Psychosocial Burdens of Pulmonary Arterial Hypertension: A Discussion Paper

Pulmonary arterial hypertension is an uncommon and devastating chronic illness with no known cure. Little is known about the disease, and even less about the psychosocial burdens. While it is important to create awareness about the physical aspects of the disease, it is equally important to create awareness about the psychosocial burdens patients and their families face. We reviewed the literature to better understand these psychosocial burdens, which include impact from physical limitations, emotional strains, financial burdens, social isolation, lack of intimacy in relationships, and an overall lack of information. The findings can be used to assist health care providers to understand the psychosocial challenges that are being experienced by patients and families in order to better provide supportive care. The creation of a standardized tool to assess the psychosocial burdens at each clinic visit can benefit health care providers by addressing challenges faced and facilitate subsequent referral to appropriate specialists.

A Patient with Pulmonary Hypertension on a Medical-Surgical Unit

The medical-surgical nurse is positioned to provide safe, clinical care to patients with pulmonary hypertension (PH). An-overview of the pathophysiology, diagnostic studies, and treatments associated with PH is described.

Pulmonary hypertension: a review for nurses

Pulmonary hypertension (PH) is a progressive disease resulting from increased pulmonary vasoconstriction, vascular remodelling and thrombosis, leading to right heart failure. Symptoms at clinical presentation are often vague and difficult to differentiate from other diseases. A good history and identification of key physical findings will facilitate earlier diagnosis resulting in tailored treatment to alleviate symptoms and improve outcomes. This article will provide an overview of PH including pathophysiology, clinical presentation, diagnostic testing, and treatment modalities with a Canadian perspective. The main focus is directed towards the care of patients with pulmonary arterial hypertension (PAH). Implications for nursing will also be discussed, focusing on education and support of patients and families.

Nitric oxide and nursing: a review

AIMS AND OBJECTIVES

This paper, therefore, aimed to review published literature in this area of pharmacological exploitation, to look at the therapeutic applications and clinical relevance and, by so doing, provide an accessible source for nurses to gain insight into the role of nitric oxide in the clinical setting.

BACKGROUND

Nitric oxide is a chemical mediator fundamental in the maintenance of adequate tissue perfusion and effective cardiovascular function; a major endogenous regulator of vascular tone. The use of nitrates are well established as pharmacological agents but it is only recently that it has been recognized that they act as a source of nitric oxide. Although widely addressed within the medical literature, there appears to be a paucity of nursing literature that explores either its physiological action, or its relevance to nursing practice.

CONCLUSIONS

This literature review provides an overview of the use of nitric oxide and its implications for nursing practice and patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of nitric oxide and its action is pertinent to nurses across diverse specialities. It helps in understanding the principles of many nitrogen-derived medications which nurses administer to their patients on a daily basis. In terms of oral medication, this is demonstrated by greater insights into the action of nitrates, the appreciation of surprising developments in medications such as sildenafil and the development of new drug opportunities such as nitric oxide-non-steroidal anti-inflammatory drugs. Equally, the use of inhaled nitric oxide therapy in adult and neonatal critical care units appears to be an increasingly valuable source of treatment. A particular research challenge is found in the attempt at nitric oxide inhibition in the management of septic shock. The authors argue that understanding such esoteric areas of therapeutic developments is increasingly to be part of the repertoire of knowledge and skills for nurses in the 21st century.

Pulmonary thromboendarterectomy in the UK

This paper describes the disease of chronic thromboembolic pulmonary hypertension. This is a disease with an extremely poor prognosis, and the surgical procedure of pulmonary thromboendarterectomy represents the only possibility of a cure for patients with this condition. Further the paper describes the role and responsibilities of critical care nurses, specialist nurses in palliative care and pulmonary hypertension when caring for these patients before and after surgery.

