肺心病英文中山大学内科学.ppt

Chronic Pulmonary Heart Disease,The second affiliated hospital of Sun Yat-sen university, pulmonary department. Shanping Jiang,OUTLINE,Definition ： Chronic lung,chest or pulmonary vascular diseasesPulmonary vascular resistance Pulmonary artery pressure Hypertrophy and dilatation of the right ventricle Right Heart Failure Prevalence：0.44%0.46% Onset ages：40 years old Incidence season：Winter and Spring Predisposing factors ：Acute respiratory infections,Etiology,Chronic bronchial and lung diseases：the most common disease is Chronic obstructive pulmonary disease 80% Thoracic deformity Pulmonary vascular disorders Others,Mechanism and Pathology,（一）Pulmonary hypertension： Definition ：mean pulmonary artery pressure （mPAP） 25 mmHg at rest or 30 mmHg during exercise. Functional changes in pulmonary vascular Hypoxia, Hypercapnia, Respiratory acidosis, vasoconstriction substancesPulmonary vasoconstrictionPulmonary hypertension Hypoxia is the most important factor leads to pulmonary hypertension Anatomic changes in pulmonary vascular Remodeling of pulmonary vessels Increased blood viscosity and blood volume,Mechanism and Pathology,（二）Dysfunction of right heart Pulmonary hypertension Afterload of right ventricular , Oxygen supply of myocardium Hypertrophy and dilatation of the right ventricle Right heart failure (三）Damages to other vital organs： Multiple organ dysfunction,Clinical Manifestations,Compensation stage of cardiac and lung function Symptoms: cough, sputum, short of breath; dyspnea and palpitation on exertion; fatigue and decrease of exercise tolerance;exacerbated by acute infection. Signs: cyanosis, signs of emphysema, moist rales and/or rhonchi; P2A2 , systolic murmur of tricuspid area, subxiphoid visible/palpable cardiac impulse, distended jugular venous.,Clinical Manifestations,Decompensation stage of cardiac and lung function Respiratory failure Symtoms: severe dyspnea,especially at night, headache, insomnia,inappetence, somnolence, dizziness,confusion, even delirium. Signs: conjunctiva congestion and edema, retinal vasodilatation, optic papillary edema; weakness or disappear of deep reflexes, pathological reflexes.,Clinical Manifestations,Decompensation stage of cardiac and lung function Right heart failure Symtoms: dyspnea aggravated, palpitation, inappetence, abdominal distention,nausea. Signs: cyanosis, arrhythmia, tachycardia,subxiphoid systolic murmur or even diastolic murmur. Tender hepatomegaly, Hepatojugular reflux, lower extremity edema, ascites.,Chest radiography： Enlarged right descending pulmonary artery diameter 15mm ; The ratio of diameter of right descending pulmonary artery to trachea1.07 ; Right descending pulmonary artery broadens2mm during dynamic observation Bulge of the middle segment of pulmonary artery or with the height3mm Enlargement of the pulmonary arteries and the major branches, with marked tapering of peripheral arteries Pulmonary cone protrudes or with the height7mm Right ventricular hypertrophy,Laboratory assessment,Electrocardiography： Main criteria : Mean frontal plane electrical axis 90 V1 R/S1 Marked clockwise rotation of the electrical axis： V5 R/S1 Rv1+Sv5 1.05mV aVR R/S or R/Q1 V:QS, Qr, qr（excluding myocardial infarction） P-pulmonale (tall peaked P waves in lead II) Secondary criteria : Low voltage QRS waveforms in limb leads Right bundle branch block,Laboratory assessment,Echocardiography The inner diameter of right ventricular outflow 30 mm The right ventricular internal dimension 20mm Anterior right ventricular wall thickened ,or with the pulsation amplitude increase Ratio of left to right ventricular internal dimension 2 Increased inner diameter of right pulmonary artery 18mm or pulmonary artery trunk20mm Ratio of right ventricular outflow inner diameter to left atrium internal dimension 1.4 Pulmonary valve curve shows the hypertention of pulmonary circulation,Laboratory assessment,Vectorcardiogram More sensitive than ECG：positive rate 80-95% Graphic show the hypertrophy of right heart Arterial blood gas analysis : Hypoxemia and/or hypercapnia Respiratory failure: PaO260mmHg PaCO2 50mmHg Blood test: Acid-base and electrolyte imbalance Blood viscosity RBC count and hemoglobin WBC count and neutrophilic ratio when infection occurs,Laboratory assessment,Medical history of COPD and other lung or pulmonary vascular diseases. Symptoms and signs of primary disease, pulmonary hypertension, right ventricular hypertrophy or dysfunction of right heart Lab findings:EKG;X-ray;UCG,et al.,Diagnosis,Differential diagnosis,Coronary heart disease Primary cardiomyopathy Rheumatic heart disease Cyanotic congenital heart disease,Compensation stage Treatment of primary disease Eliminate the predisposing factors ,avoid the acute exacerbation to restore the heart and lung function,Treatment,Decompensation stage Treatment of respiratory failure Treatment of right heart failure,Treatment,Treatment of respiratory failure Antimicrobial treatment Bronchodilators, expectorants Sputum aspiration, airway maintenance Oxygen therapy Correct the acid-base and electrolyte imbalance,Treatment,Treatment of right heart failure Oxygen therapy, infection control and the measures to improve respiratory function can ameliorate the the symptoms of heart failure in most cases Appropriate diuretics, cardiotonics and vasodilators can be chosen when the treatments mentioned above fails,Treatment,Treatment of right heart failure,Diuretics: Principle: Combine potassium-sparing diuretics and the diuretics that discharges potassium; Low dosage, short period and intermittent use.,Treatment of right heart failure,Cardiotonics : Principle:Low dosage, rapid effect and excreted ( cedilanid, strophanthin K ),correction of hypoxia and hypokalemia before use. Indications:Heart failure cant be improved after infection controled, respiratory function impr