Katherine Karczewski COPD Leads to Cor Pulmonale

8/13/2019 Katherine Karczewski COPD Leads to Cor Pulmonale

1/31

COPD Leads to Cor Pulmonale

Katherine Karczewski RN,BSN,CEN

March 1, 2012MSN 621


2/31

Course Objectives

Define Cor Pulmonale in the Chronic ObstructivePulmonary Disease(COPD) Patient.

Define briefly Chronic Obstructive Pulmonary Disease.

Identify Common Signs and Symptoms in the physicalexam of the COPD Patient with the diagnosis of CorPulmonale.

Outline Routine Diagnostic Tests used to Confirm the Cor

Pulmonale Diagnosis. Recognize Standard Treatments used for COPD Patients

with Cor Pulmonale.


3/31

Case Presentation

A 67 year old male patient well known to yourclinic with a longstanding diagnosis of COPDpresents complaining of weakness, increaseddyspnea, and fatigue. He has been experiencingthese symptoms for several months. Thesymptoms have gotten worse despite the use ofhis inhalers. He reports that he has had bilateral

lower leg edema for the past month.

What do you suspect this patient has developed?


4/31

COPD

COPD may involve chronic inflammation andobstruction of the pulmonary airways withexcess mucus production that causesobstruction and a mismatch of ventilation andperfusion.

The alveolar tissue is destroyed, along with aloss in the elastic fibers which impairs theexpiratory phase. This loss also increases airtrapping and collapse of the airway structures.

This is seen in the arterial blood gases as adecreased PO2 and an increased PCO2.


5/31

What is Cor Pulmonale in the COPD Patient?

The progress of COPD results in right sidedheart failure. The right ventricle has become

hypertrophied and dilated and its function hasbecome compromised due to pulmonaryhypertension associated with COPD.


6/31

COPD to Cor Pulmonale

These are the mechanisms that occur whenCOPD becomes Cor Pulmonale. Now lets look atthe pathway from COPD to Cor Pulmonale.

Alexandria.healthlibrary.Ca 2008


7/31

Pathway of COPD to Cor Pulmonale

COPD is the most common cause of CorPulmonale.

A chronic increase in pulmonary vascularresistance causes the right ventricle to distend

and undergo hypertrophy. When the rightventricle can no longer compensate, it causes anincrease in the right ventricular end-diastolicpressure and the right atrial pressure; causing

right heart failure know as Cor Pulmonale. Cor Pulmonale is a maladaptive response to

pulmonary hypertension.

(Up to Date, 2012)


8/31

Review

An increased PO2 and

increased PCO2.

Try again! COPD is a

chronic disorder causing

a decrease in O2 to the

patient.

Decreased PO2 and

Increased PCO2

Correct!

Based on what we know about COPD whatwould you expect the arterial blood gasesto show?


9/31

COPD to COR Pulmonale

The chronic inflammation and hypoventilationcauses the pulmonary vasoconstriction andsignals the kidney to release erythropoietin inresponse to the low oxygen levels.

This in turn stimulates the bone marrow toproduce reticulocytes which are released intothe bloodstream to become erythrocytes.

Because of the chronic low oxygen levels thisprocess is continually occurring causing anexcess of red blood cells (polycythemia).


10/31


The progression of COPD results in chronichypoxic pulmonary vasoconstriction,polycythemia, impaired gas exchange secondary

to mucus overproduction and air trapping whichdestroys the pulmonary vascular bed because ofdecreased oxygen supply.

The progression leads to pulmonary

hypertension; which puts a stress on the rightventricle causing it to distend and hypertrophy. Hypertrophy to the right ventricle is known as

Cor Pulmonale.


11/31

Clinical Presentation of the Cor PulmonalePatient

Most of the symptoms of Cor Pulmonale are notoften recognized because the symptoms ofCOPD are similar and can be overlooked. Thesymptoms of Cor Pulmonale are: increasedweakness, dyspnea, and fatigue.

The clinical exam is very important in detectingthese subtle findings.

Lets look at the clinical exam.


12/31

Clinical Examination of Patient

The patient has jugular venous distension.

Bilateral lower extremity pitting edema.

The patient uses home oxygen at 2L/nasal cannula atbedtime.

The patients resting pulse oximeter reading is 90% onroom air.

A holosystolic murmur at the left lower sternal bordercharacteristic of tricuspid insufficiency.

Right upper quadrant discomfort upon palpation. The patient complains of exertional dyspnea and fatigue

despite use of Albuterol inhaler and Pulmicort inhaler.


