Corpulmonale

Corpulmonale

1. COR PULMONALE Mrs. D. Melba Sahaya Sweety M.Sc Nursing GIMSAR

2. INTRODUTION Cor pulmonale is a Latin word that means "pulmonary heart," its definition varies, and presently, there is no consensual. Cor pulmonale is a condition that most commonly arises out of complications from high blood pressure in the pulmonary arteries ( pulmonary hypertension ). It’s also known as right-sided heart failure because it occurs within the right ventricle of your heart. Cor pulmonale causes the right ventricle to enlarge and pump blood less effectively than it should. The ventricle is then pushed to its limit and ultimately fails.

3. It is the hypertrophy of the right ventricle resulting from diseases affecting the function and/or structure of the lung, except when these pulmonary alterations are the result of diseases that primarily affect the left side of the heart or congenital heart disease (WHO, 1963) DEFINITION

4.   Cor pulmonale is the enlargement of the right ventricle secondary to diseases of the lung , thorax, or pulmonary circulation. Pulmonary hypertension is usually a pre-existing condition in the individual with cor pulmonale . The most common cause is COPD. ( lewis ) DEFINITION

5.  The prevalence of COPD in the United States is reported to be about 15 million, Cor pulmonale is estimated to account for 6% to 7% percent of all types of adult heart disease in the United States.  Chronic cor pulmonale accounted for 16.6 per cent of all cardiac cases in a five-year survey in Delhi and the figure was the highest in the world for a non-industrial population.  1   Further, the incidence was variable in the 17 Indian states, being high in Northern and Central India and low in the South. INCIDENCE

6. ETIOLOGY   Pulmonary hypertension is the most common cause of cor pulmonale .

7. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 1. Autoimmune diseases that damage the lungs, such as  scleroderma ( Build-up of collagen thickens lung tissue and causes fibrosis or scarring, making the transport of oxygen into the bloodstream more difficult.) ETIOLOGY

8. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: ETIOLOGY 2. Chronic obstructive pulmonary disease (COPD) : A group of lung diseases that block airflow and make it difficult to breathe. Emphysema and chronic bronchitis are the most common conditions that make up COPD.

9. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: ETIOLOGY 3.Acute respiratory distress syndrome (ARDS ) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs.

10. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 4. Chronic blood clots in the lungs : A pulmonary embolism is a blood clot that occurs in the lungs. which obstruct the free flow of blood through the lungs It can damage part of the lung and other organs and decrease oxygen levels in the blood. ETIOLOGY

11. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 5. Cystic fibrosis (CF) : Cystic fibrosis affects the cells that produce mucus, sweat and digestive juices. It causes these fluids to become thick and sticky. They then plug up tubes, ducts and passageways. ETIOLOGY

12. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 6. Severe bronchiectasis : A condition in which the lungs' airways become damaged, making it hard to clear mucus or a persistent cough that usually brings up phlegm (sputum) ETIOLOGY

13. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 7. Scarring of the lung tissue (interstitial lung disease): I nterstitial lung disease is another term for pulmonary fibrosis, or “scarring” and “inflammation” of the interstitium (the tissue that surrounds the lung’s air sacs, blood vessels and airways). This scarring makes the lung tissue stiff, which can make breathing difficult.   ETIOLOGY

14. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 8. Severe curving of the upper part of the spine ( kyphoscoliosis ): Kyphoscoliosis  is a thoracic cage deformity that causes extrapulmonary restriction of the lungs and gives rise to impairment of pulmonary functions ETIOLOGY

15. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 9. Obstructive sleep apnea It is a condition in which breathing stops involuntarily for brief periods of time during sleep. Normally, air flows smoothly from the mouth and nose into the lungs at all times. Periods when breathing stops are called  apnea  or apneic episodes because of airway inflammation ETIOLOGY

16. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 10. Idiopathic (no specific cause) tightening (constriction) of the blood vessels of the lungs If the main  pulmonary artery  is completely  blocked , the right ventricle (the chamber of the heart that pumps blood into the lungs) cannot get the blood into the lungs; this “right ventricular failure” then leads to death from PE ETIOLOGY

17. Lung conditions that cause a low blood oxygen level in the blood over a long time can also lead to cor pulmonale . Some of these are: 11.Sickle Cell Anemia :   Sickle cell anemia  is an inherited red blood  cell  disorder in which there aren't enough healthy red blood  cells  to carry oxygen throughout your body.  ETIOLOGY

