Pulsus Paradoxus And Treatment

Introduction

Pulsus paradoxus can seem confusing at first as it sounds like complicated medical terminology. However, together we can understand what this condition is and learn more about the underlying physiology, the mechanisms of the condition and available treatments.

Pulsus paradoxus is a condition that affects your systolic blood pressure and is caused by underlying health issues such as cardiac tamponade, severe chronic obstructive pulmonary disease (COPD), obstructive sleep apnea or severe asthma exacerbation (severe episodes of asthma worsening). 

Treatment for pulsus paradoxus varies depending on its underlying cause and can include an acute emergency intervention at the hospital as well as longer care and management. In order to understand pulsus paradoxus and its treatments, we must first speak about blood pressure.

The physiology of blood pressure and pulsus paradoxus

Blood pressure is a measure of the pressure inside the arteries and veins of your body at a given time. These blood vessels act as highways that carry blood and nutrients to your organs and tissues. Blood pressure is a measure of the pressure exerted on these vessels by the travelling blood.

Blood pressure is dependent on many factors, including how hard and how fast your heart is pumping, and the activity of the respiratory system. Normally, when you breathe in, your thoracic cavity and chest expand, causing a slight decrease in blood pressure and intrathoracic (thorax) pressure. This slight decrease in pressure is exaggerated in pulsus paradoxus. 

According to the National Health Service (NHS), a normal blood pressure range usually falls under 120 mmHg/80 mmHg when measured with a sphygmometer – a common device using a blood pressure cuff to monitor blood pressure. The first number (120 mmHg) represents the systolic blood pressure, which is the pressure measured when your heart contracts and pushes blood. The second number (80mmHg) corresponds to the diastolic blood pressure, which is the pressure measured when your heart relaxes.

In pulsus paradoxus, the physiological drop in blood pressure during inhalation is more significant. It is characterised by a drop of around 10 mmHg drop in systolic blood pressure. This significant decrease in systolic blood pressure during inhalation can have significant effects on cardiovascular and respiratory function, as the two systems are linked, as well as on overall clinical outcomes.

Some of the effects of pulsus paradoxus include:

• Decreased Cardiac Output (amount of blood pumped by the heart per minute): Pulsus paradoxus can lead to a decrease in cardiac output to the rest of the body due to reduced blood flow during inhalation. This reduction in cardiac output can impair oxygen delivery to vital organs
• Hypotension: The pulsus paradoxus’ exaggerated drop in systolic blood pressure during inhalation can result in systemic hypotension (blood pressure lower than 90/60 mmHg). Systemic hypotension may lead to symptoms such as dizziness, lightheadedness, and fainting
• Impaired Tissue Perfusion: The reduced cardiac output and hypotension associated with pulsus paradoxus can compromise tissue perfusion (tissue blood flow), leading to organ dysfunction and potentially life-threatening complications, particularly in critical conditions such as cardiac tamponade or severe asthma exacerbations
• Clinical Decompensation: Pulsus paradoxus may serve as an indicator of clinical decompensation in various medical conditions. Monitoring for pulsus paradoxus can help clinicians assess the severity of illness and guide treatment decisions, particularly in critical settings such as the emergency department or the intensive care unit

Overall, the effects of pulsus paradoxus can be profound and may require urgent intervention to stabilise cardiovascular and respiratory function, restore tissue perfusion, and prevent further clinical deterioration. Early recognition and appropriate management of its underlying causes are essential to improve patient outcomes and reduce morbidity and mortality associated with pulsus paradoxus.

Early signs and detection

Pulsus paradoxus at-home detection can be quite challenging, even if one has a sphygmomanometer since blood pressure must be measured during inhalation and exhalation. However, there are signs and symptoms commonly associated with the conditions underlying pulsus pardoxus that can indicate an urgent need for medical intervention. 

Some of these signs and symptoms include:

• Severe Shortness of Breath: If you experience sudden or severe shortness of breath that is not relieved by sitting down or usual treatments (such as asthma inhalers for asthma patients), this may indicate the presence of a serious respiratory or cardiac condition for which you should visit the hospital
• Chest Pain or Pressure: Chest pain or pressure, especially if persistent, severe or accompanied by other symptoms like shortness of breath, dizziness or sweating, can be a sign of a heart-related emergency such as cardiac tamponade or a heart attack
• Fainting or Dizziness: Feeling faint or dizzy, especially if the condition emerges suddenly or is accompanied by other concerning symptoms, may indicate a drop in blood pressure or inadequate blood flow to the brain
• Weak or Rapid Pulse: A weak or rapid pulse, particularly if accompanied by other symptoms like shortness of breath or chest pain, may suggest cardiovascular compromise
• Blue Lips or Fingernails: A Bluish discolouration of the lips, fingernails or skin known as cyanosis can indicate a lack of oxygen in the blood, which may be a sign of a serious respiratory or cardiovascular problem
• Swelling in the Legs or Feet: Sudden or severe swelling in the legs or feet, especially if accompanied by other symptoms like shortness of breath or chest pain, may indicate heart failure or other circulatory problems