13/31

Why does the patient have continued

dyspnea, fatigue, and a low pulse ox despitewearing oxygen?

The progression of the COPD causing changes inrespiratory function. The increased mucus productionand increased resistance to outflow cause the increasedSOB and fatigue.

The low pulse oximeter reading is a result of theworsening ventilation-perfusion imbalance in the lungsand increased pulmonary hypertension.

(Up to Date, 2012)


14/31

Why does

the patient have jugular vein distention,peripheral edema, and right upper quadrantdiscomfort?

Cor Pulmonale patients have pulmonary hypertension

which strains the right ventricle of the heart. Pulmonaryhypertension causes right sided heart failure and ischaracterized by:

1. Jugular vein distension2. Peripheral edema of legs and ankle

3. Right upper quadrant pain from hepaticcongestion (hepatomegaly)

(Up to Date, 2012)


15/31

Why do we hear a holosystolic murmur?

The increased intensity of the S2 heart sound(the split second heart sound) is a secondary

effect of pulmonary hypertension. The tricuspid valve insufficiency is caused by a

regurgitation of blood because of pulmonaryhypertension.

(Klabunde, 2011)


16/31

Review

Increased mucus

production, increasedright sided heart

failure, and

progression of COPD.

Yes!

Increased cardiac output

and Decreased

pulmonary vascularresistance.

No. We know cor

pulmonale has

decreased cardiac

output and increased

PVR.

Leukemia.

No we know that

polycythemia is

present in cor

pulmonale patients.

Lets Review. Why does the Cor PulmonalePatient have increased dyspnea, fatigue,and weakness?


17/31

Diagnostic Tests for the Cor PulmonalePatient

1. Chest Radiograph (CXR)2.

Electrocardiogram (EKG)3. Echocardiogram (ECHO)4. Pulmonary Function Test (PFT)


18/31

Chest Radiograph

The radiograph would show an enlargedpulmonary artery due to pulmonary

hypertension. The lateral view would show aloss of retrosternal air space due to theenlargement of the right ventricle.

(Up to Date, 2012)


19/31

Chest Radiograph

Learningradiology.com 2012
http://www.google.com/imgres?imgurl=http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow58.jpg&imgrefurl=http://www.learningradiology.com/archives03/COW%2520058-Cystic%2520fibrosis/cysticfibrosiscorrect.htm&usg=__nmIN-bAmGDm5gWwAjDD6irt3Ym0=&h=478&w=421&sz=44&hl=en&start=16&zoom=1&tbnid=CQugFfkAHxZOCM:&tbnh=129&tbnw=114&ei=RYtVT4zxBojd0QGszfDSDQ&prev=/search%3Fq%3DCOPD%2Bto%2BCor%2BPulmonale%26hl%3Den%26gbv%3D2%26tbm%3Disch&itbs=1http://www.google.com/imgres?imgurl=http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow58.jpg&imgrefurl=http://www.learningradiology.com/archives03/COW%2520058-Cystic%2520fibrosis/cysticfibrosiscorrect.htm&usg=__nmIN-bAmGDm5gWwAjDD6irt3Ym0=&h=478&w=421&sz=44&hl=en&start=16&zoom=1&tbnid=CQugFfkAHxZOCM:&tbnh=129&tbnw=114&ei=RYtVT4zxBojd0QGszfDSDQ&prev=/search%3Fq%3DCOPD%2Bto%2BCor%2BPulmonale%26hl%3Den%26gbv%3D2%26tbm%3Disch&itbs=1http://www.google.com/imgres?imgurl=http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow58.jpg&imgrefurl=http://www.learningradiology.com/archives03/COW%2520058-Cystic%2520fibrosis/cysticfibrosiscorrect.htm&usg=__nmIN-bAmGDm5gWwAjDD6irt3Ym0=&h=478&w=421&sz=44&hl=en&start=16&zoom=1&tbnid=CQugFfkAHxZOCM:&tbnh=129&tbnw=114&ei=RYtVT4zxBojd0QGszfDSDQ&prev=/search%3Fq%3DCOPD%2Bto%2BCor%2BPulmonale%26hl%3Den%26gbv%3D2%26tbm%3Disch&itbs=1http://www.google.com/imgres?imgurl=http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow58.jpg&imgrefurl=http://www.learningradiology.com/archives03/COW%2520058-Cystic%2520fibrosis/cysticfibrosiscorrect.htm&usg=__nmIN-bAmGDm5gWwAjDD6irt3Ym0=&h=478&w=421&sz=44&hl=en&start=16&zoom=1&tbnid=CQugFfkAHxZOCM:&tbnh=129&tbnw=114&ei=RYtVT4zxBojd0QGszfDSDQ&prev=/search%3Fq%3DCOPD%2Bto%2BCor%2BPulmonale%26hl%3Den%26gbv%3D2%26tbm%3Disch&itbs=1


20/31

Electrocardiogram

The EKG would possibly show a right bundle

branch block and right axis deviation because of

the right ventricle hypertrophy and atrialenlargement. There will be dominant R waves in

V1 and V2 and prominent S waves in V5 and V6because of right ventricular hypertrophy.

