慢性肺心病OUTLINEDefinition

：Chronic

lung,chestorpulmonaryvasculardiseases→Pulmonaryvascularresistance↑

→Pulmonaryarterypressure↑→Hypertrophyand

dilatationoftherightventricle

→RightHeartFailurePrevalence：0.44%～0.46%Onsetages：＞40yearsoldIncidenceseason：WinterandSpringPredisposingfactors

：AcuterespiratoryinfectionsEtiologyChronicbronchialandlungdiseases：themostcommondiseaseisChronicobstructivepulmonarydisease＞80%ThoracicdeformityPulmonaryvasculardisordersOthersMechanismandPathology（一）Pulmonaryhypertension：Definition：meanpulmonaryarterypressure（mPAP）≥25mmHgatrestor≥30mmHgduringexercise.FunctionalchangesinpulmonaryvascularHypoxia,Hypercapnia,Respiratoryacidosis,vasoconstrictionsubstances→Pulmonaryvasoconstriction→PulmonaryhypertensionHypoxiaisthemostimportantfactorleadstopulmonaryhypertensionAnatomicchangesinpulmonaryvascularRemodelingofpulmonaryvesselsIncreasedbloodviscosityandbloodvolumeMechanismandPathology（二）Dysfunctionofrightheart

Pulmonaryhypertension→Afterloadofrightventricular

↑,Oxygensupplyofmyocardium↓→Hypertrophyanddilatationoftherightventricle→Rightheartfailure

(三）Damagestoothervitalorgans：

MultipleorgandysfunctionClinicalManifestationsCompensationstageofcardiacandlungfunctionSymptoms:cough,sputum,shortofbreath;dyspneaandpalpitationonexertion;fatigueanddecreaseofexercisetolerance;exacerbatedbyacuteinfection.Signs:cyanosis,signsofemphysema,moistralesand/orrhonchi;P2>A2,systolicmurmuroftricuspidarea,subxiphoidvisible/palpablecardiacimpulse,distendedjugularvenous.ClinicalManifestationsDecompensationstageofcardiacandlungfunction

Respiratoryfailure

Symtoms:severedyspnea,especiallyatnight,headache,insomnia,inappetence,somnolence,dizziness,confusion,evendelirium.Signs:conjunctivacongestionandedema,retinalvasodilatation,opticpapillaryedema;weaknessordisappearofdeepreflexes,pathologicalreflexes.

ClinicalManifestationsDecompensationstageofcardiacandlungfunction

Rightheartfailure

Symtoms:dyspnea

aggravated,palpitation,inappetence,abdominaldistention,nausea.Signs:cyanosis,arrhythmia,tachycardia,subxiphoidsystolicmurmurorevendiastolicmurmur.Tenderhepatomegaly,Hepatojugularreflux,lowerextremityedema,ascites.

Chestradiography：Enlargedrightdescendingpulmonaryarterydiameter

≥15mm;Theratioofdiameterofrightdescendingpulmonaryarterytotrachea≥1.07;Rightdescendingpulmonaryarterybroadens＞2mmduringdynamicobservationBulgeof

themiddlesegmentofpulmonaryarteryorwiththeheight≥3mmEnlargementofthepulmonaryarteriesandthemajorbranches,withmarkedtaperingofperipheralarteriesPulmonarycone

protrudesorwiththeheight≥7mmRightventricularhypertrophyLaboratoryassessmentElectrocardiography：

Maincriteria:Meanfrontalplaneelectricalaxis≥90°V1R/S≥1Markedclockwiserotationoftheelectricalaxis：V5R/S≤1Rv1+Sv5＞1.05mVaVRR/SorR/Q≥1V１~Ｖ３:QS,Qr,qr（excludingmyocardialinfarction）P-pulmonale(tallpeakedPwavesinleadII)Secondarycriteria:LowvoltageQRSwaveformsinlimbleadsRightbundlebranchblockLaboratoryassessment

EchocardiographyTheinnerdiameterofrightventricularoutflow≥30mmTherightventricularinternaldimension≥20mmAnteriorrightventricularwallthickened,orwiththepulsationamplitudeincreaseRatiooflefttorightventricularinternaldimension<2Increasedinnerdiameterofrightpulmonaryartery≥18mmorpulmonaryarterytrunk≥20mmRatioofrightventricularoutflowinnerdiametertoleftatriuminternaldimension＞1.4PulmonaryvalvecurveshowsthehypertentionofpulmonarycirculationLaboratoryassessmentVectorcardiogram

MoresensitivethanECG：positiverate80-95%Graphicshowthehypertrophyofrightheart

Arterialbloodgasanalysis:

Hypoxemiaand/orhypercapnia

Respiratoryfailure:PaO2＜60mmHg

PaCO2＞50mmHg

Bloodtest:

Acid-baseandelectrolyteimbalanceBloodviscosity

↑RBCcountandhemoglobin

↑WBCcountandneutrophilicratio↑wheninfectionoccursLaboratoryassessmentMedicalhistoryofCOPDandotherlungorpulmonaryvasculardiseases.Symptomsandsignsofprimarydisease,pulmonaryhypertension,rightventricularhypertrophyordysfunctionofrightheartLabfindings:EKG;X-ray;UCG,etal.Diagnosis

DifferentialdiagnosisCoronaryheartdiseasePrimarycardiomyopathy

RheumaticheartdiseaseCyanoticcongenitalheartdiseaseCompensationstageTreatmentofprimarydiseaseEliminatethepredisposingfactors,avoidtheacuteexacerbationtorestoretheheartandlungfunction

TreatmentDecompensationstageTreatmentofrespiratoryfailureTreatmentofrightheartfailureTreatmentTreatmentofrespiratoryfailure

AntimicrobialtreatmentBronchodilators,expectorantsSputumaspiration,airwaymaintenanceOxygentherapyCorrecttheacid-baseandelectrolyteimbalanceTreatmentTreatmentofrightheartfailureOxygentherapy,infectioncontrolandthemeasurestoimproverespiratoryfunctioncanamelioratethethesymptomsofheartfailureinmostcasesAppropriatediuretics,cardiotonicsandvasodilatorscanbechosenwhenthetreatmentsmentionedabovefailsTreatmentTreatmentofrightheartfailureDiuretics:Principle:Combinepotassium-sparingdiureticsandthediureticsthatdischargespotassium;Lowdosage,shortperiodandintermittentuse.TreatmentofrightheartfailureCardiotonics:

Principle:Lowdosage,rapideffectandexcreted(cedilanid,strophanthinK),correctionofhypoxiaandhypokalemiabeforeuse.Indications:①Heartfailurecan’tbeimprovedafterinfectioncontroled,respiratoryfunctionimprovedanddiureticsused②s