If you experience any of these symptoms, especially in a severe or persistent manner, it is important to promptly seek medical attention. If this is your first time experiencing a symptom that you have not discussed with your physician, you should contact your local emergency number (such as 112 or 999 in the UK) or go to the nearest emergency room for evaluation. You should never hesitate to seek medical attention if your symptoms are causing you significant distress or you are unsure of their meaning. 

Treatment

Various health issues can lead to pulsus paradoxus, the treatment of which depends on its underlying cause. Pulsus paradoxus is often caused by severe COPD, severe asthma exacerbations, cardiac tamponade, and obstructive sleep apnea. Given that some of these health issues constitute medical emergencies that must be addressed by rapid medical intervention, it is important to not hesitate to seek out medical advice at your nearest emergency room.

In the case of cardiac tamponade, a condition marked by fluid buildup in the sac that surrounds the heart (the pericardium), the compression of the heart chambers by the fluid requires immediate medical intervention. This compression prevents the heart from filling up with blood properly, which translates into less blood being pumped by the heart, a drop in blood pressure and pulsus paradoxus. Treatment consists in a procedure known as pericardiocentesis which drains fluid from the pericardium to relieve compression and restore normal heart function.

Severe asthma flare-ups and exacerbations which lead to pulsus paradoxus can be treated using bronchodilators such as albuterol. Bronchodilators relax the lung muscles and expand the airways, while corticosteroids which are also commonly prescribed in this scenario reduce airway inflammation. Supplemental oxygen may also be provided. In the most severe cases, mechanical ventilation and intravenous corticosteroids may be necessary.

COPD is a chronic disease which can lead to pulsus paradoxus when severe. Treatment includes bronchodilators, supplemental oxygen, corticosteroids, and more rarely, surgical interventions such as lung volume reduction surgery or lung transplantation. The latter are not acute treatments; they are only discussed by your doctor after multiple episodes in which the condition was not managed well through other medications.

Individuals with obstructive sleep apnea that causes pulsus paradoxus can be treated via lifestyle changes such as weight loss, alcohol reduction, or the usage of a CPAP machine at night to keep the airways open during sleep. 

Importantly, it should be noted that while treatment varies depending on the cause of pulsus paradoxus, the treatments listed are still general approaches that can change according to your unique circumstance and severity of symptoms. It is essential to consult a healthcare professional to find the right treatment for you.

FAQ’s

Is pulsus paradoxus a medical emergency?

Pulsus paradoxus is a condition that can be caused by many underlying causes, some of which are most definitely medical emergencies which originate from the cardiovascular system or respiratory system. Shortness of breath and chest pain are some of the signs of these emergencies. However, it is hard to tell from symptoms alone if there is a medical emergency or what the exact cause of the pulsus paradoxus is. Only after being investigated by a medical professional at a hospital can these questions be answered. 

What is the prognosis of pulsus paradoxus?

The prognosis of pulsus paradoxus varies depending on its underlying cause, the effectiveness of treatment and early detection. Timely recognition, appropriate management and adherence to medical treatment are crucial in reducing complications and improving outcomes.

What are the symptoms of pulsus paradoxus?

Symptoms depend on the underlying cause of pulsus paradoxus but can include chest pain, weakness, dizziness, shortness of breath, and other signs of respiratory and cardiovascular decline. 

How is pulsus paradoxus diagnosed?

A medical professional will look at your blood pressure using a sphygmomanometer. A drop of 10 mmHg or more in your systolic blood pressure when you breathe in compared to when you breathe out indicates pulsus paradoxus.

Summary

While the prognosis and follow-up on pulsus paradoxus differ greatly based on its underlying cause, which can be cardiac or respiratory, it is important to seek out immediate medical attention if you feel symptoms such as the ones listed above since some can refer to medical emergencies.

Long-term management of pulsus paradoxus may involve addressing its underlying conditions, implementing lifestyle changes to prevent the recurrence of pulsus paradoxus episodes, and optimising medication regimens. It is also important to increase awareness of the signs and symptoms of pulsus pradoxus, its recurrence, and the importance of adherence to treatment and committing to timely follow-up appointments with your medical care team. 

Overall a comprehensive approach is usually needed to address the underlying cause of pulsus paradoxus, whether it is a respiratory or cardiovascular issue. It is essential to seek medical care and adhere to treatment for the most optimal outcomes.