Understanding primary pulmonary hypertension

Primary pulmonary hypertension (PPH) is a severe and progressive disease. It is characterized by persistent elevation of pulmonary artery pressure without any known cause. The hemodynamics demonstrates high pulmonary artery pressure and resistance to blood flow through the lung circulation. PPH is a diagnosis of exclusion. The diagnosis is often delayed because the initial symptoms may be mild and the exam findings subtle. The mean age of survival is 2.8 years without treatment. With treatment patients can survive for more than 10 years. Current lifetime treatment includes anticoagulation, oxygen, digoxin, calcium channel blockers, vasodilators, and diuretics. Promising results have been obtained with prostacyclin and endothelin receptor antagonists. Lung transplantation can be considered for patients with advances PPH and those not responding to medical therapy.

[Therapeutic use of nitric oxide: implications for nursing]

Nitric oxide (NO) is a gas that transmits signals in the organism. Such signal transmission takes place by means of the gas synthesis and release in different cell types. After it is released, the gas penetrates the membrane of a neighboring cell and regulates its function. Such mechanism represents an entirely new signaling principle in biological systems. The discoverers of NO as a signaling molecule were awarded the Nobel Prize in Medicine and Physiology in 1998. This discovery has revolutionized medicine and originated new treatments for old problems. In this study, we review the role of NO in some pathologies such as sepsis, arterial hypertension and pulmonary hypertension and Nitric Oxide is explained in terms of its current merit for treatment and its impact on nursing care.

Neonates with congenital cardiac defects with increased pulmonary blood flow

Generally, cardiac lesions with increased pulmonary blood flow demonstrate cardiomegaly, increased pulmonary vascular markings, and pulmonary congestion on the chest x-ray. These findings occur as a result of the following: (1) A left-to-right shunt or mixing lesion in which excess volume of blood flow causes dilation of cardiac chambers, resulting in the appearance of cardiomegaly, and in which increased pulmonary artery blood flow causes increased pulmonary vascular markings; (2) Obstruction of blood flow that produces pulmonary venous hypertension and resultant pulmonary edema.

Continuous intravenous prostacyclin for advanced primary pulmonary hypertension

This article discusses the use of prostacyclin therapy for patients with advanced primary pulmonary hypertension, from patient selection through initiation, dosing, outpatient management, and outcomes. Advanced practice nurses are key to helping patients adapt to this complex medical therapy.

Prostacycline (Flolan). Intravenous nursing responsibilities in the care of the patient with primary pulmonary hypertension

Primary, or unexplained, pulmonary hypertension is an extremely rare lung disorder. For no apparent reason, blood pressures in the pulmonary artery increase far in excess of normal levels. Prostacycline (Flolan, epoprostenol) has proved effective in the long-term care of patients with Type III or Type IV primary pulmonary hypertension (PPH). These patients require intensive intravenous therapy-related education in the safe and compliant administration of prostacycline. The IV nurse's multiple roles in the care of these patients are clearly delineated: instructor, advocate, and clinical resource specialist.

Epoprostenol therapy for primary pulmonary hypertension

Although a rare disease, PPH is deadly. Until recently, patients had little hope for remission of this disease. Originally viewed as a "bridge to transplantation," new research findings suggest that epoprostenol significantly improves PPH so that transplantation may not be necessary. Treatment with epoprostenol is difficult to manage, however, because it requires continuous central infusion. Nurses have a key role in ensuring that patients safely and effectively manage this therapy.

Preventing pulmonary hypertensive crisis in the pediatric patient after cardiac surgery

Pulmonary hypertension is seen in infants and young children who have congenital heart defects resulting in excess pulmonary blood flow. The critical care nurse can implement several interventions in the immediate postoperative period to help prevent the potentially lethal complication of pulmonary hypertensive crisis in a cardiac surgery patient. Respiratory interventions include hyperventilation, maintaining an alkalotic pH, supplemental oxygen, and low positive end-expiratory pressure. In addition, the nurse must consider the serum potassium, hematocrit, and patient temperature, and administer appropriate medications.

