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Pulmonary Vascular Disease. Pulmonary Circulatuion. Dual supply Pulmonary arteries Bronchial arteries Low pressure system Pulmonary artery receives entire cardiac output (a filter). Low pressure system…. Thin walled vessels Low incidence of atherosclerosis At normal pressures.

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pulmonary circulatuion
Pulmonary Circulatuion
  • Dual supply
    • Pulmonary arteries
    • Bronchial arteries
  • Low pressure system
  • Pulmonary artery receives entire cardiac output (a filter)
low pressure system
Low pressure system….
  • Thin walled vessels
  • Low incidence of atherosclerosis

At normal pressures

pulmonary oedema
Pulmonary Oedema
  • Accumulation of fluid in the lung
    • Interstitium
    • Alveolar spaces
  • Causes a restrictive pattern of disease
pulmonary oedema causes
Pulmonary Oedema (causes)
  • Haemodynamic ( hydrostatic pressure)
  • Due to cellular injury
    • Alveolar lining cells
    • Alveolar endothelium

Localised – pneumonia

Generalised – adult respiratory distress syndrome (ARDS)

increased pulmonary venous pressure
Increased pulmonary venous pressure
  • Left ventricular failure
  • Mitral stenosis
  • Mitral incompetence

Pressure increase forces fluid into interstitial space. Initially compensated by lymphatic drainage

development of pulmonary oedema
Development of pulmonary oedema
  • Fluid builds up first in interstitial space “stiff lung”
  • Eventually gets into alveolar space
pulmonary embolus
Pulmonary Embolus
  • Common
  • Often subclinical
  • An important cause of sudden death and pulmonary hypertension

95% + of emboli are thromboemboli

embolus
Embolus
  • A detached intravascular mass carried by the blood to a site in the body distant from its point of origin
  • Most emboli are thrombi – others include gas, fat, foreign bodies and tumour clumps
source of most pulmonary emboli
Source of most pulmonary emboli…..
  • Deep venous thrombosis (DVT) of lower limbs
risk factors for pe are those for dvt
Risk factors for PE are those for DVT….
  • Factors in vessel wall (eg endothelial hypoxia)
  • Abnormal blood flow (venous stasis)
  • Hypercoaguable blood (cancer patients, post-MI etc)

- Virchow’s triad

effects of pe
Effects of PE
  • Sudden death
  • Severe chest pain/dyspnoea/haemoptysis
  • Pulmonary infarction
  • Pulmonary hypertension
effects of pe depend on
Effects of PE depend on…
  • Size of embolus
  • Cardiac function
  • Respiratory function
effect of embolus size
Large emboli

Death

Infarction

Severe symptoms

Small emboli

Clinically silent

Recurrent pulmonary hypertension

Effect of embolus size…
pulmonary infarct ischaemic necrosis
Pulmonary Infarct (ischaemic necrosis)
  • Embolus necessary but not sufficient
  • Bronchial artery supply compromised (eg in cardiac failure)
pulmonary hypertension
Pulmonary Hypertension
  • Primary (rare, young women)
  • Secondary
pulmonary hypertension mechanisms
Pulmonary Hypertension (mechanisms)
  • Hypoxia (vascular constriction)
  • Increased flow through pulmonary circulation (congenital heart disease)
  • Blockage (PE) or loss (emphysema) of pulmonary vascular bed
  • Back pressure from left sided heart failure
morphology of pulmonary hypertension
Morphology of pulmonary hypertension
  • Medial hypertrophy of arteries
  • Intimal thickening (fibrosis)
  • Atheroma
  • Right ventricular hypertrophy
  • Extreme cases (congenital heart disease, primary pulmonary hypertension) – plexogenic change/necrosis
cor pulmonale
“Cor Pulmonale”
  • Pulmonary hypertension complicating lung disease
  • Right ventricular hypertrophy
  • Right ventricular dilatation
  • Right heart failure (swollen legs, congested liver etc)
pulmonary vasculitis
Pulmonary vasculitis
  • Arteritis with ischaemia and focal necrosis – Wegeners granulomatosis, polyarteritis nodosa
  • Anti basement membrane antibodies (Goodpasture’s disease)