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Tuesday, June 8, 2021

Pulmonary Heart Disease (Cor Pulmonale): Cause, Symptoms, Management, Nursing Intervention

 Pulmonary Heart Disease (Cor Pulmonale)

 Pulmonary heart disease ( cor Pulmonale ) is typically due to right heart strain caused by excessively high pressure in pulmonary circulation. This alteration in the structure or function of the right ventricle results from disease of lung structure or function or its vasculature, such as pulmonary hypertension ( except when this alteration results from disease of the left side of the heart or from congenital heart disease ). It is heart disease caused by lung disease.

Pathophysiology and Causes of Pulmonary heart disease

  • Cor Pulmonale is often chronic ( associated with right ventricular hypertrophy ), but may develop acutely due to pulmonary embolism and less commonly, acute respiratory distress syndrome (ARDS) associated with right ventricular dilatation.
  • Pulmonary hypertension and subsequent cor Pulmonale may develop due to pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia, anatomic compromise of the pulmonary vascular bed.
  • Causes include
    • Pulmonary vascular disease.
    • Idiopathic pulmonary hypertension
    • Underlying lung disease such as COPD, cystic fibrosis, interstitial lung disease.
    • Polycythemia vera, sickle cell disease.
    • Significant kyphoscoliosis.
    • Obstructive sleep apnea.
What are the Signs and Symptoms of cor Pulmonale?

  • Fatigue.
  • Tachypnea.
  • Exertional dyspnea cough.
  • Anterior chest pain.
  • Hemoptysis.
  • Distended jugular veins
  • Peripheral edema
  • Possible cyanosis.
  • Right upper abdominal discomfort.
  • Jaundice
  • Syncope with exertion.
  • Split-second heart sound on auscultation of chest.
Diagnostic evaluation.

  • Chest x-ray shows right-sided heart enlargement and enlargement of central pulmonary arteries.
  • ECG changes are consistent with right-sided heart hypertrophy and right heart strain.
  • Echocardiogram shows right-sided heart enlargement.
  • Right heart catheter examination to confirm diagnosis and evaluate for pulmonary hypertension and underlying disease.
  • ABG levels-decreased PaO2 and pH increased Paco2
  • PFTs to confirm underlying lung disease such as obstruction.
  • V/Q scanning or chest CT of history and physical examination suggest pulmonary thromboembolism as the cause or if other diagnostic tests do not suggest other etiologies. If interstitial lung disease is suspected, chest CT will aid in diagnosis.
  • Hematocrit for polycythemia, serum alpha1 -antitrypsin if deficiency is suspected, antinuclear antibody level for collagen vascular disease, such as scleroderma, coagulation studies to evaluate hypercoagulability states.


Management for Pulmonary heart disease (Cor Pulmonale) 

Goal is the treatment of underlying lung disease and management of heart disease.

  • In case of hypoxemia, supplemental oxygen to improve oxygen delivery to peripheral tissues, thus decreasing cardiac work and lessening sympathetic vasoconstriction. Liter flow individualized during activities, rest, and sleep.
  • Targeted therapy such as prostacyclin analogues and endothelin-receptor antagonists may be used in primary pulmonary hypertension ( PPH).
    • Epoprostenol, treprostinil, and iloprost are prostacyclin (PG12) analogues and have potent vasodilatory properties. Epoprostenol and treprostinil are administered via the IV route and iloprost is inhaled.
    • Bosentan is a mixed endothelin -A and endothelin -B receptor antagonist indicated for pulmonary arterial hypertension, including PPH. In clinical trials, bosentan improved exercise capacity decreased rete of clinical deterioration and improved hemodynamics.
    • The PDE5 inhibitors sildenafil and tadalafil promote selective smooth muscle relaxation in lung vasculature. Their use in secondary pulmonary hypertension, such as in patients with COPD, is unclear.
  • The use of the cardiac glycoside digoxin is somewhat controversial; it can improve RV function but must be used with caution and should be avoided during acute hypoxia.
  • Oral anticoagulants in underlying thromboembolic event or primary PAH.
  • Diuretics are used if RV filling volume is markedly elevated and to manage peripheral edema.
    • Used cautiously due to hemodynamic adverse effects with excessive volume depletion.
    • Can lead to a decline in cardiac output as well as hypokalemic metabolic alkalosis.
  • Vasodilators including calcium channel blockers, particularly oral sustained-release nifedipine and diltiazem, can lower pulmonary pressures, although these agents appear more effective in primary rather than secondary pulmonary hypertension.
  • Bronchodilators to improve lung function.
  • Mechanical ventilators to improve lung function.
  • Sodium restriction to reduce edema.
Complication of Pulmonary heart disease (Cor Pulmonale)

  • Respiratory failure 
  • Dysrhythmias.
Nursing assessment for Cor Pulmonale

  • Determine if patient has long-standing history of lung disease.
  • Assess the degree of dyspnea, fatigue, hypoxemia.
  • Inspect for jugular vein distention and peripheral edema.
Nursing diagnosis for Cor Pulmonale

  • Impaired Gas Exchange related to excess fluid in lungs; increased pulmonary vascular resistance.
  • Excess Fluid Volume related to right-sided heart failure.

Pulmonary artery catheter; indications and use

Nursing Interventions for Cor Pulmonale

Improving Gas Exchange

  • Monitor ABG values and oxygen saturation as a guide in assessing adequacy of ventilation.
  • Use continuous low-flow oxygen as directed to reduce pulmonary artery pressure.
  • Avoid CNS depressants (opioids, hypnotics), They have depressant action on respiratory centres and mask symptoms of hypercapnia.
  • Monitor for signs of respiratory infection because infection causes CO2 retention and hypoxemia.
Attaining Fluid Balance

  • Watch alterations in electrolytes levels, especially potassium, which can lead to disturbance of cardiac rhythm.
  • Employ ECG monitoring when necessary and monitor closely for dysrhythmias.
  • Limit physical activity until improvement is seen.
  • Restrict sodium intake based on evidence of fluid retention.
Patient Education and Health Maintenance  

  • Emphasize importance of stopping smoking; cigarette smoking is a major cause of pulmonary heart disease.
    • Ask patient about smoking habits.
    • Inform patient of risks of smoking and benefits to be gained when smoking is stopped.
    • Discuss use of behaviour modification techniques and smoking cessation aids.
  • Teach patient to recognize and treat infections immediately.
  • Advise patient to avoid environments with poor air quality, have good ventilation but keep windows closed and use air conditioning, if necessary.
  • Explain to patient and family that restlessness, depression, and poor sleeping, as well as irritable and angry behaviour, maybe characteristic; patient should improve with rise in oxygen and fall in CO2 levels.
  • Explain use of supplemental oxygen, which will reduce further workload on the right side of heart.

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