内科学教学课件：慢性肺源性心脏病

1、Chapter 11 Section 3 慢性肺源性心脏病 (chronic pulmonary heart disease, chronic cor pulmonale),目的与要求 1掌握慢性肺心病的概念、病因及肺动脉高压 的形成机制。 2掌握慢性肺心病的临床表现、辅助检查、诊 断、心肺功能失代偿期的治疗。 3熟悉慢性肺心病的鉴别诊断。,Definition 慢性肺源性心脏病(chronic pulmonary heart disease，简称慢性肺心病)是由肺组织、肺血管或胸廓的慢性病变 肺血管阻力增加 肺动脉压力增高 右心室肥厚或(和)扩张伴或不伴右心功能衰竭的心脏病。,一、Etiol

2、ogy 按原发病的不同部位，可分为四类：,（一）chronic broncho-pulmonary diseases COPD: most common cause (up to 80-90%). The others: bronchial asthma, bronchi- ectasis,tuberculosis,etc.,（二)Disease of thoracic movement disorder severe spinal side or backward convex, spinal tuberculosis, wide pleural adhesion, etc. They ar

3、e rare.,（三）diseases of pulmonary blood vessel Idiopathic pulmonary arterial hypertension(IPAH) , Chronic thromboembolic pulmonary hypertension (CTEPH),pulmonary arteriolar inflammation .They are rare.,（四）the others Primary lung hypoventilation, sleep apnea syndrome(SAS).They are rare.,二、Pathogenesis

4、 共同点: 反复气道感染和低氧血症体液因子和肺血管的变化肺血管阻力增加，肺动脉血管的结构重塑肺动脉高压右心室肥厚、扩大。先决条件：pulmonary hypertension,（一） Formation mechanism of pulmonary hypertension 1.Functional change of pulmonary vessel Hypoxia and hypercapnia pulmonary vasoconstriction hypoxia is the most important factor in pulmonary arterial hypertension

5、.,(1) humoral factors lung inflammation activate inflammatory cells release inflammatory mediums EDCF ，5HT leukotriene（LT） contracting pulmonary vascular TXA2 AT- NO PGE1 dilating pulmonary vascular EDRF,（2）nerver factorsHypoxia and hypercapnia stimulate carotid sinus and aortic body chemistry recep

6、tor sympathetic nervous excitement catecholamine secretionpulmonary vasoconstriction,（3）direct effect of hypoxia on pulmonary vascular Hypoxia the permeability of the Ca 2 +on the smooth muscle cell membrane content of intracellular Ca 2 + muscle excited-contraction coupling effect pulmonary vasocon

7、striction,2. Pulmonary vascular structural change 主要原因: 长期反复发作的慢性阻塞性肺疾病及支气管周围炎，可 累及邻近肺小动脉 随肺气肿的加重，肺泡内压增高，压迫肺泡毛细血管 肺泡壁破裂造成毛细血管网的毁损 肺血管重塑,功能性因素较解剖学因素更为重要 急性加重期纠正缺氧和高碳酸血症肺动脉压 部分患者可恢复到正常范围。,3. Increased volume and viscosity of blood chronic hypoxia secondary RBC blood viscosity hypoxiaaldosteronewater a

8、nd sodium retention hypoxiarenal arteriole contractionrenal blood flowwater and sodium retention blood volume blood viscosity, blood volume pulmonary artery pressure ,4. thrombosis 多发性肺微小动脉原位血栓形成。 Multiple small lung artery thrombosis,(二) Heart disease and heart failure pulmonary circulation resista

9、nce right ventricular hypertrophy right heart decompensationright heart dischargeright ventricular end-diastolic pressureright ventricle expanding right heart failure,(三) damage of other important organs Hypoxia and hypercapnia result in the damage of the other important organs such as brain, liver,

10、 kidney, gastro-intestinal ,endocrine system, blood system, etc.,三、Clinical Manifestation,(一)肺、心功能代偿期 (compensatory period of lung and heart function) the main performance is that of COPD . Cardiac function compensation is good Lung function is partly compensatory,1. Symptoms cough, expecteration, s

11、hort of breath, palpitations after the activity ，dyspnea, fatigue and reduced labor endurance.,2.Signs -Signs of primary disease and emphysema-Signs of pulmonary hypertension and right ventricular enlargement: P2 A2,tricuspid area can hear systolic murmurs,Enhanced heart throb under the xiphoid .,(二

12、) 肺、心功能失代偿期 (phase of cor-pulmonary function dyscompensation)Main: respiratory failure right heart failure.1. Respiratory failureAcute respiratory infection is the common cause.Clinical manifestations see chapter “respiratory failure”,2Right heart failure,Symptoms： palpitations,loss of appetite,abdo