Increased P wave amplitude in Lead II due toright atrial enlargement.

(Up to Date, 2012)


21/31

Echocardiogram

The echocardiogram will show right ventricular

hypertrophy, right ventricular dilation and

tricuspid regurgitation due to right atrialenlargement.

(Up to Date, 2012)


22/31

Pulmonary Function Test

The pulmonary function test will indicate an

impaired diffusion capacity due to the acidotic

pH. It may also show a restrictive ventilatorydefect.

(Up to Date, 2012)


23/31

Right Heart Catheterization

This is considered the gold standard for CorPulmonale Diagnosis.

The patient who presents with chest pain andhas nondiagnostic or normal results of the chestradiograph, echocardiogram, EKG, andpulmonary function tests will have a right heart

catheterization done to confirm the diagnosis.

(Up to Date, 2012)


24/31

Review

Stress test, CXR,

and echo.No! this may be

ordered to confirm

CHF diagnosis.

Chest radiograph,EKG, Echo and PFT.

Yes !

CXR, ABGs and

sputum specimen.Try again!

This may be used to

diagnose a lung

infection.

What diagnostic tests do you order to confirmthe Cor Pulmonale diagnosis?


25/31

3 Major Physiological Goals ofCor Pulmonale Treatment

1. Reduce the right ventricular after load causinga reduction of the pulmonary artery pressure.

2. Decrease right ventricular pressure.

3. Improve the contractility of the right ventricle.


26/31

Treatment of Patients with Cor Pulmonale

Oxygen therapy for patients with hypoxemia.The oxygen will improve hypoxicvasoconstriction. Oxygen also may improve

pulmonary artery pressure and pulmonaryvascular resistance and polycythemia associatedwith hypoxia.

(Up to Date,2012)


27/31

Treatment (cont.)

Diuretic therapy to improve right ventricular function dueto increased right ventricular pressures.

Diuretics must be used carefully because cor pulmonale

patients are preload dependent and an under filling ofthe right ventricle may decrease the stroke volume andincrease their symptoms.

The diuretics may also increase the patients risk ofdeveloping arrhythmias and metabolic acidosis becauseof the loss of potassium from the diuretics.

(Up to Date, 2012)


28/31

Treatment (cont.)

Inotropic agents are used to increase the rightventricle contractility and decrease the right

ventricle afterload by inducing pulmonaryvasodilation.

(Up to Date,2012)


29/31

Conclusion

Reduce rightventicular afterload.

Yes! That is one!

Decrease right

ventricularpressure.

Yes! That is two!

Improve the

contractility of theright ventricle.

Yes! That is three!

What are the 3 major physiological goalswe carry out when treating a patient withCor Pulmonale?


30/31


COPD is the fourth leading cause of death in theUnited States. COPD leads to Cor Pulmonale.

Nurse Practitioners will be expected to managethe treatment of patients with Cor Pulmonale..The management of Cor Pulmonale will focus onthe extent of the lung disease and heart failure

of the patient.


31/31

References

Klabunde, R. (2011). . In Cardiovascular PhysiologicalConcepts(2nd ed., ). Philadelphia, PA: LippincottWilliams & Wilkins.

Klings, E. (2011, August 17th). Cor Pulmonale RetrievedFebruary 20, 2012 from Up to Date online textbook:

http://www.uptodate.com.Porth, C. M., & Matfin, G. (2009). PathophysiologyConcepts of Altered Health States(8th ed., ).Philadelphia, PA: Lippincott Williams & Wilkins.

alexandria.health library.ca. (2008).

http://alexandriahealthlibrary.ca/documents/notes/bom/unit_8a/micopd_001.pngintprop.lf2.cuni.cz/.../ekg1/ekg-copd.htm. (nd.).

http://intprop.lf2.cuni.cz/.../ekg1/ekg-copd.htm

Katherine Karczewski COPD Leads to Cor Pulmonale

Documents

Transcript of Katherine Karczewski COPD Leads to Cor Pulmonale