18. ACUTE COR PULMONALE Acute cor pulmonale is the result of a sudden increase in right ventricular pressure, as seen in massive pulmonary embolism or acute respiratory distress syndrome CHRONIC COR PULMONALE Chronic cor pulmonale can be further characterized by hypoxic or vascular obliterans pathophysiology . The most common disease process associated with hypoxic subtype is chronic obstructive pulmonary disease (COPD). The most common process associated with obliterans subtype is pulmonary thromboembolic disease. SUB TYPE OF COR PULMONALE

19. Due to etiological factors ( hormonal, mechanical & others) Right ventricular work increases PATHOPHYSIOLOGY Pulmonary endothelial injury results in smooth muscle proliferation and vascular scarring  Pulmonary Hypertension    Right ventricular Hypertrophy (e.g., thickening, dilation, or both)   Chronic hypoxemia  changes in vascular mediators such as Nitric Oxide, Endothelin1 (ET1) and platelet-derived growth factors (PDGF A and B). (Nitric oxide is a vasodilator) thus hypoxemia reduces endothelial cell production of nitric oxide  Pulmonary Vasoconstriction and Increased pulmonary vascular resistance.

20. Shortness of breath or lightheadedness during activity is often the first symptom of cor pulmonale . Palpitation like your heart is pounding. Over time, symptoms occur with lighter activity or even while you are at rest. Symptoms are: Fainting spells during activity Chest discomfort, usually in the front of the chest CLINICAL MANIFESTATION

21. Chest pain Swelling of the feet or ankles Symptoms of lung disorders, such as wheezing or coughing or phlegm production B luish tinge on skin, nail bed, lips, or gums (cyanosis)  loud S2 (accentuation of the pulmonary component of the second heart sound) narrow splitting of S2. CLINICAL MANIFESTATION

22. A holosystolic murmur of tricuspid regurgitation at the left lower sternal border, right-sided S4 heart sound Abdomen: Hepatomegaly , ascites .   Chronic Hypoxemia Anginal pain -due to right ventricular ischemia Hemoptysis - due to rupture of a dilated or atherosclerotic pulmonary arteriole.  CLINICAL MANIFESTATION

23. History Collection – Collect history regarding the aetiology and signs and symptoms 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. DIAGNOSTIC EVALUATIO N

24. Blood Antibody Test – Antinuclear antibody (ANA) level for collagen vascular disease, anti-SCL-70 antibodies in scleroderma  and Coagulations studies to evaluate hypercoagulability states ( eg , serum levels of proteins S and C, antithrombin III, factor V Leyden, anticardiolipin antibodies, homocysteine ) to detect chronic venous thromboembolism DIAGNOSTIC EVALUATIO N

25. Arterial Blood Gas Analysis Arterial blood gas measurements may provide important information about the level of oxygenation and type of acid-base disorder . Chest radiograph: Enlargement of the pulmonary artery and Left ventricle is seen . Electrocardiogram: Shows features of right ventricular hypertrophy/enlargement DIAGNOSTIC EVALUATIO N

26.  Doppler Echocardiography It usually demonstrates signs of chronic right ventricular (RV) pressure overload and to estimate pulmonary arterial pressure Chest CT angiography to rule out pulmonary thromboembolism   Ventilation/perfusion (V/Q) scanning can be particularly useful in evaluating patients with cor pulmonale , especially if pulmonary hypertension is due to chronic thromboembolic pulmonary hypertension. DIAGNOSTIC EVALUATIO N

27. Ultrafast , ECG-gated CT scanning It is used to study right ventricular (RV) function. In addition to estimating RV ejection fraction (RVEF), this imaging modality can estimate RV wall mass.  Magnetic Resonance Imaging To detect myocardial scar and fibrosis,   valve function, patterns of blood flow and pulmonary hypertension.   DIAGNOSTIC EVALUATIO N

28. Lung Biopsy Itmay occasionally be indicated to determine the etiology of underlying lung disease. This is especially true if interstitial lung disease (ILD) is the suspected etiology for pulmonary hypertension resulting in cor pulmonale . Pulmonary Function Test (PFT) and 6-minute walk test for assessment of the severity of lung disease and exercise capacity respectively DIAGNOSTIC EVALUATIO N

29.   Right heart catheterization In patients with cor pulmonale , right heart catheterization reveals evidence of right ventricular (RV) dysfunction without left ventricular (LV) dysfunction. Hemodynamically , this typically presents as a mean pulmonary artery pressure (PAP) above 25 mmHg, which leads to elevated RV systolic pressures and central venous pressures (CVP). However, these findings are also seen in LV dysfunction. One method of differentiating left-sided from right-sided disease includes measuring the pulmonary capillary wedge pressure (PCWP), which is an estimation of left atrial pressure. Thus, RV dysfunction is also defined as having a PCWP below 15 mmHg, because failure of the LV would result in elevated LV end diastolic pressures and, subsequently, left atrial pressures . DIAGNOSTIC EVALUATIO N

