Cord pulmonar cronic

Diagnostic pozitiv - obiective

1. afirmarea bolii pulmonare cronice 2. Identificarea insuficientei respiratorii cronice 3. Identificarea HTP 4. Afirmarea HVD

Afirmarea bolii pulmonare cronice

1. Boli pulmonare: BPOC, fibroze pulm, supuratii pulmonare cr 2. Boli cai respiratorii superioare: adenoidite cr, obstructii traheale cronice 3. Boli pleurale/ de perete toracic: simfize pl, obezitate, S.A. 4. Boli vasculare pulmonare: embolii repetate, anemie falciforma

Identificarea insuficientei respiratorii cronice

1. 2. 3. 4. 5. 6. 7. 8. poliglobulia: Ht >55% Dispneea progresiva Cianoza progresiva calda Hipocratismul digital, Disfunctia respiratorie restrictiva/ mixta Gazometrie cu p O2 < 90 mmHg, pCO2> 50 mmHg, Sa O2<90% Acidoza respiratorie

Identificarea HTP
1. 2. 3. 4. 5. 6. Zg II intarit, dedublat la pulmonara Clic de ejectie P, Galop Tri, SS de I.Tri. Rx cord-pulm: hil marit, diametrul a. P > 20mm, Eco-doppler: regurgitatie tricuspidiana Cateterism cardiac: PAP > 30 mmHg

Afirmarea HVD
1. Hartzer +, cardiomegalie, 2. Galop xifoidian, 3. Rx c-p: unghi cardio-hepatic optuz, arc mij. stg. marit (HTP) 4. Eco-cardio: diametrul transvers VD crescut, grosimea VD> 5 mm, miscari paradoxale SIV, fractia de ejectie VD < 45% 5. EKG: HVD/ BRD, DAD, P inalt,

Diagnostic FUNCTIONAL
1. 2. CPC compensat FEj VD > 45% CPC decompensat: Dispnee accentuata Cianoza se raceste Staza jugulara, hepatomegalie de staza Edeme, ascita

Diagnosticul complicatiilor
1. 2. 3. 4. Encefalopatia hipercapnica Aritmiile: FiA, FaA, Ta Si, BSA, Tromboembolii Suprainfectii pulmonare

Diagnosticul diferential
1. 2. Al afectiunilor hidropigene cu HTvenoasa: ICG, IC hipodiastolica din pericardite Al afectiunilor hidropigene fara HTvenoasa: nefropatii glomerulare (GNAD, sdr nefrotic), ciroza hep, edeme carentiale Afectiuni cianogene: sunt cardiac dr stg, hemoglobinopatii

3.

PROFILAXIE
1. 2. 3. 4. EVITA OBEZITATE EVITA EFFORT, SUPRASOLICITAREA CARDIACA TERAPIA CORECTA A BOLII PULMONARE REGIM HIPOSODAT, HIPOCALORIC

TERAPIE
1. LA POLICITEMIE (Ht > 55%) -- sangerare 300 ml x 2-3 pana la evolutie favorabila, apoi 1 sangerare/ luna Oxigenoterapie cronica SCADE MORTALITATEA !! HEPARINIZARE in caz de BPOC acutizat, Ht > 55%, CPC de cauza vasculara -- heparina 50 mg / 6-8 ore x 10 zile apoi -- heparina 50 mg / 12 ore x 10 zile Vasodilatator Ca bloc Terapia decompensarii cardiace: --- FUROSEMID 60mg/zi 3-4 zile im + --- SPIRONOLACTONA 100 mg/ zi (! Hemoconcentratie) + --- DIGOXIN la CPC impur cu FEj VS < 50%

2. 3.

4. 5.

TERAPIA I.C. -- NYHA I

1. 2. 3. 4. TA 110 140 mmHg IECA I doze mici: Enap 2,5 mg x 2/ zi TA > 140mmHg Di tiazidic + IECA: Nefrix 25 mg + Enap 5 mg x 2/ zi TA 90 110 mmHg IECA doze f f mici: Enap 1,25 mg x 2/ zi IC NYHA I + I.Mi.A IECA + Diuretic + Digoxin 1 cpr/zi ( la TA > 100 mmHg si AV > 80/min se asociaza blocant) IC + FiA IECA 4-6 sapt --- dispneea persista : IECA + Nefrix 25 mg/ Furosemid 20 40 mg + KCl 2-3 G SAU Nefrix/ Furosemid + Spironolactona 25 MG( K< 4,5 mEg, creatinina< 2 mg% ml

5.

TERAPIA I.C. -- NYHA II

NYHA II FARA ASCITA
IECA 4-6 sapt Dispneea persista : IECA + Nefrix 12,5-25 mg sau Furosemid 20-40 mg/zi + KCl / Spironolactona 25 mg (daca K+ < 4,5 mEg/l, creatinina < 2mg%ml) 3. Simptome persista: IECA + Diuretic + KCl + Digoxin 0,25 mg/zi

NYHA II CU ASCITA MICA (5-6 kg)

1. 2. IECA + Spironolactona 25 mg (daca K+ < 4,5 mEg/l, creatinina < 2mg%ml) Daca simptomele persista: IECA + Spironolactona 25 mg + Digoxin

TERAPIA I.C. -- NYHA II

NYHA II CU ASCITA MODERATA (10-14 kg)
1. 2. FUROSEMID 40-80 mg +KCl / Spironolactona 50-100mg 7-10 zile Pauza 1-2 zile apoi: -- IECA + diuretic+ KCl -- sau la persistenta dispneei : IECA + diuretic + Digoxin

NYHA III si IV
FUROSEMID 80-120 MG 10-20 zile + DIGOXIN Pauza 1-2 zile apoi: FUROSEMID 40 mg + SPIRONOLACTONA 100mg + IECA doze mici + DIGOXIN