one horizontal. Left lung - The left lung is divided into two lobes, an upper and a lower, by the oblique fissure, which extends from the costal to the mediastinal surface of the lung both above and below the hilum.

12. DEFINITION Cor pulmonale is defined as an alteration in the structure and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory system.

13. ETIOLOGY Pulmonary Vascular disease Pulmonary embolism COPD

14. PATHOPHYSIOLOGY

15. CLINICAL MANIFESTATIONS Fatigue Tachypnea Exertional dyspnea Cough. Cyanosis can be seen in chest Chronic Hypoxemia Anginal pain -due to right ventricular ischemia Hemoptysis - due to rupture of a dilated or atherosclerotic pulmonary arteriole. R ight upper quadrant abdominal discomfort, and jaundice. Peripheral edema occurs due to elevated pulmonary artery pressure

16. DIAGNOSTIC EVALUATION History Collection Physical Examination- increase in chest diameter, distended neck veins and cyanosis may be seen. On auscultation of the lungs, wheezes and crackles may be heard . On percussion, hyper-resonance of the lungs may be a sign of underlying COPD.   Pulmonary function tests   ABG analysis- Reveals decreased PaO2 & pH and Increased PaCo2.(hypercapnia).

17. Hematocrit count- It is done for polycythemia ,   Serum alpha1-antitrypsin, if deficiency is suspected Antinuclear antibody (ANA) level for collagen vascular disease, and anti-SCL-70 antibodies in scleroderma Coagulations studies to evaluate hypercoagulability states ( eg , serum levels of proteins S and C, antithrombin III, factor V Leyden, anticardiolipin antibodies, homocysteine ) Brain Natriuretic Peptide- Brain natriuretic peptide (BNP) is a peptide hormone that is released in response to volume expansion. ECG – ECG changes can be seen due to Right Ventricle Hypertrophy. ECG changes may include the following : Right axis deviation P-pulmonale pattern (an increase in P wave amplitude in leads 2, 3, and aVF ) Low-voltage QRS because of underlying COPD with hyperinflation 2-D and Doppler Echocardiography- Magnetic Resonance Imaging Cardiac Catheterization

18. MANAGEMENT Medical Management A. Pharmacological Management Diuretics Calcium channel blockers Vasodilator drugs Bronchodilators- Theophylline Warfarin- Anticoagulation with warfarin is recommended in patients at high risk for thromboembolism. Thrombolytic therapy   Inotropes with vasodilatory properties

19. B. Non Pharmacological Management Oxygen Therapy

20. II. Surgical Management Phlebotomy   Lung transplantation

21. Nursing Management Assessment Determine if the patient has experienced orthopnea, cough, fatigue, epigastric distress, anorexia, or weight gain or has a history of previously diagnosed lung disorders. Ask if the patient smokes cigarettes, noting the daily consumption and duration. Ask about the color and quantity of the mucus the patient expectorates. Determine the type of dyspnea if it is related only to exertion or is continuous. Observe if the patient has difficulty in maintaining breath while the history is taken. Evaluate the rate, type, and quality of respirations. Observe the patient for dependent edema from the abdomen (ascites) and buttocks and down both legs. Inspect the patient's chest and thorax for the general appearance and anteroposterior diameter. Look for the use of accessory muscles in breathing.

22. Nursing Diagnosis Impaired gas exchange related to excess fluid in lungs; increased pulmonary vascular resistance . Decreased cardiac output related to an ineffective ventricular pump Excess Fluid volume related to right sided heart failure Acute pain related to right ventricular ischemia & decreased oxygen supply Activity intolerance related to abnormal pulse, ECG changes & chest pain.

23. COMPLICATIONS Exertional syncope. Hypoxia and significantly limited exercise tolerance. Peripheral oedema . Peripheral venous insufficiency. Tricuspid regurgitation. Hepatic congestion and cardiac cirrhosis. Death.

24. PROGNOSIS The overall five-year survival rate for cor pulmonale complicating COPD is approximately 50%. Prognosis also appears to be significantly improved by smoking cessation and correct use of long term o2 therapy.

25. HEALTH EDUCATION Advice patient to take protein rich diet. Educate patient regarding his disease condition. Educate patient regarding modification in lifestyle like cessation of smoking & alcohol consumption. Advice patient to reduce spicy & fatty foods. Instruct patient to avoid caffeine intake which can increase pulse rate & produce angina. Educate patient to minimize level of activities to prevent strain. Advice patient for regular follow-up & care.

26. RELATED RESEARCH Boissier , F., Katsahian et. Al . (2013). Conducted a study to assess Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome. The study was conducted among 226 patients with ARDS revealed cor pulmonale in 22% .A greater proportion of patients with cor pulmonale (79.6%) had infection-related lung injuries compared to patients without lung injury (57.6%) (p value < 0.01). Having an infection-related lung injury was associated with a 2.87 (p < 0.01) increased risk of cor pulmonale. In this sample, 28-day mortality rates were higher among patients with cor pulmonale (60%) than patients without (30%).

27. THEORY APPLICATION

28. PRESENTER’S VIEW Cor pulmonale commonly has a chronic and slowly progressive course, acute onset or worsening cor pulmonale with life-threatening complications can occur. Cor pulmonale has poor prognosis. SUMMARY Pulmonary heart disease, also known as cor pulmonale is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance (such as from pulmonic stenosis) or high blood pressure in the lungs. Cor pulmonale is failure of the right side of the heart.

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