Cardiopulmonary Pressures

54 yo M with pulmonary hypertension (Clinic Series)

Tyra Fainstad, MD
Yilin Zhang, MD.
Expert review by Peter Leary, MD (UWMC, pulmonary hypertension specialist)


OBJECTIVES


CASE

A 54-year-old man is noted to have a 3/6 pan-systolic murmur best heard over the right upper sternal border on a routine annual exam. He has no past medical history and takes no medications. He undergoes an echocardiogram (TTE) and presents for follow-up of the results.

His TTE showed signs of aortic sclerosis without significant stenosis and an estimated pulmonary artery systolic pressure (PASP) of 40 mmHg and mean pulmonary arterial pressure (mPAP) of 30 mmHg. He denies palpitations, shortness of breath, orthopnea, chest pain, leg swelling or significant weight gain. His vital signs were normal and the remainder of his cardiopulmonary exam is unremarkable.

What is normal range for pulmonary pressures? 

How do estimates of pulmonary pressures from a TTE compare to those determined by right heart catheterization (RHC)? 

Does he need a RHC? 


What is your differential for causes of PH? 


CASE CONTINUED

You obtain a 6 min walk (he does not desaturate) and an EKG (normal). What is the next step? 

What therapy can you recommend to the patient while he is waiting for a Pulmonary appointment? Would you diurese him?


CASE CONTINUED

What is his prognosis? What factors are associated with a poor prognosis?

How will you counsel him about end-of-life planning?  (optional, ~5 min) 


TAKE HOME POINTS


REFERENCES

  1. McLaughlin VV, et al. ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension. Journal of American College of Cardiology. 2009; 53(17): 1573 – 1619.
  2. Parasuraman S, et al. Assessment of pulmonary artery pressure by echocardiography – a comprehensive review. IJC Heart & Vasculature. 2016; 12: 45-51.
  3. Janda S, et al. Diagnostic accuracy of echocardiography for pulmonary hypertension: a systematic review and meta-analysis. Heart. 2011 Apr; 97(8): 612-22.
  4. Fisher MR, et al. Accuracy of Doppler Echocardiography in the Hemodynamic Assessment of Pulmonary Hypertension. Am J Respir Crit Care Med. 2009; 179: 615-621.
  5. Brown LM, et al. Delay in recognition of pulmonary arterial hypertension: factors identified from the REVEAL Registry. CHEST. 2011;140(1):19.
  6. Hoeper MM, et al. Am J Respir Crit Care Med. 2002.

Inpatient Antibiotics, Part 2: Common Sites of Infection

OBJECTIVES:

  1. Name pathogenic bacteria implicated in common infections (pneumonia, UTI, intra-abdominal and skin and soft tissue)
  2. Propose empiric antibiotic regimens for these common sites of infection


Pneumonia: Interactive Board 

UTI:

Skin and Soft Tissue Infections: Interactive Board

Intra-abdominal Infections:

Final Board:

REFERENCES:

  1. Gilbert, DN, et al. (2017). Sanford guide to antimicrobial therapy 2017. Retrieved from: http://webedition.sanfordguide.com
  2. Mandell, LA et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007; 44:S27–72
  3. Kalli, AC et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases. 2016; 63(5):e61–111.
  4. Marik, PE. Aspiration Pneumonitis and Aspiration Pneumonia. NEJM. 2001. 344(9): 665-671.
  5. DiBardino, DM & Wunderink, RG. Aspiration pneumonia: A review of modern trends. Journal of Critical Care. 2015, 30: 40-48.
  6. Gupta, K et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases. 2011; 52(5): e103–e120.
  7. Hootn, TM et al. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases. 2010; 50:625–663
  8. Sievert, DM et al. Antimicrobial-Resistant Pathogens Associated with Healthcare-Associated Infections: Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010. Infect Control Hosp Epidemiol. 2013 ;34(1): 1-14.
  9. Stevens, DL et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014; 59(2): e10–52.
  10. Anaya, DA & Dellinger, EP. Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clinical Infectious Diseases. 2007; 44: 705–10.
  11. Solomkin, JS et al. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clinical Infectious Diseases 2010; 50:133–64