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Chapter 24.docx

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NURS 203
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Chapter 24 Pulmonary Vascular Disease: Pulmonary Embolus 2 types of emboli – tiny ones that produce wedge shaped hemorrhagic emboli or can chip off large ones. Where do most Pul emboli embolize from? MC SITE for thrombosis is the deep veins of the lower leg. This is NOT the most common site for embolization; it is the femoral vein (this is the MC site for embolization). Makes sense b/c venous clots propagate toward the heart (deep veins to the femoral vein, and the femoral vein is a larger vessel, therefore it is more likely to chip off). So, the femoral vein is the MC site for embolization to the lung. The deep veins are the MC site where deep venous thrombosis begins. (when it get to the femoral vein, it is dangerous for embolization). So, small ones produces hemorrhagic infarct that is only if you have an underlying lung dz. If I have a small embolus, prob won’t infarct b/c don’t have abnormal lungs. However, if you have preexisting lung dz you will infarct. 85% of the time embolus will not produce infarct. However, in the 15%, most of the pts with infarcts have preexisting lung dz (ie they are smokers). The other type of embolus is a saddle embolus (it is huge) and blocks off the orifices of the pulmonary vessels and pulmonary arteries. If you knock off at least 3 out of the 5 orifices, you are dead in a millisecond, so there is no infarction b/c you don’t have time to infarct. It produces acute right heart strain and immediate death. Screening test of choice: Ventilation perfusion scan – will have ventilation, no perfusion; confirmatory test is pulmonary angiogram. Restrictive Pulmonary Disease Restrictive – something is restricting it from filling. Example: restricted filling of the heart = restrictive cardiomyopathy. Or restriction in filling up of the lungs with air. Have 2 terms: compliance (filling term, inspiration term) and elasticity (recoil, expiration term); For restrictive lung dz, picture a hot rubber bottle for restrictive lung dz. The hot rubber bottle is difficult to ‘blow up’, therefore compliance is decreased and it is hard to fill the lung up with air. So, what’s preventing it from blowing up? Fibrosis (interstial fibrosis, MC’ly). If you get the hot water rubber bottle filled with air and let the air out, what happens to the elasticity? Increases. So, compliance is decreased and cannot fill it up, but once you do fill the lung up, it comes out quickly (elasticity increases). Example: pt with sarcoid – diff to fill lungs, but get it out fast (due to fibrosis). So, all TLC, RV, TV (all lung capacities have all equally decreased). FEV1/FVC on spirometer – take a deep breath (ie pt with sarcoid) – FEV1 (amount you get out in one sec – normally it is 4 liters) is decreased, FVC (total that got out after deep inspiration) is decreased (b/c increased elasticity) – this is the same as FEV1, so the ratio is often 1. Normally, the FVC is 5 liters, and the FEV1 is normally 4 liters – so, the normal FEV1/FVC ratio is 4/5 =80%. B/c the elasticity is increased, the FVC is the same as FEV1, and therefore the ratio is increased to 1 instead of 0.8. Examples of restrictive lung dz’s: 1. Pneumoconiosis – airborne/dustborne dz’s – famous in big cities (LA, NY). Cole worker pneumoconiosis – esp. in west Virginia/Penn, have an anthrocotic pigment that causes a fibrous rxn in the lung, leading to restrictive lung dz. Have an increased incidence of TB, but not cancer. 2. Silicosis – Sandblasters get graffiti off things, or work in foundries and deal with rocks (ie quartz), and break them down, and breathe in dust, leading to silicoses). Have nodules in the lung that are hard has rock (literally) b/c there is quartz in them and it looks like metastatic dz in the lung (silica dioxide – which is sand in the lung) – again, increased of TB, not cancer. If pt happens to have rheumatoid arthritis, and also has one of these pneumoconiosis (ie Cole workers), have a potential for a syndrome, which is called caplan syndrome. Caplan syndrome consists of rheumatoid nodules in the lung (same as extensor surfaces in the arm). Rheumatoid arthritis commonly involves the lung with fibrosis. And rheumatoid nodules can form in the lung. The combo of rheumatoid arthritis (rheumatoid nodules) in the lung, plus pneumoconiosis (silicosis/asbestosis/Cole workers) = caplan syndrome. 3. Asbest
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