Critical Care Nursing Theory
Pulmonary hypertension
Pulmonary Hypertension
- Pulmonary hypertension is a condition that is not clinically evident until
late in its progression.
- Pulmonary hypertension exists when : The systolic pulmonary artery pressure exceeds 30 mm Hg
or
 The mean pulmonary artery pressure exceeds 25 mm Hg
- These pressures cannot be measured indirectly as can systemic blood
pressure
- They must be measured during right-sided heart catheterization.
- In the absence of these measurements, clinical recognition becomes the
only indicator for the presence of pulmonary hypertension.
Forms of pulmonary hypertension:1- Primary (or idiopathic) pulmonary hypertension.
2- Secondary pulmonary hypertension.
Primary pulmonary hypertension
- It is an uncommon disease in which the diagnosis is made by excluding
all other possible causes.
- The exact cause is unknown, but there are several possible causes .
- The clinical presentation of primary pulmonary hypertension exists with
no evidence of pulmonary and cardiac disease or pulmonary embolism.
- It occurs most often in women 20 to 40 years of age and is usually fatal
within 5 years of diagnosis.
Dr. Abdul-Monim Batiha - Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pulmonary hypertension
Causes of primary pulmonary hypertension:1- Altered immune mechanisms
2- Silent pulmonary emboli
3- Raynaud’s phenomenon: a condition with in which the blood supply to
the fingers and toes is restricted and they become cold, white and numb.
Also called dead man’s fingers, vasospasm
4- Oral contraceptive use
5- Sickle cell disease
6- Collagen diseases
Secondary pulmonary hypertension
- It is more common and results from existing cardiac or pulmonary
disease.
- The prognosis depends on
1- Severity of the underlying disorder
2- Changes in the pulmonary vascular bed.
- A common cause of secondary pulmonary hypertension is pulmonary
artery constriction due to hypoxemia from COPD.
Causes of secondary pulmonary hypertension:1- Pulmonary vasoconstriction due to hypoxemia
2- Chronic obstructive pulmonary disease
3- Kyphoscoliosis
4- Obesity
5- Smoke inhalation
6- High altitude
7- Neuromuscular disorders
8- Diffuse interstitial pneumonia
9- Reduction of the pulmonary vascular bed (must impair 50% to 75% of
the vascular bed)
10- Pulmonary emboli
11- Vasculitis
12- Widespread interstitial lung disease
(sarcoidosis, systemic
sclerosis)
13- Tumor emboli
Dr. Abdul-Monim Batiha - Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pulmonary hypertension
14- Primary cardiac disease
15- Congenital (patent ductus arteriosus, atrial septal defect,
16- ventricular septal defect)
17- Acquired (rheumatic valvular disease, mitral stenosis,myxoma, left
ventricular failure)
Pathophysiology
- The underlying process of pulmonary hypertension varies, and multiple
factors are often responsible.
- Normally, the pulmonary vascular bed can handle the blood volume
delivered by the right ventricle.
- It has a low resistance to blood flow and compensates for increased
blood volume by dilation of the vessels in the pulmonary circulation.
- However, if the pulmonary vascular bed is destroyed or obstructed, as in
pulmonary hypertension,
1- The ability to handle whatever flow or volume of blood it receives is
impaired,
2- The increased blood flow then increases the pulmonary artery pressure.
- As the pulmonary arterial pressure increases, the pulmonary vascular
resistance also increases.
Both
1- Pulmonary artery constriction (as in hypoxemia or hypercapnia)
2- A reduction of the pulmonary vascular be (which occurs with
pulmonary emboli)
Result in:a. Increase in pulmonary vascular resistance
b. Increase in pulmonary vascular pressure.
Result in :- This increased workload affects right ventricular function.
Dr. Abdul-Monim Batiha - Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pulmonary hypertension
- The myocardium ultimately cannot meet the increasing demands
imposed on it, leading to:1- Right ventricular hypertrophy
(enlargement and dilation)
2- Right ventricular failure.
Clinical Manifestations:1- Dyspnea is the main symptom of pulmonary hypertension, occurring at
first with exertion and eventually at rest.
2- Substernal chest pain also is common, affecting 25% to 50% of
patients.
3- Weakness,
4- Fatigue,
5- Syncope,
6- Occasional hemoptysis,
7- Occasional signs of right-sided hear failure:a- Peripheral edema,
b- Ascites,
c- Distended neck veins,
d- Liver engorgement,
e- Crackles,
f- Heart murmur.
Medical Management:- The goal of treatment is to manage the underlying cardiac or pulmonary
condition.
- Supplemental oxygen with exercise for patients with primary pulmonary
hypertension because most of them do not have hypoxemia at rest.
- Continuous oxygen supplementation for patients who may have resting
hypoxemia such as patient with:1- Severe right ventricular failure,
2- Decreased cardiac output,
Dr. Abdul-Monim Batiha - Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pulmonary hypertension
3- Progressive disease
Appropriate oxygen therapy:1- Reverses the vasoconstriction
2- Reduces the pulmonary hypertension in a relatively short time.
- In the presence of cor pulmonale, treatment should include:1- Fluid restriction,
2- Diuretics to decrease fluid accumulation,
3- Cardiac glycosides (eg, digitalis) in an attempt to improve cardiac
function,
4- Calcium channel blockers for vasodilation,
5- Rest.
- In primary pulmonary hypertension, vasodilators have been
administered with variable success eg,
a. Calcium channel blockers,
b. Intravenous prostacyclin.
- Prostacyclin (PGX [Flolan]) is one of the prostaglandins produced by
the pulmonary endothelium.
- Intravenous prostacyclin (epoprostenol) helps to decrease pulmonary
hypertension by:a. Reducing pulmonary vascular resistance
b. Reducing pulmonary vascular pressures
c. Increasing cardiac output.
- Anticoagulants such as warfarin (Coumadin) have been given to patients
because of chronic pulmonary emboli.
- Heart– lung transplantation has been successful in selected patients with
primary hypertension who have not been responsive to other therapies.
Dr. Abdul-Monim Batiha - Assistant Professor Of Critical Care Nursing
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Critical Care Nursing Theory
Pulmonary hypertension
Nursing Management:- The major nursing goal is to identify patients at high risk for pulmonary
hypertension, such as those with:- COPD,
- Pulmonary emboli,
- Congenital heart disease,
- Mitral valve disease.
- The nurse also must be alert for signs and symptoms,
- Administer oxygen therapy appropriately,
- Instruct patients and their families about the use of home oxygen
supplementation.
Dr. Abdul-Monim Batiha - Assistant Professor Of Critical Care Nursing
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