A.

Responses to Altered Ventilatory

Function

 Non-invasive Oximetry (e.g. Pulse

Oximeter)
 Invasive
ABG (Arterial Blood Gas)
Pulmonary Capillary
Wedge Pressure (PCWP)
 - an integrated measurement of
the compliance of the left side of
the heart and the pulmonary
circulation.
 Introduction

 Pulmonary capillary wedge

pressure (PCWP) is frequently
used to assess left ventricular
filling, represent left atrial pressure,
and assess mitral valve function.
 It is measured by inserting a
Pulmonary capillary wedge pressure
balloon-tipped, multi-lumen
(PCWP) is frequently used to assess left
catheter (Swan-Ganz catheter) into
ventricular filling, represent left atrial
a central vein and advancing the
pressure, and assess mitral valve function.
catheter into a branch of the
Right heart catheterization remains a vital
pulmonary artery. The balloon is
tool in the diagnosis, prognostic
then inflated, which occludes the
evaluation, and management of patients
branch of the pulmonary artery and
with suspected pulmonary hypertension
then provides a pressure reading
(PH) and selected heart failure patients.
that is equivalent to the pressure of
Objectives: the left atrium.

 Review the pathophysiology of Right heart catheterization (RHC)

pulmonary capillary wedge
- An invasive procedure that requires
pressure.
expertise and close monitoring. This was
 Identify the indications for checking described initially in the eighteenth
pulmonary capillary wedge century, and since then, the procedure
pressure. and its applications have drastically

 Outline the most common adverse grown. Though employed widely in the

events associated with right heart past, the failure of multiple studies to show

catheterization. any benefit of RHC in patients with

advanced heart failure or cardiogenic
 Explain the importance of
shock has decreased its utility in everyday
collaboration and communication
practice.
among the interprofessional team
to ensure the appropriate selection
of candidates to measure
pulmonary capillary wedge
pressure and to improve outcomes
of patients undergoing this
procedure
Anatomy and Physiology  In the right atrium, both the
diastolic and the systolic pressure
 To measure the PCWP, a catheter
are usually less than 5 mmHg (with
is inserted through a central vein
mild variations). While in the right
(either femoral, subclavian, or
ventricle, the systolic pressure is
internal jugular) and advanced into
about 25 mmHg, and the diastolic
the superior or inferior vena
pressure remains similar to right
cava to reach the right atrium.
atrial diastolic pressure (<5
 The internal jugular vein is the
mmHg). In contrast, the pulmonary
preferred access. From the right
artery systolic pressure is similar to
atrium, the catheter is advanced
the right ventricular systolic
through the tricuspid valve into the
pressure in the absence of
right ventricle. Once in the right
pulmonic stenosis, but the diastolic
ventricle, the catheter is advanced
pressure increases to about 10
to the right ventricular outflow tract,
mmHg.
then to the pulmonary artery after
crossing the pulmonic valve. The Indications
tip of the catheter lies in the main
Measurement of the PCWP
pulmonary artery, where the
balloon can be inflated for  Differentiate between cardiogenic
measurement of the pulmonary pulmonary edema and
capillary wedge pressure. In most noncardiogenic pulmonary edema
cases, the PCWP is also an
 Confirm the diagnosis
estimate of left ventricular end-
of pulmonary arterial hypertension
diastolic pressure (LVEDP). The
normal pulmonary capillary wedge  Assess the severity of mitral
pressure is between 4 to 12 stenosis
mmHg. Elevated levels of PCWP
 Differentiate between different
might indicate severe left
forms of shock
ventricular failure or severe mitral
stenosis.  Measure key hemodynamic

 The location of the catheter can be parameters and assess response

determined by the waveform on to therapy

the monitor or by measuring both

the systolic and the diastolic
pressure with the tip of the
catheter.
 PA catheters might have a
separate lumen designated for
infusing drugs.

Contraindications  The distal lumen or yellow port is

located at the distal end of the
Absolute Contraindications  catheter and resides in the

 Right-sided endocarditis pulmonary artery. It is used to

monitor PA pressures and to
 Tumors or masses on the right
obtain a mixed venous sample.
side of the heart
Medications and infusions should
 Lack of consent not be inserted through this port.

 Relative Contraindications  The red port is for balloon inflation

and deflation. The balloon sits
 Tricuspid or pulmonary valve
approximately 2 cm from the distal
disorders
end of the catheter. Each PA
 Left bundle branch block, as there catheter is accompanied by a 1.5
is a chance of precipitating ml syringe used to inflate or deflate
complete heart block the balloon. The inflated balloon
helps to guide the catheter from
the right atrium into the PA by
Equipment following intracardiac blood flow.
The inflated balloon also helps to
The PA catheter or Swan-Ganz catheter is
measure the PCWP.
usually between 60 to 110 cm in length
and around 4 to 8Fr in caliber. It was  Temperature or thermistor is used
named after its inventors, Jeremy Swan to measure core temperature in the
and William Ganz. pulmonary artery. This helps to
measure the cardiac output via the
Most PA catheters have 4 separate
thermodilution method.
lumens, each of which serves
individualized functions.