Perioperative management of pulmonary circulation in children with congenital cardiac defects

Congenital cardiac defects and the clinical symptoms they exhibit are affected intimately by the relation they have with pulmonary circulation. Cardiac lesions that increase pulmonary blood flow often occur clinically with signs and symptoms of congestive heart failure, including hepatomegaly, tachycardia, diaphoresis, and feeding difficulties. However, in the neonatal period, pulmonary vascular resistance often remains elevated, decreasing the pulmonary blood flow and, therefore, severity of symptoms. Cardiac lesions that reduce pulmonary blood flow often manifest early in life with clinical signs and symptoms of cyanosis, tachypnea, and acidosis. Finally, cardiac lesions that result in isolated pulmonary blood flow manifest immediately in the neonatal period, with profound cyanosis and acidosis. In all three groups of cardiac anomalies, critical care nurses play a key role in the control of pulmonary vascular resistance and blood flow by collaborating in therapies designed to increase, decrease, or promote mixing to reduce morbidity and mortality.

Pulmonary artery pressure measurement in patients with elevated pressures: effect of backrest elevation and method of measurement

OBJECTIVE

To determine whether pulmonary artery pressure measurement is accurate if the head of the bed is elevated; to compare the end-expiratory graphic recording and digital monitor methods for pulmonary artery pressure measurement; to determine whether either mean arterial pressure or mixed venous oxygen saturation changes during backrest elevation.

DESIGN

Nonrandomized clinical trial.

SETTING

A six-bed cardiac surgical intensive care unit of a 540-bed federal facility.

POPULATION

Twenty-five postoperative cardiac surgical patients with elevated pulmonary artery pressures (systolic higher than 35 mm Hg).

INTERVENTIONS

In supine patients pulmonary artery pressures were measured at each of the following backrest elevations: 0, 20, 30, 45 and again at 0 degrees. Measurements were obtained once during mechanical ventilation and once during normal breathing after extubation.

MAIN OUTCOME MEASURES

End-expiratory graphic recording of pulmonary artery pressures; digital monitor values of pulmonary artery pressures; mean arterial pressure; and mixed venous oxygen saturation.

RESULTS

No statistical difference was found in pulmonary artery pressures measured at each of the backrest elevations during mechanical ventilation or normal breathing after extubation. Pulmonary artery diastolic and pulmonary capillary wedge pressures obtained with the digital monitor method were significantly lower than the end expiratory graphic recording method during normal breathing after extubation but not during mechanical ventilation. No changes in mean arterial pressure or mixed venous oxygen saturation occurred during backrest elevation.

CONCLUSIONS

These results show that pulmonary artery pressures can be measured accurately with the head of the bed in an elevated position. The data indicate that obtaining pulmonary artery pressure measurements from the digital display of the bedside monitor is accurate when respiratory wave form fluctuations are minimal but may lead to inaccurate values with prominent respiratory fluctuations. Further research is needed to validate this finding in different patient populations and with other models of monitoring equipment.

Prostaglandins for the control of pulmonary hypertension in the postoperative cardiac surgery patient: nursing implications

Right ventricular failure associated with pulmonary hypertension is a potential complication in selected cardiac surgical patients following cardiopulmonary bypass. Treatment modalities are generally focused on reduction of right ventricular afterload. PGE1 infusion is one method of providing afterload reduction by its vasodilating action on the pulmonary vasculature. Nursing management of the patient receiving PGE1 requires a thorough knowledge of the hemodynamic alterations occurring in right ventricular failure and pulmonary hypertension, as well as the effect of PGE1 on these hemodynamic parameters. The nurse must understand the rationale for concomitant administration of a vasoconstrictor with the PGE1 as well as possible methods of administering these agents. Lastly, recognition and management of possible adverse effects associated with PGE1 infusion are essential components of nursing care.