0:00

All right everyone. We're moving on with

0:03

pulmonary hypertension. We talked a little about about the definition. It's awareness

0:06

and the clinical and some treatment options.

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So now we're going to dive into the Imaging but we're going to start off with

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the Workhorse the radiograph.

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And with this we're going to kind of look at some of the

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radiographic abnormalities that you can see with pulmonary hypertension,

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including pulmonary size and size of the

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cardiac Chambers as well as some of them potential etiologies.

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You can at least suggest based on

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just the radiograph.

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So remember the pulmonary hypertension organization, we're going

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to kind of focus a bit on the anatomic.

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And remember the multiple etiologies lead

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to a common final pathway. So our role

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is to see if we can find it pulmonary hypertension or

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at least suggested remember early on

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they may not have a lot of symptoms and the findings

0:55

may be subtle. So if you just suggest it at least gives

0:58

it a chance.

1:00

Is this a primary pulmonary disease? Is it a primary cardiac disease

1:03

or post capillary or is this maybe an

1:06

intrinsic cause and sometimes there's a combination?

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So when you're doing the radiographic evaluation first

1:13

and foremost, the main pulmonary artery will usually

1:16

dilate and we'll go over anatomically where

1:19

that is. There are measurements that people use I don't

1:22

use them too often but one is the right kind of

1:25

lower lobe pulmonary artery and it's a greater than 1.6 centimeters

1:28

the interlobar artery.

1:30

You can also if you have a lateral projection take a

1:33

look at the right ventricle and the atrial Chambers to

1:36

try to figure out if there might be a cardiac problem.

1:39

You can also beautifully see if there's something going on

1:42

the lungs that may be inducing some hypoxia or a great

1:45

deal of tissue loss or vascular destruction left

1:48

heart chambers. You can see nicely

1:51

PA in a lateral we talked about that in

1:54

our last block.

1:56

And any other Associated findings, I mean, is this a very obese

1:59

patient? Are we looking at sleep apnea? Do they have a tips sickle cell

2:02

that sort of thing.

2:05

So earlier mild pulmonary hypertension. It may be normal. We

2:08

see the aortic Arch and in the main pulmonary

2:11

arteries here. It does not really look like there's an increased convexity here,

2:14

but the low bar arteries do look a little

2:17

bit big. This is greater than one point six. So you kind of

2:20

like and you look in the lateral and the right ventricle is

2:23

dilated. Remember you start getting up

2:26

about a third of the way up the sternum and that tells you the

2:29

right ventricles probably dilating or hypertrophy. Okay.

2:32

So at this point you kind of say, huh? I

2:35

wonder if there might be some evidence here some early pulmonary hypertension.

2:40

When it gets a little bit more advanced you can see the

2:43

pulmonary arteries are big but the main pulmonary artery is pretty big a

2:46

lot bigger than the aortic Arch. So this person

2:49

along with the right ventricle here is enlarged

2:52

and you can see how large the pulmonary arteries are

2:55

on the lateral. This is the left and this is the right. So in

2:58

this patient clearly you got to say findings are

3:01

consistent with more advanced pulmonary hypertension and

3:04

presumed right ventricular hypertrophy.

3:07

Now this was known already at the time because they have an indwelling

3:10

line getting pulmonary artery vasodilator.

3:14

and then

3:16

once you see this, whoo.

3:18

Cats out of the bag man. This is very severe.

3:21

The main pulmonary artery is very large.

3:24

So you can measure this into a low bar artery if you

3:27

wish one of the things you can do is the segmental arteries should

3:30

be the same size as the bronchus. So you look for

3:33

a vessel on end and the Broncos are they the same

3:36

size as the artery bigger the arteries bigger, then

3:39

that's pretty strongly suggested that you got pulmonary

3:42

hypertension present.

3:44

The right ventricular purchasing this patient is quite severe and you

3:47

can see the right pulmonary artery left pulmonary artery are very large.

3:50

Let Atrium and ventricle are normal.

3:54

so very Advanced main pulmonary artery who

3:57

interlobar artery is big if you look

4:00

very carefully there's actually intimal calcification

4:03

within the pulmonary artery and this patient

4:06

intramocalsification is strongly associated with

4:09

Advanced pulmonary hypertension often from

4:12

a left to right shunt and it represents,

4:15

you know, atherosclerotic disease

4:18

essentially because the pulmonary artery pressures are essentially systemic

4:22

Now when right ventricular hypertrophy gets so

4:25

big.

4:26

The heart actually rotates horizontal right?

4:30

Why you see that here and so you start

4:33

to see this gentle convexity.

4:37

That used to be like, oh, that's the left ventricle. No, in this

4:40

case. It's the right ventricular outflow track.

4:43

and right Central

4:45

Okay, it's rotated.

4:49

Emphysema and pulmonary hypertension is patient has very hyperinflated

4:52

lungs. You can see the sternal diaphragm is

4:55

greater than 90 degrees. The diaphragm is flat.

4:58

In this case the pulmonary artery here kind of

5:01

large, but the segmental artery is bigger than

5:04

the bronchus.

5:07

And so in this case the right ventricle doesn't look too big but

5:10

the lungs are very hyperinflated. This would be

5:13

a case you'd say hey, there's Advanced obstructive pulmonary physiology

5:16

radiographic findings, and I won't go into

5:19

our suggestive for emphysema. And there is likely concurrent pulmonary

5:22

hypertension.

5:24

Now the way emphysema gets

5:27

it is, you know, you destroy enough of the alveoli. You

5:30

also destroy the concurrent capillary. So

5:33

you lose the vascular bed vessel destruction with chronic

5:36

bronchitis pulmonary hypertension is seen much

5:39

earlier because the abnormality is in the

5:42

bronchi.

