Pulsus paradoxus

In medicine, a pulsus paradoxus (PP), also paradoxic pulse and paradoxical pulse, is an exaggeration of the normal variation in the pulse during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD).Khasnis A, Lokhandwala Y. Clinical signs in medicine: pulsus paradoxus. J Postgrad Med. 2002 Jan-Mar;48(1):46-9. PMID 12082330. [http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2002;volume=48;issue=1;spage=46;epage=9;aulast=Khasnis Free Full Text] .]

The "paradox" in "pulsus paradoxus" is that, on clinical examination, one can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse. It results from an accentuated decrease of the blood pressure, which leads to the (radial) pulse not being palpable and may be accompanied by an increase in the jugular venous pressure height (Kussmaul sign). As is usual with inspiration, the heart rate is slightly increased, [cite journal |author=Guntheroth W, Morgan B, Mullins G |title=Effect of respiration on venous return and stroke volume in cardiac tamponade. Mechanism of pulsus parodoxus |journal=Circ. Res. |volume=20 |issue=4 |pages=381–90 |year=1967 |pmid=6025402 [http://circres.ahajournals.org/cgi/content/abstract/circresaha;20/4/381 Abstract] ] due to decreased left ventricular output. [cite journal |author=Soucek M, Kára T, Jurák P, Halámek J, Spinarová L, Meluzín J, Toman J, Rihácek I, Sumbera J, Frána P |title=Heart rate and increased intravascular volume |journal=Physiological research / Academia Scientiarum Bohemoslovaca |volume=52 |issue=1 |pages=137–40 |year=2003 |pmid=12625819 [http://www.biomed.cas.cz/physiolres/pdf/52/52_137.pdf Free Full Text] .]

Mechanism of reduced blood pressure during inspiration in normal conditions

During inspiration, systolic blood pressure decreases slightly, and pulse rate goes up slightly. This is because the intrathoracic pressure becomes more negative relative to atmospheric pressure. This increases systemic venous return, so more blood flows into the right side of the heart. However, the decrease in intrathoracic pressure also expands the compliant pulmonary vasculature. This increase in pulmonary blood capacity pools the blood in the lungs, and decreases pulmonary venous return, so flow is reduced to the left side of the heart. Reduced left-heart filling leads to a reduced stroke volume which manifests as a decrease in systolic blood pressure. The decrease in systolic blood pressure leads to a faster heart rate due to the baroreceptor reflex, which stimulates sympathetic outflow to the heart.

Measurement of PP

PP is quantified using a blood pressure cuff and stethoscope, by measuring the variation of the pressure in systole with respiration. Normal systolic blood pressure variation (with respiration) is considered to be ≤10 mmHg. Pulsus paradoxus is an inspiratory reduction in systolic pressure >10 mmHg. Pulsus paradoxus can also be measured by listening to Korotkoff sounds during blood pressure measurement -- slowly decrease cuff pressure to the systolic pressure level where sounds are first heard. Then, cuff pressure is slowly lowered further until Korotkoff sounds are heard "throughout" the respiratory cycle. If the pressure difference between hearing the first sounds and hearing them throughout the respiratory cycle is >10mmHg, it can be classified as pulsus paradoxus.

Predictive value for tamponade

PP has been shown to be predictive of the severity of cardiac tamponade. [Curtiss EI, Reddy PS, Uretsky BF, Cecchetti AA. Pulsus paradoxus: definition and relation to the severity of cardiac tamponade. Am Heart J. 1988 Feb;115(2):391-8. PMID 3341174.]

Causes

Pulsus paradoxus can be caused by several physiologic mechanisms. Anatomically, these can be grouped into:
*"cardiac causes",
*"pulmonary causes" and
*"non-pulmonary and non-cardiac causes".

Considered physiologically, PP is caused by:
*decreased right heart functional reserve, e.g. myocardial infarction and tamponade,
*right ventricular inflow or outflow obstruction, e.g. superior vena cava obstruction and pulmonary embolism, and
*decreased blood to the left heart due to pulmonary vasodilation/hyperinflation, e.g. asthma, COPD and anaphylactic shock.

List of causes

Cardiac:
*cardiac tamponade
*pericardial effusion
*pulmonary embolism
*cardiogenic shock

Pulmonary:
*tension pneumothorax
*asthma

Non-pulmonary and non-cardiac:
*anaphylactic shock
*superior vena cava obstruction

References

ee also

*Precordial exam
*Pulsus alternans

External links

* [http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2002;volume=48;issue=1;spage=46;epage=9;aulast=Khasnis Clinical signs in medicine: pulsus paradoxus] - Mechanism, pathophysiology, detection and management of patient with pulsus paradoxus.