 The proximal lumen or blue port is

located in the right atrium and
measures the right atrial
pressure. It can also be used
to administer medications. Some

Technique
Before performing any procedure, it is
important to perform a time-out. During the
time out, the healthcare team performing
the procedure should
1) verify the patient details,
2) confirm the procedure and site,
3) ensure patient consent,
4) ensure normal labs,
5) review patient medications, and
6) ensure appropriate personnel and
equipment are at the bedside.
 The most common vein accessed
for the RHC is the internal jugular
vein. Usually, an ultrasound is
used for locating the vein and
guiding the needle. The ultrasound
also helps to assess the location of
the nearby artery to confirm the
patency of the vessel and to
ensure that there is no thrombus
inside the vessel lumen. Though it
can be performed without an
ultrasound as well, imaging
guidance has shown to decrease
complications.
 The first step of the procedure is to
clean the area with an antiseptic
solution, and the patient is draped
to make a sterile working field.
Using a vascular probe, the
position of the vessel is confirmed
again. Following this, local
anesthesia is provided at the site
of insertion. The central vein is
then punctured with the needle
provided, and a guidewire is
introduced into the vein by the
Seldinger technique. The
ultrasound can be used to confirm
the location of the guidewire inside
the vein.
 After the guidewire is confirmed to
be in place, the needle is removed.
A scalpel blade is then used to
make a 3 to 4 mm incision
adjacent to the guidewire to ensure
easy passage of the dilator. Care
should be taken not to cut the
guidewire. An 8.5 Fr dilator with an
introducer sheath is inserted over
the wire into the vein. The wire and
dilator assembly should then be
removed together as a unit leaving
the introducer sheath in place.
 Once the introducer sheath is in
position, the pulmonary artery (PA)
catheter is inserted through it and
advanced up to 20 cm. This should
place its distal tip within the right
atrium, which can be confirmed on
the monitor with a right atrial
pressure waveform. Once the
position inside the right atrium is
 confirmed, the balloon is then
inflated with air using the 1.5 mm
syringe.
 The catheter is then advanced into
the right ventricle and then into the
pulmonary artery.
advancements are confirmed by
checking the appropriate
waveforms and pressures on the
monitor. Once the catheter is
advanced into the pulmonary
artery to the point where the
waveform changes into a wedge
form, the balloon should
deflated. The catheter will then
show the PA pressures.
 After obtaining the appropriate PA
pressures, a PCWP/pulmonary
artery occlusion pressure can now
be measured. This is done by
inflating the balloon slowly while
observing the monitor. The balloon
is inflated only until the
pressure waveform changes into a
wedged waveform. When
balloon is inflated, it creates a
static column of blood between the
artery distal to the catheter and the
pulmonary vein. This post-capillary
pressure, known as the PCWP, is
an indirect estimate of the pressure
in the left atrium.
 Once the procedure is done, a
chest X-ray should be ordered to
confirm the position of the catheter
and to check for any complications.
The tip of the PA catheter should
not extend beyond 2 cm of the
hilum and is usually within the
mediastinal shadow.
The
The utility of RHC is dependant on the
accuracy and completeness of the data
obtained. Essential measurements during
the procedure include: 
 Oxygen saturation (superior vena
cava, inferior vena cava,
pulmonary artery, sinoatrial)
be  Right atrial pressure
 Right ventricular pressure
 Pulmonary artery pressure
 Left heart filling pressure (wedge
pressure, left atrial pressure, or
LVEDP)
 Cardiac output/cardiac index
 Pulmonary vascular resistance
PA
 Systemic blood pressure
the  Heart rate
 Response to acute vasodilators
Misinterpretation of the wedge pressure is
a common pitfall in the invasive diagnosis
of pulmonary hypertension. The wedge
pressure should be measured at end-
expiration and in several different
segments of the pulmonary vasculature.
LVEDP should be obtained if there is any
doubt about the accuracy of the wedge the dose of diuretic drugs and other drugs
pressure tracing or if the results are used to reduce pulmonary venous and
unexpected in a given patient. A fluid capillary pressure, thereby reducing
challenge may be necessary to elicit the pulmonary edema. Therefore, it can also
presence of diastolic dysfunction. guide therapeutic efficacy. 