5:43

The read index is increased. There's reduced patchy

5:46

areas of ventilation and you get vasoconstriction chronic

5:49

vasoconstriction, then leads to

5:52

pulmonary hypertension. That's why they're called the Blue bloaters, right?

5:55

Because they get pulmonary hypertension cyanosis and

5:58

stuff. Emphysema is called the pink puffers.

6:01

It occurs later in the disease.

6:05

Now this patient clearly has enlarged pulmonary arteries.

6:08

You can see the neck oof. Very

6:11

large patient the lungs look

6:14

clear.

6:15

What would be the likeliology for the pulmonary hypertension? You'd

6:18

suggest it's probably going to be sleep. Apnea. Okay,

6:21

maybe trachea bronchumulation too. So you

6:24

can see the pulmonary artery is markedly enlarged.

6:28

Now patients with Advanced fibrosis,

6:31

especially usual interstitial pneumonitis. You

6:34

can see the reticulation. The low lung volumes left

6:37

greater than right.

6:39

The pulmonary artery is very large here.

6:42

Again, not commented

6:45

on the report. So with patients with

6:48

Advanced pulmonary fibrosis, you need to take a close look

6:51

at the pulmonary artery because that usually indicates they're

6:54

going to be coming in more often to the

6:57

hospital or to their clinic or to the ER.

7:00

Okay, they need to know about this they

7:03

can try and treat it and at least try to alleviate some of the symptoms but

7:07

it's a common complication every patient with

7:10

Advanced pulmonary fibrosis. Look at the pulmonary artery

7:13

doesn't look large.

7:16

This patient has large pulmonary artery main pulmonary

7:19

artery. They have extensive recurved reticular

7:22

opacities. They've had a biopsy this

7:25

is this turned out to be lymphocytic interstitial pneumonitis.

7:29

And a patient with an autoimmune disorder.

7:32

They have known pulmonary hypertension. Now. They

7:35

do have chronic hypoxia. That's probably one

7:38

of the causes but again multi-factorial issues.

7:42

This may also be related to an autoimmune

7:45

pulmonary hypertension like Scleroderma and

7:48

various other autoimmunes. Sometimes develop

7:51

pulmonary hypertension, even when there's not any lung

7:54

disease.

7:56

so multifactorial

7:58

patient with sickle cell Progressive dyspnea pitting edema

8:03

and you can see here three years ago, but now this patient

8:06

here the pulmonary artery is much larger. Okay, no

8:09

edema.

8:11

They do have some chronic pulmonary veins hypertension.

8:15

And so here you could suggest hey, there's pulmonary hypertension

8:18

like the developing maybe a post capillary cause

8:21

of chronic pulmonary venous hypertension because of the cephalization

8:24

right because cephalization occurs in the chronic setting.

8:27

It is not an acute process.

8:29

And the other thing is that even without that Sickle Cell

8:32

has a predisposition developing pulmonary

8:35

hypertension from some other mechanism.

8:40

18 year old postpartum you can see the vessels are

8:43

enlarged up high. That's the arteries and

8:46

veins. They are constricted in the lower lobes. This

8:49

is chronic compensated heart failure or

8:52

chronic pulmonary venous hypertension.

8:54

The pulmonary arteries are enlarged you can see the segmental

8:57

artery here and the bronchus adjoining it. It is

9:00

too big main pulmonary artery is also convex.

9:04

So chronic this is a post capillary cause remember

9:07

cephalization is

9:10

commonly taught being acute. It's really not in

9:13

acute process. It's a long-standing. This is a patient with congestive heart

9:16

failure with CT and treated and you

9:19

can see the vessel sizes. They don't change.

9:23

mitral stenosis

9:25

That's a common cause for pulmonary hypertension. You

9:28

can see the right ventricle is quite hypertrophied slash

9:31

dilated left atrial Chambers a little dilated that

9:34

goes along with the mitral stenosis and cephalization or

9:37

chronic pulmonary venous hypertension. The this

9:40

patient likely has some pulmonary artery hypertension.

9:44

present

9:46

now this one looks a little different.

9:49

The pulmonary artery is definitely enlarged and

9:52

you can see how large they are here. Centrally.

9:54

Whoo, right pulmonary left pulmonary artery right

9:57

ventricle. Wow, there's probably a huge ripe ventricular. Heave

10:00

here, right?

10:01

So in this patient this you look

10:04

at the vessels and they all look the same size. They

10:07

look the same size and that's

10:10

a pretty good indication that you probably have a

10:13

shunt shunt vascularity some ASD

10:16

vsd PDA kind of thing.

10:19

Okay.

10:20

And to distinguish between cephalization and

10:23

shunt again. You want to look closely

10:26

at the lower low vessels that's where

10:29

the answer is. These will be dilated. These will

10:32

be the same size in a shunt. These will be constricted in

10:36

cephalization and it's a chronic process and

10:39

organic change, right? They cares vascular sclerosis

10:42

down in the lower lobes.

10:46

So

10:47

summary radiograph is offers a lot

10:50

of information. Again. It's a snapshot of a patient's cardiopulmonary status.

10:54

First of all, do you see any possible or

10:57

suspect findings of pulmonary hypertensions the

11:00

pulmonary artery large right chamber size and if

11:03

so take a close look at the pulmonary vessels.

11:06

The lungs and the heart chambers and

11:09

see if you can come up with what you think might be

11:12

going on. Either way. You're probably going

11:15

to end up eventually going to a pulmonary CTA

11:18

plus or minus then a right

11:21

heart cat.

11:23

With that. Thank you very much.