13、minal distention, nausea, etc,Signs 1.Jugular vein engorgement2.Hepatomegaly and tenderness3.Liver jugular vein reflux (+)4.Lower extremity edema 5. ascites(severe)6.Elevated venous pressure,六、laboratory and auxiliary examination,(一) Radiography pulmonary hypertension- Broadening of lower right pulm

14、onary trunk - Obvious protruding of pulmonary artery right ventricle hypertrophy -Apex of heart upward and round,(二) Electrocardiogram The main standards -Electric axis is bias to the right side -Clockwise of right ventricle - V1 R/S 1， V5 R/S 1 -P wave of pulmonary type Reference standard -low volt

15、age in the limb lead -IRBBB or CRBBB,(三) UCG The main standards:-Inside diameter of right ventricular outflow tract30mm-Inside diameter of right ventricular20mmReference standard:-Inside diameter of right atrium 25mm,(四) Heart vector diagram right ventricle enlarged graphics,(五) Arterial blood gas a

16、nalysis -Hypoxemia or hypercapnia -respiratory failure: PaO260mmHg and/or PaCO250mmHg,(六) Blood test 1.Red blood cell and hemoglobin can be increased.2. The whole blood viscosity and plasma viscosity are increased.3. Total number of white blood cells or neutrophils is increased when infection. 4. Se

17、rum electrolyte can be disorder.,1. The performance of the primary disease (Chronic bronchitis, emphysema and other lung chest diseases or pulmonary vascular lesions) 2.The performance of pulmonary hypertension.,七、 Diagnosis,3. The right ventricle hypertrophy or right heart failure. 4. The ECG, X-ra

18、y, echocardiography, total can make a diagnosis.,八、Differential diagnosis （一）coronary heart disease （二） primary cardiomyopathy （三） rheumatic heart disease （四） cyanosis congenital heart disease,（一）coronary heart disease 1.有典型的心绞痛、心肌梗死的病史或心电图表现。 2. 有左心衰竭的发作史。 3. 冠心病的的危险因素：原发性高血压、高脂血症、 糖尿病史更有助鉴别。 4. 体检

19、、X线及心电图检查呈左心室肥大为主的征象。,（二）primary cardiomyopathy 1.无慢性呼吸道疾病史。 2. 无肺动脉高压的X线表现。 3. 本病多为全心增大；超声为大心室，小开口,（三）rheumatic heart disease 风心病三尖瓣疾病应与肺心病的相对三尖瓣 关闭不全相鉴别。 1.往往有风湿性关节炎和心肌炎的病史。 2. 其他瓣膜如二尖瓣、主动脉瓣常有病变。 3.X线、心电图、超声心动图有特殊表现，,（四） cyanosis congenital heart disease 1.儿童和青少年发病 2. 无肺气肿的体征。 3.心脏听诊有特征性杂音 4. 心脏超声

20、：特征性改变,九、Treatment,（一）肺、心功能代偿期 （ compensatory period of lung and heart function ） same as chronic bronchitis and emphysema 1.Breathing exercise 2.Enhance the body immunity 3. Long time oxygen therapy(LTOT),（二）肺、心功能失代偿期（5项） (decompensation period of lung and heart ) Control infection Control respirat

21、oy failure Control heart failure Deal with complications nursing,1. Control infection,empirical use of antibiotics or choose sensitive antibiotic according to sputum culture.,2. treatment of respiratory failure See section of respiratory failure,3.treatment of right heart failure,The heart failure t

22、reatment of Cor pulmonale is different from the other heart failure.The reason is that this heart failure can be improved by controlling infection, improving the respiratory function. Only those invalid or severe patients after treatment can appropriately use diuretics or digitalis.,(1)Diuretics pri

23、nciple The effect is moderate small dose short-course and intermittent use (generally no more than 4 days). combination of excretion and storage of potassium diuretics .,Side effects of Diuretics result in low potassium, low chlorine alkalosis (increase hypoxia) make sputum ropy Increase blood visco

24、sity Increase the respiratory failure,(2) Digitalisuse with caution : patients with chronic cor pulmonale have chronic hypoxia and infection which increased the susceptibi-lity to digitalis .These patients are easy to poisoning which result in arrhy-thmia,even sudden death., small dose (1/2 or 1/3 o

25、f routine dose) quick effect, quick discharge of digitalis such as Strophanthoside-K ，cedilanid （毒毛花甙K或西地兰）. to correct hypoxia. preventing and treating hypokalemia. it is unfavorable to take the heart rate as an indications of the application of digitalis and assessment treatment effect of digitali

26、s, the mathods of digitalis use, infection was under control, respiratory function was improved, diuretic got good curative effect ,but the patients still had repeated edema. right heart failure is the main performance and has no obvious infection in patients. combination of acute left heart failure arrhythmia of above ventricular, indications,3.Vasodilators Role: dilate pulmonary vascular reduce pulmonary arterial hypertension