Of note, operators should proceed early It is also used to evaluate and diagnose
with trans-septal LA catheterization for pulmonary arterial hypertension (PAH), as
patients with mitral valve disease or prior patients with group 1 PAH will have
mitral valve replacement. PCWP ≤ 15 mmHg.[19] Furthermore, it is
used in the calculation of pulmonary blood
Complications flow along with pulmonary artery

Pulmonary artery catheterization is an pressure. 

invasive procedure that carries innate PCWP is also useful in differentiating

risks. Several complications have been cardiogenic shock (PCWP > 15 mmHg)
described following the procedure, with from non-cardiogenic shock (PCWP ≤ 15
studies noting the occurrence of mm Hg). It is also used to evaluate blood
complications is between 5% and 10%. volume status to guide fluid administration

The most common complications that can during hypotensive shock, where the

occur as a result of this procedure include: PCWP goal should be maintained

between 12 to 14 mmHg.
arrhythmias, thromboembolism,
pulmonary ischemia, hemoptysis, Pleural Fluid Analysis

pulmonary hemorrhage, perforation of the

pulmonary artery, knotting of the catheter, a test that examines a sample of

arterial puncture, hematoma, and local fluid that has collected in the

infection can occur during or after the pleural space.

procedure. This is the space between the

lining of the outside of the lungs
Clinical Significance (pleura) and the wall of the chest.
When fluid collects in the pleural
As mentioned before, PCWP is a
space, the condition is called
reasonable surrogate marker of left atrial
pleural effusion.
pressure and LVEDP. It is helpful to
measure PCWP to diagnose the severity
of left ventricular failure and quantify the
degree of mitral valve stenosis. By
measuring PCWP, the clinician can titrate
 2. Review of systems: conducted by the
nurse to learn of any clinical conditions
that may require additional attention. This
can be done during a phone screen prior
to the day of the procedure.
a. Cardiovascular: coronary artery disease
(CAD), congestive heart failure (CHF),
valvular disease, arrhythmia
b. Respiratory: cystic fibrosis, asthma
obstructive sleep apnea, use of
continuous positive airway pressure
(CPAP), noninvasive positive-pressure
ventilation (NPPV), or bilevel positive
airway pressure (BIPAP),
O2 requirements, artificial airway
c. Gastrointestinal (GI): dietary
restrictions/requirements,
nutrition/metabolic screening
(1) Diarrhea, dental problems, difficulty
swallowing, persistent nausea/vomiting
(N/V), appetite, weight loss/gain, bone
marrow transplant (BMT), tube feeds, total
Pulmonary Angiography
parenteral nutrition (TPN), end-stage
A pulmonary angiogram is an diseases, esophageal disease/surgery,
angiogram of the blood vessels major burn/trauma, major GI or oral
of the lungs. The procedure is surgery, myocardial infarction (MI)/stroke,
done with a special contrast dye diabetes, surgical patient more than 70
injected into the body's blood years old, pressure ulcer
vessels. This is done in the groin d. Genitourinary: problems with urination,
or arm. The dye shows up on X- anuria, ostomy, suprapubic Foley catheter
rays. Fluoroscopy is often used e. Reproductive/sexual health: female; last
during this test. menstrual period (LMP), pregnancy,
breastfeeding
Procedure-Specific Considerations
f. Tubes/lines/drains: such as
1. Review chart, history, indication for
percutaneous nephrostomy tubes, biliary
procedure.
tubes, abscess drains, blood
suction/drains, chest tubes, peritoneal (6) Ability to lie flat for duration of pre-,
abscess drains intra-, and postprocedure as appropriate
g. Skin assessment: rashes, open (7) Claustrophobia
wounds/sore, discoloration, redness, (8) Previous history/problems tolerating
itchiness procedural sedation—agents/amounts
h. Musculoskeletal: difficulty walking, from previous experiences
moving extremities, assistive devices for
walking, Morse Falls Scale, 3. Preprocedure laboratory testing:
deteriorating/debilitating conditions Blood work is necessary with
affecting mobility numerous IR procedures. Patients need to
i. Internal/external devices: be instructed if any preprocedure blood
pacemaker/defibrillator, joint/valve, work is needed to be drawn and the
piercings/tattoos, medication patches, rationale for the needed blood work.
subcutaneous ports, external catheters Oftentimes, evaluation of renal function is
j. Pain: current, chronic, new onset; mandatory for procedures where contrast
location, character duration, frequency is necessary. Additionally, other factors,
scores per hospital policy such as coagulation status, need to be
k. Assistive/prosthetic devices: dentures, known for determining risk of bleeding.
glasses/contacts, hearing aids, Patients requiring blood work should be
crutches/cane, walker told to have it done few days prior to the
l. Past anesthesia/sedation procedure when possible to avoid delays
history: IR procedures are routinely the day of the procedure. When of
performed under moderate sedation or childbearing age, may require testing at
some form of anesthesia (monitored least 7 days prior to the procedure
anesthesia care [MAC] or general
anesthesia). It is important for the nurse to 4. Allergies: known allergies with
be familiar with patient’s existing description of types of reactions; past
documented history and physical (H&P), reactions involving contrast, severity, and