30. AIM OF THE MANAGEMENT : Improving oxygenation and right ventricular (RV) function by increasing RV contractility and decreasing pulmonary vasoconstriction . MANAGEMENT Oxygen therapy relieves hypoxemic pulmonary vasoconstriction, which then improves cardiac output, lessens sympathetic vasoconstriction, alleviates tissue hypoxemia, and improves renal perfusion. MEDICAL MANAGEMENT

31. Diuretics are used to decrease the elevated right ventricular (RV) filling volume in patients with chronic cor pulmonale .   Anticoagulation and thrombolytic agents  for massive pulmonary embolism Calcium channel blockers: vasodilate the pulmonary arteries Beta agonists ( epoprostenl , iloprost ): bronchodilate MANAGEMENT

32. Pulmonary Vasodilators : 1. Prostaglandins decrease pulmonary artery pressure and increase right ventricular ejection fraction and cardiac output . 2 . Aerosolized prostacyclin causes pulmonary artery vasodilatation and improves cardiac output and arterial oxyhemoglobin saturation in patients with chronic pulmonary hypertension.   MANAGEMENT

33.   Inotropes with vasodilatory properties : 1 . Dobutamine is an inotropic agent with vasodilatory effect which improves right ventricular function and cardiac output, but its effect on systemic blood pressure is unpredictable . 2 . Amrinone lowers pulmonary artery pressure and rises cardiac output and systemic blood pressure.   Bronchodilators- Theophylline , Endothelin receptor antagonist : Bosentan is an endothelin receptor antagonist that produces pulmonary vasodilation and attenuates ventricular remodeling and improve survival on chronic use. MANAGEMENT

34. SURGICAL MANAGEMENT Phlebotomy : Phlebotomy is indicated in patients with chronic cor pulmonale and chronic hypoxia causing severe polycythemia ,  is the process of making a puncture in a vein, usually in the arm, with a  cannula for the purpose of drawing blood.

35. SURGICAL MANAGEMENT Uvulopalatopharyngoplasty (UPPP) in selected patients with sleep apnea and hypoventilation may relieve cor pulmonale . It is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat.

36. SURGICAL MANAGEMENT Pulmonary embolectomy is indicated in patients with acute pulmonary embolism and hemodynamic instability when thrombolytic therapy is contraindicated.

37. SURGICAL MANAGEMENT Lung transplantation  or pulmonary transplantation , is a surgical procedure in which a patient's diseased lungs are partially or totally replaced by lungs which come from a donor.

38. COMPLICATION  S yncope Hypoxia Pedal edema Passive hepatic congestion D eath .

39.  Ask the patient to describe any history or cardiopulmonary disease . 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. Check 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 . Administer oxygen to relieve hypoxia. NURSING MANAGEMENT

40. 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 . Auscultate the patient's lungs, listening for normal and abnormal breath sounds. Listen for bibasilar rales and other adventitious sounds throughout the lung fields. NURSING MANAGEMENT

41. Decreased cardiac output related to an ineffective ventricular pump as evidenced by dyspnea at rest and/or peripheral edema   Impaired gas exchange related to expiratory airflow obstruction as evidenced by decreased oxygen saturation levels  Impaired tissue perfusion related to decreased cardiac contractility and expiratory airflow obstruction as evidenced by increased capillary refilling time >3 seconds NURSING DIAGNOSIS

42.  Imbalanced nutrition status less than body requirement related to breathlessness , Wheezing, Haemoptysis as evidenced by weight loss • Disturbed sleep pattern related to shortness of breath and sleep apnea as evidenced by presence of dark circles around the eyes, Redness of eyes and Drowsiness NURSING DIAGNOSIS

43. Activity intolerance related to decreased cardiac activity and laboured respirations as evidenced by difficulty in performing activities of daily living Fatigue related to decreased cardiac activity and laboured respirations as evidenced by difficulty in performing activities of daily living Anxiety related to sign and symptoms , diagnostic measures and treatment process as evidenced by patient`s verbalization and facial expressions NURSING DIAGNOSIS

44. Avoid strenuous activities and heavy lifting. Avoid travelling to high altitudes. Get a yearly flu vaccine, as well as other vaccines, such as the pneumonia vaccine. If you smoke, stop. Limit how much salt you eat. Your provider also may ask you to limit how much fluid you drink during the day. Use oxygen if your provider prescribes it. Women should not get pregnant. LIFE STYLE MODIFICATION

45.   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. HEALTH EDUCATION