1、Chronic Pulmonary Heart Disease The second affiliated hospital of Sun Yat-sen university, pulmonary department.Shanping Jiang 第1頁，共25頁。OUTLINEDefinition ： Chronic lung,chest or pulmonary vascular diseasesPulmonary vascular resistance Pulmonary artery pressure Hypertrophy and dilatation of the right

2、ventricle Right Heart FailurePrevalence：0.44%0.46%Onset ages：40 years oldIncidence season：Winter and SpringPredisposing factors ：Acute respiratory infections第2頁，共25頁。EtiologyChronic bronchial and lung diseases：the most common disease is Chronic obstructive pulmonary disease 80%Thoracic deformityPulm

3、onary vascular disordersOthers第3頁，共25頁。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 vascularHypoxia, Hypercapnia, Respiratory acidosis, vasoconstriction substancesPulmona

4、ry vasoconstrictionPulmonary hypertensionHypoxia is the most important factor leads to pulmonary hypertension Anatomic changes in pulmonary vascular Remodeling of pulmonary vesselsIncreased blood viscosity and blood volume第4頁，共25頁。Mechanism and Pathology（二）Dysfunction of right heart Pulmonary hypert

5、ension 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第5頁，共25頁。Clinical ManifestationsCompensation stage of cardiac and lung functionSymptoms: cough, sputum

6、, 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

7、venous.第6頁，共25頁。Clinical ManifestationsDecompensation 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, o

8、ptic papillary edema; weakness or disappear of deep reflexes, pathological reflexes. 第7頁，共25頁。Clinical ManifestationsDecompensation stage of cardiac and lung function Right heart failure Symtoms: dyspnea aggravated, palpitation, inappetence, abdominal distention,nausea. Signs: cyanosis, arrhythmia,

9、tachycardia,subxiphoid systolic murmur or even diastolic murmur. Tender hepatomegaly, Hepatojugular reflux, lower extremity edema, ascites. 第8頁，共25頁。 Chest radiography：Enlarged right descending pulmonary artery diameter 15mm ; The ratio of diameter of right descending pulmonary artery to trachea1.07

10、 ; Right descending pulmonary artery broadens2mm during dynamic observation Bulge of the middle segment of pulmonary artery or with the height3mmEnlargement of the pulmonary arteries and the major branches, with marked tapering of peripheral arteries Pulmonary cone protrudes or with the height7mmRig

11、ht ventricular hypertrophyLaboratory assessment第9頁，共25頁。第10頁，共25頁。Electrocardiography： Main criteria :Mean frontal plane electrical axis 90V1 R/S1Marked clockwise rotation of the electrical axis： V5 R/S1Rv1+Sv5 1.05mVaVR R/S or R/Q1 V:QS, Qr, qr（excluding myocardial infarction）P-pulmonale (tall peak

12、ed P waves in lead II) Secondary criteria :Low voltage QRS waveforms in limb leadsRight bundle branch block Laboratory assessment第11頁，共25頁。第12頁，共25頁。 EchocardiographyThe inner diameter of right ventricular outflow 30 mmThe right ventricular internal dimension 20mmAnterior right ventricular wall thic

13、kened ,or with the pulsation amplitude increaseRatio of left to right ventricular internal dimension 2Increased inner diameter of right pulmonary artery 18mm or pulmonary artery trunk20mmRatio of right ventricular outflow inner diameter to left atrium internal dimension 1.4Pulmonary valve curve show

14、s the hypertention of pulmonary circulation Laboratory assessment第13頁，共25頁。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

15、-base and electrolyte imbalance Blood viscosity RBC count and hemoglobin WBC count and neutrophilic ratio when infection occursLaboratory assessment第14頁，共25頁。Medical history of COPD and other lung or pulmonary vascular diseases.Symptoms and signs of primary disease, pulmonary hypertension, right ven

16、tricular hypertrophy or dysfunction of right heartLab findings:EKG;X-ray;UCG,et al.Diagnosis第15頁，共25頁。Differential diagnosisCoronary heart disease Primary cardiomyopathy Rheumatic heart diseaseCyanotic congenital heart disease第16頁，共25頁。Compensation stageTreatment of primary diseaseEliminate the pred

17、isposing factors ,avoid the acute exacerbation to restore the heart and lung function Treatment第17頁，共25頁。Decompensation stageTreatment of respiratory failureTreatment of right heart failureTreatment第18頁，共25頁。Treatment of respiratory failure Antimicrobial treatmentBronchodilators, expectorantsSputum

18、aspiration, airway maintenance Oxygen therapyCorrect the acid-base and electrolyte imbalanceTreatment第19頁，共25頁。Treatment of right heart failureOxygen therapy, infection control and the measures to improve respiratory function can ameliorate the the symptoms of heart failure in most cases Appropriate

19、 diuretics, cardiotonics and vasodilators can be chosen when the treatments mentioned above failsTreatment第20頁，共25頁。Treatment of right heart failureDiuretics:Principle: Combine potassium-sparing diuretics and the diuretics that discharges potassium; Low dosage, short period and intermittent use.第21頁，共25頁。Treatment of right heart failureCardiotonics : 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 improved and diuret