including surgical history in which interventions. Patients with known contrast
anesthesia was utilized: reactions may be premedicated with
(1) Head/neck surgery/cancer steroids, antihistamines, and H2
(2) Prior complications with anesthesia antagonists. It is important for the IR nurse
(3) Blood relatives who have anesthesia conducting the intake screen to inquire if
complications (malignant hyperthermia the patient has had a “breakthrough”
[MH]) reaction after receiving premedication; this
(4) Postoperative nausea/vomiting information must be communicated to
(5) Difficult intubation/extubation the IR provider.
5. Medications: It is important to review
the patient’s current prescription 6. Discharge planning: Planning for the
medications because some of them may discharge should begin prior to the
be contraindications for the procedure, if procedure.
not stopped or managed appropriately. a. Transportation: Special consideration
Patients should bring a list of their for transportation, indicated hospital
medications with them. Hospital policy admission, or home health care should be
regarding patients bringing medications discussed with the patient at the time of
from home for use in hospital should be the phone screening. For OPs who will be
known by the nurse. going home after meeting postprocedure
a. Anticoagulants—increased risk of discharge criteria, it is important to plan for
bleeding during IR procedure. Patients traveling home with a responsible
should be informed well in advance to companion especially if moderate sedation
“hold” medications in preparation to or MAC/general anesthesia was utilized
undergo a procedure. for the procedure.
b. Nonsteroidal anti-inflammatories b. Psychosocial support: Undergoing
(NSAIDs)—in general, do not cause an IR procedure can be a very stressful
significant bleeding problems except in time for the patient. It is important to
patients with existing coagulopathies, inquire about the patient’s sources of
hemophilia, von Willebrand disease, or emotional support. Family and caregivers
severe thrombocytopenia. Paradoxically, should be involved in the patient’s care if
NSAIDs tend to diminish the antiplatelet agreeable. The nurse should screen for
effect of aspirin when given concomitantly depression, anxiety, self-harm, suicide,
and therefore should not be given to and domestic abuse. Special needs
patients receiving aspirin therapy for should be taken into consideration (e.g.,
cardiovascular disease. language, cultural/psychosocial, physical,
c. Diabetic agents—insulin regimen or oral spiritual). Address and facilitate practices
agent administration for control of glucose related to religion, culture, or
needs to be known, to provide instructions alternative/complementary therapies that
on when to self-administer these prior to will need to be integrated as part of the
the procedure. Additionally, metformin care as appropriate.
instructions “to hold for 48 hours c. Behavioral screening: Risks for tobacco
postadministration of contrast” should be use, alcohol use (Clinical Institute
explained to the patient. Withdrawal Assessment [CIWA] score),
d. Cardiac and antihypertensives and drug use should be inquired about
e. Thyroid medications additional support needed to assist the
f. Inhalers/prednisone patient.
d. Patient education: The nurse
conducting the preprocedure screen has
an opportunity to educate the patient on
what to expect upon arrival on the day of
the procedure including parking,
registration process, preprocedure nursing
Ventilation-Perfusion Scan (V/Q)
process, consenting, and meeting with the
members of the IR team. used to see how well air moves and
e. Advance care directives (ACD): Indicate blood flows through the lungs. The
whether copy is in medical record or perfusion scan measures the blood
status, otherwise. Offer information supply through the lungs. A ventilation
regarding ACD and whether patient and perfusion scan is most often done to
accepted or refused the information. detect a pulmonary embolus (blood clot in

7. Instructions for date of service:

Patient instructions in preparation for an
upcoming procedure are important to
ensure optimization and decrease
possibility of having to be rescheduled.
Instructions should include:
a. Home medications on hold
the lungs)
b. Home medications which can be taken
with a sip of water (i.e., antihypertensives A VQ scan can help to diagnose a blood
such a β-blocker) clot in the lungs. If left untreated, blood
c. Explanation of nil per os (NPO) 6 hours clots can be fatal. If you have symptoms of
prior to the procedure when moderate a blood clot, such as shortness of breath
sedation, MAC, or general anesthesia is to and a sharp pain when you breathe in,
be utilized your doctor might recommend a VQ scan.
d. Transportation back home needs to be
 An unstable form of a chemical
via companion or caregiver
element that releases radiation as it
e. Preprocedures for specific
breaks down and becomes more
imaging/interventions and personal
stable. Radioisotopes may occur in nature
belongings.
or be made in a laboratory. In medicine,
they are used in imaging tests and in
treatment.
Capnography
refers to the noninvasive
measurement of the partial
pressure of carbon dioxide (CO2)
in exhaled breath expressed as
the CO2 concentration over time.
The relationship of
CO2 concentration to time is
graphically represented by the
CO2 waveform, or capnogram